Regency Manor Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain monthly medication regimen review (MRR) documentation (Pharmacy reviews) for nine residents (R6, R7, R11, R14, R25, R26, R32, R33 and R37) of nine reviewed for pharmacy medication review. Findings include: R37 A review of the record for R37 revealed R37 was admitted into the facility on [DATE]. Diagnoses included Anxiety, Depression, Diabetes, and Stroke. A review of the electronic medical record revealed no documentation of Medication Regimen Reviews by the pharmacist in the last 12 months. A review of the active Medication Administration Record (MAR) for July 2025 revealed 13 medications were administered daily. R37’s medications included daily antiseizure and antipsychotic medication. R33 A review of the record for R33 revealed R33 was admitted into the facility on [DATE]. Diagnoses included Schizoaffective disorder, Bipolar, Depression, and Hypertension. A review of the electronic medical records revealed no documentation of Medication…

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

Based on observation, interview, and record review, the facility failed to ensure resident food items brought in from outside were dated and failed to monitor the temperature of the resident refrigerator. This deficient practice had the potential to affect all residents that consume food. Findings include:On 7/15/25 at 10:00 AM, the resident refrigerator located in the break room was observed. There was no thermometer observed inside the refrigerator, and the temperature log located on the side of the refrigerator was last updated on 6/26/25. In addition, there were 3 undated food containers in the refrigerator. On 7/16/25 at 11:00 AM, Dietary Manager G was queried about the resident refrigerator and stated that she used to be responsible for monitoring that refrigerator, but that housekeeping is now responsible. On 7/16/25 at 11:15 AM, Dietary Manager G stated that she found the refrigerator thermometer buried underneath some food containers and confirmed that the temperature log was not up to date. According to the policy Use and Storage of Food Brought in by Family or Visitors…

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 have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP) and failed to ensure nursing staff used appropriate Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all 37 the residents in the facility. Findings include: On 7/16/25 at 10:00 AM, the facility's Water Management Plan (WMP) was requested from the Administrator. The Administrator provided the following policies for the WMP: Legionella Surveillance revised 1/5/25 which noted: It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections .2. In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies. A second undated…

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

Based on observation, interview, and record review, the facility failed to maintain a home-like environment free of offensive odors. This deficient practice had the potential to affect all residents, staff, and visitors. Findings include:On 7/15/25 at 9:00 AM, there was a strong odor of urine upon entry into the facility. The urine odor persisted on the ramp leading to the upper level and was evident in the hallway leading to the resident rooms. All hallways throughout the facility were observed to be carpeted. On 7/15/25 at 11:00 AM, the urine odor was still present throughout the facility. On 7/16/25 at 10:00 AM, pervasive urine odors remained throughout facility. On 7/16/25 at11:20 AM, Maintenance Supervisor F was queried regarding the schedule for cleaning the carpets. Maintenance Supervisor F stated he was unsure, but that he would ask his boss. After speaking with corporate staff, Maintenance Supervisor F stated that carpets are cleaned every 6 months by an outside company, and that they are probably about due to be done again. When asked for documentation or an invoice 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.

Based on interview and record review the facility failed to provide eight hours of Registered Nurse (RN) coverage potentially affecting all 37 residents residing in the facility. Findings include:Review of the Daily Staff Postings for May 27 through May 30th, 2025, revealed May 27 did not have 8 hours of 24 hours of Registered Nurse (RN) coverage. Review of the Daily Staff Postings for June 1st through June 30th, 2025, RN coverage was missing 13 days of 30 days for that month. Review of Daily Staff Postings for July 1st through July 10th, 2025, RN coverage was missing two of 10 days for that month. On 7/16/25 at 1:20 PM, Timecard Reports were requested, but no other information was provided by the end of the survey.On 7/16/2025 at 1:30 PM, the Director of Nursing (DON) who was also the Nursing Home Administrator (DON/NHA) revealed they shared responsibility for ensuring there was 8 hours in 24 hours of RN coverage with Unit Manager (UM) Registered Nurse A. The NHA/DON further revealed there was difficulty filling and maintaining stable staffing and there were many call-ins.…

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 that two of eight multi-use, single resident medications were labeled with an open date in one of two medication carts. Findings Include:On 7/16/2025 at 11:30 AM, the South medication cart was reviewed with Licensed Practical Nurse (LPN) B and revealed two ophthalmic (eye) preparations (Restasis and Atropine Sulfate) that were opened without open dates. LPN B revealed any medications for single patient use should include the resident name and date opened.At 11:45 AM, Unit Manager (UM) A was queried regarding the expectations regarding when medications should be date and confirmed, labeled medications for a single resident, should be dated when opened.At 1:30 PM, The Director of Nursing (DON) confirmed multi-use medications for single patient use should be dated when opened.On 7/16/2025 at 1:30 PM, a policy regarding medication storage and labeling was requested and was not received by the end of survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00152611. Based on observation, interview, and record review, the facility failed to provide adequate monitoring and supervision for one resident (R700) out of 14 reviewed for supervision. Findings include: A review of a Facility Reported Incident (FRI) noted the following, .On April 21,2025, one of the neighbors came to the door to let staff know that one of our residents was walking down the street. The staff immediately ran outside and saw that it was [R700]. The CNA (Certified Nursing Assistant) ran up the street to walk [R700] back and the nurse ran back to get her car to bring [R700] back to the facility. Staff noted the dining room alarm was not working properly so door alarm did not sound when [R700] went out the dining room. A review of the medical record revealed R700 admitted into the facility on 4/17/2024 with the following medical diagnoses, Dementia and Insomnia. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status…

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 MI00150065. Based on observation, interview, and record review, the facility failed to maintain a homelike environment in the resident showers and ensure the ice machine on the first floor was backflow protected. This deficient practice had the potential to affect all 39 residents in the facility. Findings include: On 2/12/25 at 9:50 AM, the ice machine drain line on the first floor was observed to extend down approximately 2 inches into the floor drain which was observed to have a buildup of black mold. Further observations of the sink located inside the room where the ice machine was located, revealed lime build-up around the faucet aerator. On 2/12/25 at 9:55 AM and 12:30 PM, observations of the facility's two shower rooms were observed with black mold, and an unknown brown substance around the perimeter of the shower, in addition to the shower walls. On 2/12/25 at 4:00 PM, findings of the ice machine and showers were brought to the attention of the Nursing Home Administrator (NHA), and she acknowledged she would look into the concerns. According…

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 transport a resident from a doctors appointment in a respectful manner for one sampled resident (R901) of one reviewed for resident rights. Findings include: On 2/12/25 at 9:32 AM, R901 was observed lying in bed. Certified Nursing Assistant (CNA A) reported that R901 went out yesterday for a medical appointment for their feet. On 2/12/25 at 10:54 AM, R901's Interested Party (IP) reported that R901 had a doctor's appointment for R901's foot, the van was an hour and a half late to pick R901 up for the appointment and late for the return to the facility. The IP also explained that when the van arrived at the doctor's office the driver had two children without car seats inside the van, and was observed cursing and hitting the children in the van. The doctor's office manager approached the driver, and she then began to curse at the office manager. After the exchange the office manager called the facility to report the driver and eventually,…

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: MI00149826. Based on observation, interview, and record review, the facility failed to ensure a wound vac (a medical device that uses negative pressure for wound healing) was consistanly applied for one sampled resident (R901) of two reviewed for skin management. Findings include: On 2/12/25 at 9:32 AM, R901 was observed lying in bed, their feet were lying flat on the bed, and without a wound vac on their foot. Certified Nursing Assistant (CNA) A was asked to lift the blanket off R901's feet for observation. R901's right foot was observed without a sock or bandage. R901's left foot was observed wrapped with a white bandage, the foot was observed to be leaking with fluids through the bandage and onto the bed. CNA A was asked where R901's wound vac was, CNA A reported, the resident came back from a doctor's appointment without it on. CNA A was observed to go into a bag and pull out the wound vac. The wound vac was observed with dried blood in the darinage tube and a large amount…

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: MI00150065 Based on observation, interview and record review, the facility failed to document showers for two dependent residents (R903 and R904) of four residents reviewed for complete medical records. Findings include: A review of information provided to the State Agency revealed concerns that female residents were not being adequately showered and groomed. On 2/12/25 at 9:41 AM, R904 was observed in bed on their back. Attempts to interview the resident were to no avail as they appeared confused and refused to speak with the surveyor. A review of R904's medical record revealed that they were admitted into the facility on 9/20/19 with diagnoses that included Dementia, Schizoaffective Disorder, and Diabetes. Further review revealed that the resident is enrolled onto hospice and required extensive to total dependence for activities of daily living. On 2/12/25 at 9:45 AM, R903 was observed in bed lying on their back, and asked about receiving showers. The resident explained that they thought they received a shower yesterday but was unsure. A 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.

This citation pertains to Intake MI00149636. Based on interview and record review, the facility failed to provide evidence of a comprehensive facility-wide infection control program encompassing outcome and process surveillance, accurate data collection/documentation/analysis, identifying, preventing, reporting, investigating and treating infections potentially affecting all 32 residents residing in the facility. Findings include: On 1/24/25 at 12:03 PM, the Nursing Home Administrator (NHA) report the Director of Nursing (DON) was not at the facility. A request was made to review the infection control program, the NHA reported they would have to look in the Infection Control Program book in the DON's office. The NHA later provided the Infection Control Program book which revealed no documentation of a encompassing outcome and process surveillance, and accurate data collection/documentation/analysis. The NHA reported the DON was on vacation and when contacted, the DON was asked about the documentation and reported the documentation was with them. A review of the facility's policy,…

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

This citation pertains to Intake: MI00143867 Based on interview and record review, the facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) committee met quarterly, and was composed of the required committee members, potentially affecting all 33 residents residing in the facility. Findings include: On 6/13/24 at 1:00 PM, during a QAPI review, the sign-in sheets for the QAPI committee meetings were reviewed with the Nursing Home Administrator (NHA), and the following was noted: -May 2023-There was no NHA or Director of Nursing present for the meeting. -June 2023-There was no NHA or Director of Nursing present for the meeting. -There were no sign-in sheets for a QAPI meeting for July 2023, August 2023, September 2023, and October 2023. -November 2023-The only QAPI members present were the Medical Director and a representative from Pharmacy. -December 2023: The only QAPI members present were the Medical Director and a representative from Pharmacy. -There were no sign-in sheets for a meeting that would have been held January 2024. -February 2024: The only…

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 enhance barrier precautions were implemented for two residents (R17 and R12 ) identified with an indwelling urinary catheter device and skin impairment and failed to ensure infection control surveillance was documented. Findings include: On 06/11/24 at 12:51 PM, R17 was observed to be in their room. R17 was queried about their urinary catheter and it was determined an indwelling urinary catheter was present. No signage for enhanced barrier precautions and no personal protective equipment other than gloves was observed in or outside the room. A review of the record for R17 revealed R17 was admitted into the facility on [DATE]. Diagnoses included Obstructive Uropathy (unable to urinate independently). The care plan dated 04/30/24 documented, .requires an indwelling urinary catheter related to retention . On 06/11/24 at 3:52 PM, R12 was asked about the dressing on their lower legs dated for 06/11/24. R12 reported these were chronic…

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 care conferences were conducted regularly for four residents (R2, R8, R20, and R23) of five reviewed for care conferences. Findings include: R2 A review of the clinical record for R2 revealed, R2 was admitted into the facility on [DATE]. Diagnoses included High Blood Pressure, Stroke, Paralysis of one side, Schizoaffective/Bipolar Disorder. A review of the care plan documented I have verbal behavioral symptoms .requires assist with (activities of daily living) ADL's .at risk for bowel and bladder decline .at risk for adverse consequences related to antipsychotic and antianxiety medication . A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with 15/15 Brief interview for mental status score (BIMS). The MDS further documented dependence for ADL care. A review of the medical record documented the most recent care conferences were dated 04/05/23 and 09/26/23 and the next care conference was documented as due…

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 follow up and or document physician notification of pharmacy recommendations from the medication regimen reviews for four residents (R2, R8, R15, and R23) of four reviewed for unecessary medications. Findings include: R2 A review of the clinical record for R2 revealed, R2 was admitted into the facility on [DATE]. Diagnoses included High Blood Pressure, Stroke, Paralysis of one side, Schizoaffective/Bipolar Disorder. A review of the care plan documented .at risk for adverse consequences related to antipsychotic and antianxiety medication . A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with 15/15 Brief interview for mental status score (BIMS). The MDS further documented dependence for ADL care. A review of the Medication Regimen reviews dated August 2023 and February 2024 revealed pharmacy identified concerns and to see the actual report for details. The actual reports were requested on 06/13/24 at 12:05 PM but…

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 related to Intake MI00144653. Based on observation, interview, and record review facility failed to obtain resident representative contact for one of one resident (R29) who has had multiple hospitalizations. Findings include: On 6/11/2024, record review revealed R29 was admitted on [DATE] at 10:22 PM. On 6/12 2024 Nurse Practitioner (NP) M identified diagnoses included Advanced Dementia, History of Covid, Dysphagia with Chronic PEG (Percutaneous Endoscopic Gastrostomy) tube for primary nutrition, Labile Hypertension, Chronic Obstructive Pulmonary Disease, History of Pulmonary Embolism with Atrial Fibrillation, Gastro Esophageal Reflux Disease, Debility. A record review on 6/12/2024 revealed R29 had an Emergency Contact L. Phone calls to that emergency contact as R29's representative were incomplete and contact with the responsible party was not made. On 7/18/2023 at 3:46 PM, the record revealed a note by social worker B that the listed emergency contact was attempted several times with no 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.

Based on interview and record review, the facility failed to develop an elopement baseline care plan for one (R133) of one resident reviewed for care plans. Findings include: On 6/11/24 at 12:26 PM, R133 was observed sitting on their bed. Attempts to interview the resident was to no avail as they were pleasantly confused. A review of R133's medical record were reviewed and revealed they were admitted into the facility on 5/30/24 with diagnoses including Unspecified Dementia, Brief Psychotic Disorder, and Paranoid Personality Disorder. Further review of the medical record revealed that the resident was severely cognitively impaired, and required supervision for ambulation. Further review of R133's medical record revealed a Resident Elopement Assessment-Assessment dated for 5/30/24 revealed that the resident was At Risk of Elopement. Further review of the medical record revealed the following progress note: 05/31/2024 11:26 PM Resident is confused and easily to redirect. [R133] left the facility and was found on the side of the building. resident is unharmed. Administrator and MD…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement care plan interventions for behavioral management of individuals on psychotropic medication for one of one resident (R17) reviewed. Findings include: On 6/11/2024 at 8:42 AM, observed R17 in bed on their right side, bedding covers below waist, in a loose brief. Upon entering and introducing self, R17, turned onto their left side, answered yes to my query if the care they received was good and pulled a sheet over their head. On 6/11/2024 at 11:30 AM, observed R17, in activities/dining room watching television. A record review revealed R17 was admitted on [DATE] with relevant diagnoses of Schizophrenia, Malignant Neoplasm of Brain, Benign Neoplasm of Left Adrenal Gland, Anemia, Multinodular Goiter, Diabetes Type 2, and Hyperlipidemia. R17's Basic Interview for Mental Status (BIMS) score was an 8 suggesting moderate cognitive impairment. R17's Minimum Data Set Assessment (MDS) Mood and Behavior scores indicated there were 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 interview and record review the facility failed to thoroughly complete a discharge summary for one resident (R32) of one resident reviewed for discharge. Findings include: A review of R32's medical record revealed they were admitted into the facility on [DATE] with the following diagnoses, Alzheimer's Disease, Heart Disease and Hypertension and discharged to another long-term nursing facility on 4/11/24. Further review of the medical record revealed the following progress notes: 04/09/2024 03:20 PM (3:20pm). Resident will be transferring to [nursing facility] on Thursday morning. The son POA (power of attorney) will be picking [R32] up early. The reason for transfer is the son reported he has a family friend who works at that facility plus the son feels like resident needs more activity and more space to get around. Resident is not happy being here. 04/11/2024 09:13 AM (9:13am). Resident transferred to [nursing facility] in private vehicle with guardian (son) @ (at) 9:07 am . Further 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 Based on observation, interview, and record review, the facility failed to follow a hospital recommendation, follow a physician's order, and follow up on a dental consultation for two residents (R8 and R23) of two residents reviewed for Quality of Care. Findings include: R23 On 6/11/24 at 12:30 PM, R23 was observed sitting in a wheelchair the dining room eating lunch, pleasantly confused. A review of R23's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Chronic Kidney Disease, Diabetes, Chronic Obsructive Pulmonary Disease, and Vascular Dementia. Further review revealed the resident was severely cognitively impaired and required extensive assistance of one person for Activities of Daily Living. Further review of R23's medical record revealed hospital documents noting they were admitted into the hospital from [DATE] to 3/14/24, and noted the following, .Neurology consulted for increased falls and confusion-consistent with Parkinsonism (A disorder of the central…

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 supervise and assess the effectiveness of interventions for one sampled resident (R23) of two residents reviewed for falls resulting in, multiple falls and transfers to the hospital. Findings include: On 6/11/24 at 12:30 PM, R23 was observed sitting in a wheelchair the dining room eating lunch, pleasantly confused. A review of R23's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Chronic Kidney Disease, Diabetes, Chronic Pulmonary Disease and Vascular Dementia. Further review revealed that the resident was severely cognitively impaired and required extensive assistance of one person for Activities of Daily Living. A review of R23's progress notes revealed the following 12 falls: 01/04/2024 03:53 AM (3:53am) Observed resident on the floor at the foot of the bed. resident assessed, ROM (range of motion) to all extremities, WNL (within normal limits) for resident. Assisted the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain orders for indwelling catheter care for one (R17) of one residents reviewed for catheters. Findings include: Record review revealed R17 was admitted on [DATE] with relevant diagnoses Chronic Schizophrenia, Depression/Anxiety, Dementia, Obstructive Uropathy with Urinary Retention, Diabetes and Anemia. R17's Brief Interview for Mental Status (BIMS) score was an 8 suggesting moderate cognitive impairment. On 6/11/2024 at 8:52 observed R17 in bed with intact indwelling catheter, with bag on the bed. On 6/12/2024 a record review revealed an order Change (name of urinary cather) catheter PRN (as needed) 18 FR (French). With 10 cubic centimeter (cc) balloon, initiated on 4/30/24 and discontinued on 6/7/2024. On 6/12/2024 a record review revealed an order (name of catheter) cath care every shift, initiated on 4/20/2024 and discontinued 6/7/2024. On 6/12/2024, the Medication Administration Record (MAR) revealed an order, Change indwelling catheter as…

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 as needed (PRN) psychotropic medication had adequate indication for use and a stop date for one resident (R17) of one reviewed for antipsychotic medications. Findings include: On 6/11/2024 at 8:42, R17 was observed to be in bed with the bedding covers below their waist. R17 answered yes to the query about whether the care they received was good and pulled a sheet over their head. On 6/11/2024 at 11:30 AM, R17 was observed in the activities/dining room watching television. A record review revealed R17 was admitted on [DATE] with relevant diagnoses of Schizophrenia, Malignant Neoplasm of Brain, Benign Neoplasm of Left Adrenal Gland, Anemia, Multinodular Goiter, Diabetes Type 2, and Hyperlipidemia. R17's Basic Inventory of Mental Status (BIMS) score was an 8 suggesting moderate cognitive impairment. R17's MDS (Minimum Date Set Assessment) Mood and Behavior scores indicated there were no concerns. On 6/12/2024 at 12:20 PM, 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: MI00143867 Based on observation, interview, and record review, the facility failed to ensure (urine) odors were limited and interventions and ventilation were adequate to resolve urine odors. Findings include: On entry 6/11/2024 at 8:00 AM, upon entry into the facility from the main door, there was a strong odor of urine and damp air. On 06/11/24 at 9:00 AM and 4:30 PM, in room eleven and the entry between rooms [ROOM NUMBERS], there was a strong odor of urine. The resident bathroom also had a pungent odor of urine. On 06/11/24 at 10:32 AM, R2 reported their room often smelled like urine. The odor was reported as chronic by staff. On 06/12/24 at 1:40 PM, room eleven had a urine odor upon entry. The vent in the bathroom did not actively draw air when tested with a tissue. A non sampled resident of the room acknowledged the urine odor and reported the odor comes and goes. At 2:00 PM the bathroom for room [ROOM NUMBER] and the resident hall bathroom were observed 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.

This citation pertains to MI00142236 and MI00142614. Based on observation, interview, and record review, the facility failed to ensure food items and the kitchen were maintained in a safe and sanitary manner with the potential to affect all residents of the facility. Findings include: On 03/06/24 at 11:10 AM, a tour of the kitchen areas was conducted with the dietary manager and revealed: A large can of beans was observed to have rust on the bottom rim of the can. This was observed along with three cans of fruit (diced pear, mandarin oranges), a case of canned corned beef hash, a bag of corn flakes, and a bag of puffed rice puff cereal. This was reported by the Dietary Manager as the facility emergency food supply. A chest freezer next to this area had a bag of pizza rolls open the air of the freezer. The chest style vegetable freezer had frost build up along the top inside edge and on the rear wall of the freezer. The top seal (between the rim and lid) was firm/hard and not pliable to the touch and did not appear fully fitted to the rim. There was rust on the outside of the freezer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practices. This citation pertains to Intakes MI00142236 and MI00142614. Based on observation, interview, and record review, the facilty failed to ensure a clean and safe environment was maintained, this practice had the potential to affect all residents that reside in the facility. Findings include: On 03/06/24 at 8:10 AM, on entry into the facility the cover had fallen off the baseboard heater in the entry lobby to the facility and laid on the floor. This revealed vertical fins/tines that were bent and smashed. At 8:48 AM, during a facility tour, the following was observed; -room [ROOM NUMBER], there was a urine odor, clothes piled on floor in closet, plastic bin on side, plastic hangers, holes on left hand wall, 18 screw size holes near a tv mount, and the center of bed was faded. -room [ROOM NUMBER], cable raveled up behind dresser at window, paint chipped, epoxy at corner or right hand window, cabinet doors that do not close, observed staff into sweep,but room dirty middle…

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 MI00142236 and MI00142614. Based on observation, interview, and record review, the facility failed to ensure handrails were firmly mounted to the wall in the upper hallway affecting five of five residents who lived in rooms along the hallway, resulting in the potential for falls. Findings include: On 03/06/24 at 9:34 AM, during a tour of the facility a hand rail was observed to separated at the inside corner at the right side of the food service elevator. The rail to the right of the kitchen/break room door was loose and easily jiggled. The railing left of the food service lift door was loose and the brackets moved with the railing. The left end of the handrail at right side of the office door was loose and easily jiggled when grasped. The hand rail between the bathroom and room [ROOM NUMBER] jiggled when pressure was applied. The handrail between room [ROOM NUMBER] and second bathroom jiggled when grasped. A section of handrail between room [ROOM NUMBER] and a third bathroom…

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.