Autumn Woods Residential Health

Based on observation, interview, and record review the facility failed to provide routine finger nail care for two sampled residents (R16 and R20) of six reviewed for activities of daily living. R16On 8/12/2025 at 9:25 AM, R16 was observed in bed with long nails, with a yellowish tint, and a buildup of brown debris under them. R16 was asked if they preferred their nails at the observed length. R16 was observed to hold their hands up towards their face and expressed that the nails were long and that they should be cut. On 8/13/2025 at 9:40 AM, R16 was asked if the staff had cut their nails, R16 reported they had not been cut. R16's nails were observed in the same condition.On 8/13/2025 at 9:47 AM, Unit Manager, Licensed Practical Nurse (LPN A) was asked to observe R16's nails. LPN A expressed, R16's nails were long and needed to be cut. LPN A was asked the expectation for resident's nails to get cut. LPN A explained, it is as needed, and nails are to be checked on shower days.A review of R16's care plan noted, Focus: The resident has an ADL self-care performance deficit related to…

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

Based on interview and record review, the facility failed to schedule a hematology (specialty for diseases of the blood) appointment for one resident (R8) out of one reviewed for consultation appointments. Findings Include:On 8/13/2025 at 10:40 AM, R8 was observed in their bed. R8 stated they were doing okay, but their hands have been hurting them.A review of the medical record revealed R8 admitted into the facility on 3/7/2025 with the following medical diagnoses, Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental status score of 12/15, indicating an impaired cognition. R8 also required assistance with bed mobility and transfers.Further review of the medical record revealed an active order with a start date of 3/18/2025 for a hematology appointment follow up.On 8/13/2025 at 2:05 PM, an interview was conducted with the Director of Nursing (DON). The DON reported they were unaware of a hematology appointment and would look into it.No further information was received by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely monitoring for two ventilator residents (R3, R35) of four residents reviewed for respiratory care needs. Findings include: R3 On 08/11/2025 at 9:36 AM, R3 was observed to be in bed and restless with non-purposeful movements of the arms and legs. R3 had a tracheostomy (artificial airway inserted via a throat incision) which was connected to a mechanical ventilator (assists resident to breath effectively) via a corrugated plastic tubing (circuit). On 08/11/2025 at 10:42 AM, R3's restlessness continued and the circuit connecting the tracheostomy to the ventilator became disconnected at the tracheostomy site with a movement of R3's left arm which tangled the circuit tubing. An alarm sounded and a red light turned on above the outside of the resident's doorway. No staff were observed to be in the hallway. At 10:44 AM, staff came around the corner from the nurse station, turned back toward the nurse station and then walked up 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 interview and record review, the facility failed to provide mental health services in a timely manner for one resident (R186) out of three reviewed for mood and behavior. Findings include:A review of the medical record revealed R186 admitted into the facility on 5/13/2025 with the following medical diagnoses, Schizophrenia and Bipolar Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 12/15, indicating an impaired cognition. R186 also required assistance with bed mobility and transfers.Further review of the physician's orders revealed that R186 received Haldol (Antipsychotic) injection, once a month.On 8/13/2025 at 11:04 AM, a request for psychiatric notes for R186 was requested and not received by the end of survey.On 8/13/2025 at 11:23 AM, an interview was conducted with Social Service Director (SSD) D. SSD D reported they are on the list to be seen, and they just switched to a new Nurse Practitioner. SSD D reported the new Nurse Practitioner comes in every Monday and will be seeing R186 soon.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.

Based on observation, interview, and record review the facility failed to ensure safe storage of medication for one resident (R149) of four residents reviewed for medication storage. Findings include:On 8/11/25 at 9:49 AM, an observation on R140's bedside table, a medication cup of pills containing approximately eight pills, two blue oval, two large round white, one small round white, one small yellow round, one white capsule, and one yellowish clear gel capsule. Two bottles of Nystatin Powder were also on the bedside table on 8/11/25, 8/12/25, and 8/13/25. When R149 was queried, they revealed their nurse always leaves the pills for them to take when they are ready. Further inquiry revealed R149 identified the medication as some are blood pressure pills. They also indicated the powder is for under my folds.A review of the Electronic Medical Record (EMR) revealed on 4/7/23, R149 was admitted with the following relevant diagnoses: End Stage Renal Disease with dependence on Renal Dialysis, Chronic Heart Failure, Diabetes, Dependence on Oxygen, and Polyosteoarthritis. Further review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly store a nebulizer mouthpiece for two residents (R6 and R191) out of two reviewed for nebulizer storage. Findings include:R6 On 8/13/2025 at 10:40 AM, R6 was observed in bed and wearing oxygen. R6 reported they were about to get out of bed and in their chair. A nebulizer mouthpiece was noted to be laying on the nightstand, with no barrier beneath it and an undated line. R6 was asked if they use the nebulizer mouthpiece often and they stated they use it everyday. On 8/13/2025 at 1:02 PM, Licensed Practical Nurse (LPN) “V”. LPN “V” reported they do store the nebulizer mouth pieces in a bag. LPN “V” reported that R6 had just used the nebulizer before they went outside. LPN “V” reported they were going to find a bag. A review of the medical record revealed R6 admitted into the facility on 3/7/2025 with the following medical diagnoses, Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea. A review of the most recent…

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 MI00152547. Based on observation, interview, and record review, the facility failed to ensure a clean environment for one resident, (R702) of three residents reviewed for home-like environment. Findings include: A review of the complaint submitted to the State Agency revealed the resident's room was observed as dirty upon visitation. On 4/28/25 at 10:58 AM, attempts to arouse R702 were made to no avail however, an observation of the resident's room revealed unidentifiable brown stains on the fitted and flat linen sheets the resident was laying on. The floor of the room was sticky underneath the surveyor's shoes, the door had what appeared to be an unidentifiable dried liquid on it, the baseboards throughout the perimeter of the room were observed as stained with an unknown caked on substance. The resident's bathroom was also observed with feces on the toilet seat. A review of R702's medical record revealed the resident was admitted into the facility on [DATE] with diagnoses 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 MI00148207. Based on observation, interview, and record review, the facility failed to maintain privacy from electronic devices (camera) located in the room of one resident (R704) of three reviewed for privacy. Findings include: On 11/20/24 at 10:30 AM, a sign was observed on the outside of R704's the door. The sign revealed, Introduce oneself to the mother on camera when entering resident room. Once in R704's room an approximately 4 x 6 inch camera was observed on R704's overbed table located below the window. R704's bed was about two feet away from the camera. On the left side of the same window toward the head of the bed, a (name of) camera (used to monitor in real-time) was observed affixed to the wall next to the window about 10 inches from a larger camera. Both cameras were facing R704's room entry door. On 11/20/24 at 10:45 AM, Licensed Practical Nurse (LPN) B was queried about the function of the cameras. LPN B revealed, the camera is connected to R704's mother's phone.…

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 MI00147638 Based on interview, and record review, the facility failed to prevent verbal and physical abuse for one resident (R801) out of four reviewed for abuse. Findings include: A review an investigation summary revealed the following, On 10/14/2024 at around 7:00 AM, Nurse D and Certified Nursing Assistant (CNA) E reported to A.D.O.N (Assistant Director of Nursing) . that they observed Licensed Practical Nurse (LPN) C yelling profanities at R801 for trying to sleep on the couch in the dayroom during their midnight shift on 10/13/2024 between 2:30am -3:30am. When R801 refused to get up off the couch LPN C continued to yell at them then got behind the couch and started lifting the couch to get R801 off. R801 then rolled onto the floor. Staff helped R801 up and took R801 to the room . A review of the medical record revealed R801 was admitted into the facility on 2/26/2022 with the following diagnoses, Presence of Right Artificial Joint and Depression. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of…

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

Based on interview and record review, the facility failed to report an abuse allegation in a timely manner for one resident (R801) out of one reviewed for reporting. Findings Include: A review an investigation summary revealed the following, On 10/14/2024 at around 7:00 AM, Nurse D and Certified Nursing Assistant (CNA) E reported to ADON (Assistant Director of Nursing) . that they observed Licensed Practical Nurse (LPN) C yelling profanities at R801 for trying to sleep on the couch in the dayroom during their midnight shift on 10/13/2024 between 2:30am -3:30am. When R801 refused to get up off the couch LPN C continued to yell at them then got behind the couch and started lifting the couch to get R801 off. R801 then rolled onto the floor. Staff helped R801 up and took R801 to the room . A review of the initial report revealed that the incident was reported to the SA on 10/14/2024. On 10/24/2024 at 11:58 AM, an interview was conducted with ADON B. ADON B was asked why the incident was reported to the SA on 10/14/2024 when the incident occurred on 10/12/2024. ADON B stated the incident…

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

Based on observation, interview, and record review, the facility failed to maintain the sanitizer buckets, failed to ensure dishware was dry before stacking, and failed to ensure resident food items were dated. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 7/23/24 between 8:55 AM-9:30 AM, during an initial tour of the kitchen with Dietary Staff P, the following items were observed: There were 2 red sanitizer buckets with wiping cloths inside observed in the kitchen area. Dietary Staff P stated the buckets contained sanitizer solution. The sanitizer level in both buckets was tested with a test strip, and the strip did not change color to denote the presence of sanitizer solution in the buckets. Dietary Staff P stated the buckets would be changed. According to the 2017 FDA Food Code, Section 3-304.14 Wiping Cloths, Use Limitation, .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114;…

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 R79 Review of the facility record for R79 revealed an admission date of 12/26/24 with diagnoses that included Osteomyelitis of the Left Ankle and Foot and Chronic Obstructive Pulmonary Disease. On 07/23/24 at 10:58 AM, R79 reported they were bothered by their toenails being too long and needing to be trimmed and stated they could not recall seeing a Podiatrist since their admission to the facility. On 07/24/24 at 11:54 AM, R79's feet were observed with staff assisting to remove the bedding and socks. R79's toenails were excessively long on multiple toes including some sharp, unfiled corners and particularly on the bilateral great toes which were approximately one inch beyond the nail bed. On 07/24/24 at 1:31 PM, the facility Director of Nursing (DON) reported non-diabetic residents can have their toenails trimmed by nursing staff and diabetic residents are referred to Podiatry for toenail care. On 07/24/24 at 1:43 PM, the DON observed R79's feet with the surveyor and acknowledged that multiple toenails needed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC- An IV-Intraveneous line inserted via the veins in the arm) dressing was dated and documented when changed for two residents (R82, R131) of two reviewed for PICC line care. Findings include: R82 On 07/23/24 at 9:24 AM, R82 was observed to be in bed, a rolled gauze dressing was observed to be wrapped around the left upper arm of R82. A single lumen PICC line cap was visible at the bottom edge of the the dressing. A date was not visible on the tape which held the dressing in place. The insertion site was not visible. An IV pump was observed at the left side of the bed. On 07/24/24 at 8:44 AM, 12:13 PM, 1:14 PM and 3:47 PM, R82 was observed to be in bed with the rolled gauze dressing wrapped around the left upper arm of R82. A single lumen PICC line cap was visible at the bottom edge of the the dressing. A date was not visible on the tape which held the dressing in place. The insertion…

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 M100144913 and M100145603. This citation had two deficient practice statements. Deficient practice statement #1. Based on interview, and record review, the facility failed to ensure a mechanical lift sling was in good repair and two trained staff were present during transfer to prevent a fall from a mechanical lift for one (R494) of one resident reviewed for falls, resulting in a hospitalization. Findings include: Review of the facility record for R494 revealed an admission date of 3/1/2022 with diagnoses that included Cerebral Infarction with Left Hemiplegia, Muscle Weakness, and Anxiety Disorder. Additional review of R494's record revealed a progress note dated 7/8/2024, documented R494 had a fall (from a mechanical lift due to a ripped sling), subsequently assessed by nursing staff then reported the fall to Nurse Practitioner F. The note indicated R494 hit their head, was on blood thinners, and they had a throbbing headache, and sent to the emergency room. The Post-Fall…

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 store medication in a safe and secure manner for four (R97, R102, R11 and R33) of the 35 total sampled residents, reviewed for medication and storage. Findings include: R97 On 7/23/24 at 9:12 AM, R97 was observed lying in bed. R97's overbed table was observed with a single white pill in a medication cup. R97 was asked how long the pill had been in their room. R97 stated, I don't know, maybe this morning. R97 was asked what the pill was for, R97 was observed to move their hands and said neuropathy (nerve damage). R102 On 7/23/24 at 11:22 AM, R102 was observed in their room with a medication cup that had one orange gel capsule, the cup was observed in their window seal. R102 was asked about the pill. R102 stated, I didn't take it because I had a bowel movement this morning. I told the nurse I didn't want it. R111 On 7/23/24 at 2:19 PM, R111 was observed in their room with a red inhaler on the overbed table. R111 was asked if they normally…

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 repair or replace a bed in disrepair for one (R136) of eight resident's reviewed. Findings include: Review of the facility record for R136 revealed an admission date of 07/12/23 with diagnoses that included Infection of the Right Ankle and Foot, Diabetes Mellitus with Diabetic Neuropathy, and Muscle Weakness. The record indicated that R136 was most recently readmitted to the facility on [DATE] following a Right Above Knee Amputation. On 07/23/24 at 11:17 AM, R136 reported the height adjustment of their bed had not worked since I've been here. The resident demonstrated using the remote control that the head and foot adjustments worked and when they attempted to adjust the bed height the bed did not move and it made a loud grinding noise. R136 stated they had reported this issue to staff and it was never addressed. On 07/24/24 at 12:03 PM, R136 was interviewed further regarding the reporting of their bed malfunction. When asked if they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00142307. Based on interview, and record review the facility failed to follow up on medical appointments and consultations for skin for one resident (R904) of four residents reviewed for skin management. Findings include: A review of the Intake summary revealed, . head is getting worse. [R904] has cancer in it. They have not giving me a referral so [R904] can see an oncologist and [R904] is in serious pain. I think this is abuse. They have known [R904] had this cancer since November and nothing is getting done. It is getting worse. Please help. Areview of R904's medical record revealed, R904 was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis of Multiple Fractures of Ribs. R904 was discharge to the hospital on 2/14/24. A review of R904's referral form scanned into the medical record dated 10/19/23 noted, Recommended follow up information: [local Dermatology] 3-7 days. A review of R904's orders revealed, Order: Dermatology consult for forehead lesion one…

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 MI00142307. Based on interview, and record review the facility failed to complete wound care treatments as ordered for one resident (R904) of four residents reviewed for skin management. Findings include: A review of the intake summary revealed, . head is getting worse. [R904] has cancer in it. They have not giving me a referral so [R904] can see an oncologist and [R904] is in serious pain. I think this is abuse. They have known [R904] had this cancer since November and nothing is getting done. It is getting worse. Please help. Areview of R904's medical record revealed, R904 was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis of Multiple Fractures of Ribs. R904 was discharge to the hospital on 2/14/24. A review of R904's orders revealed, Order: Cleanse with wound cleanser. Pat dry. Apply Honey Gel to Lt. upper face Skin barrier wipe to peri wound. Cover with calcium alginate Ag and dry dressing every night shift for wound care AND as needed for wound care…

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 citaiton pertains to Intake MI00139994. Based on interview and record review, the facility failed to administer prescribed pain mediations on multiple days for one resident (R703) out of two reviewed for medication administration. Findings Include: A review of the Intake noted the following, Complainant stated the resident was only given Tylenol when [R703] is supposed to be taking Morphine. A review of the medical record revealed that R703 admitted into the facility on 9/29/2023 with the following diagnoses, Pressure Ulcer of Sacral Region, Stage 4 (damage to deep skin tissue including tendons and nerves) and Alzheimer's Disease. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 99, indicating severly impaired cognition. R703 also required extensive 1 person assist with bed mobility and transfers. A review of the physician orders revealed the following orders, Order: Acetaminophen-Codeine Oral Tablet 300-30 MG. Directions: DAW (Dispense as written) Give one tablet by mouth every 8 hours for pain. Start Date: 9/29/2023 .…

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 MI00139994. Based on interview and record review, the facility failed to initiate wound treatment for one resident (R703) out of one reviewed for wounds, resulting in the potential worsening of existing pressure ulcers and/ or development of new wounds. Findings Include: A review of the intake noted the following, Staff failed to change the dressing on the resident's wounds as ordered. When [R703] went home there was no dressing on [R703's] wound at all and it hadn't been cleaned. A review of the medical record revealed that R703 admitted into the facility on 9/29/2023 with the following diagnoses, Pressure Ulcer of Sacral Region, Stage 4 (damage to deep skin tissue including tendons and nerves) and Alzheimer's Disease. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 99, indicating severe cognitive impairment. R703 also required extensive 1 person assist with bed mobility and transfers. Further review of the MDS revealed the following, Number of stage 4 pressure ulcers: 1. 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 This citation pertains to Intake MI00138295. Based on observation, interview, and record review, the facility failed to properly label/date and flush/disconnect an enteral feeding (tube feeding) for one resident (R702) of one reviewed for PEG (percutaneous endoscopic gastrostomy) care, resulting in the potential for administration error, altered nutrition, and/or PEG tube occlusion. Findings include: A review of R702's record revealed that the resident was initially admitted into the facility on [DATE] and most recently re-admitted from the hospital on [DATE]. R702's medical diagnoses include Respiratory Failure, Hemiplegia and Hemiparesis (weakness/paralysis on one side) following Cerebral Infarction, Tracheostomy Status, Gastrostomy Status, Contracture, Pulmonary Embolism, Tachycardia, and Essential (Primary) Hypertension (high blood pressure). Further review of R702's record revealed that the resident was severely cognitively impaired and fully dependent on staff for care and activities of daily living. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes MI00138295 and M100138310. Based on observation, interview, and record review, the facility failed to administer medications per order for one resident (R702) of six reviewed for quality of care, resulting in the potential for exacerbation of chronic health conditions. Findings include: A review of multiple complaints submitted to the State Agency alleged that the facility failed to properly administer R702's medications blood pressure and seizure medications per order. A review of R702's record revealed that the resident was initially admitted into the facility on [DATE] and most recently re-admitted from the hospital on [DATE]. R702's medical diagnoses include Respiratory Failure, Hemiplegia and Hemiparesis (weakness/paralysis on one side) following Cerebral Infarction, Tracheostomy Status, Gastrostomy Status, Contracture, Pulmonary Embolism, Tachycardia, and Essential (Primary) Hypertension (high blood pressure). Further review of R702's record revealed that the resident is…

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 open food items were dated, ensure sanitizer test strips were available for use, ensure staff donned beard restraints, and ensure staff changed gloves to prevent cross contamination. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 5/22/23 between 8:30 AM-9:15 AM, during an initial tour of the kitchen with Dietary Staff G, the following items were observed: In the walk-in cooler, there was an opened, undated 1 gallon container of salad dressing, and an opened, undated 1 gallon container of pickle relish. Dietary Staff G confirmed the items should have been dated when opened. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that the resident's name, date, time, and order information for enteral feeding (Liquid nutrient solution fed through a PEG-Percutaneous Endoscopic Gastostomy tube inserted in through the stomach) was completed, for four (#'s R25, R42, R128, and R195) residents reviewed for tube feedings, resulting in the potential for tube feeding not administered according to the physicians orders. Findings include: Resident 25 (R25). On 5/22/23 at 10:18 AM, R25 was observed in their room sleeping. Observed in the room was a tube feeding in progress, the formula bottle was observed without a blank label with R25's information. Next to the formula there was a water bag that was labeled with R25's order information. A review of R25's medical record noted, Order: in the evening Isosource 1.5 via PEG @ (at) 83cc (cubic centimeters)/hr (hour) x 18 hours (hr) or total volume 1494cc infused. 1/19/23. Order: in the evening Autoflush via PEG H2O @ 65cc/hr x…

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 medication refrigerators were maintained within an appropriate temperature range for two of four medication refrigerators and failed to ensure the resident identifier and date opened were labeled on the medication container when opened for three of five medications carts observed, resulting in the potential for the use of expired medication, inadvertent use of another residents medication and degraded medication. Findings include: On [DATE] at 8:37 AM, the third floor high medication cart was reviewed with Licensed Practical Nurse (LPN) Z. Two vials of insulin were not dated with the open date on the vials. On [DATE] at 2:53 PM, the low 300 east medication was observed with LPN Z with one insulin not dated on vial. [DATE] 07:58 AM, the two west low hall cart was reviewed with LPN K. A Breo inhaler and an Incruse inhaler were dated but not labeled with the residents name on the inhaler. On [DATE] at 8:29 AM, the one east high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for three residents (R39, R85, R139) and five confidential group residents of fifteen residents reviewed for palatable food, resulting in resident dissatisfaction during meals. Findings include: Resident #39 (R39) On 5/22/23 at 10:13 AM, during an initial tour of the facility, R39 was interviewed about food palatability at the facility and stated, The food needs to be fixed. On 5/24/23 at 1:25 PM, R39 was further interviewed about the food served at the facility and stated, The food is terrible. On 5/24/23 at 1:38 PM, a review of R39's electronic medical record (EMR) revealed that R39 was most recently admitted to the facility on [DATE] with diagnoses that included Kidney disease and Depression, with psychotic features. R39's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R39 had a moderately impaired cognition. 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 upon observation, interview and record review, the facility failed to implement the care plan for turning/repositioning frequency for five (R15, R114, R116, R131, R156) of seven residents reviewed for repositioning resulting in resident dissatisfaction with care, discomfort and potential for onset of or worsening of pressure ulcers. Findings include: Review of the facility record for R15 revealed an admission date of 05/02/23 with diagnoses that included Atherosclerotic Heart Disease, Acute Kidney Failure and Depression. R15's Minimum Data Set (MDS) assessment dated [DATE] indicated R15 required Moderate level assistance for bed mobility and transfers. The Brief Interview for Mental Status (BIMS) assessment score of 12/15 indicated Moderate cognitive impairment. On 05/22/23 at 9:13 AM, R15 reported long call light response times, sometimes up to 2 hours. R15 stated They tell me they're understaffed if I say something. R15 was laying on their back in the bed during this initial observation. On 05/22/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake number MI00136364. Based on observation, interview, and record review the facility failed to administer medication to prevent seizures for one resident (R139) of one resident reviewed for medication administration, resulting in the potential for the resident to experience an increase in seizure activity and injury related to seizure activity. Findings include: On [DATE] at 1:30 PM, R139's electronic medical record (EMR) was reviewed and indicated the following medication order for R139: Briviact Tablet 100 milligram (mg) Give 1 tablet by mouth every 12 hours related to Epilepsy Start Date: [DATE]. On [DATE] at 1:34 PM, R139's May's Medication Administration Record (MRR) was reviewed and revealed that R139 was not administered Briviact on [DATE] and [DATE]. On [DATE] at 1:38 PM, R139's care plan was reviewed and revealed the following, Focus: The resident has a seizure disorder r/t (related to) epilepsy. Date Initiated: [DATE]. Revision on: [DATE]. Goal: The resident will remain…

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

Based on observation, interview and record review, the facility failed to provide a home-like environment for one resident, (R145) reviewed for homelike environment resulting in an unsanitary environment with wet and a buildup of dried tube feeding formula on the tube feeding pole and floor, and the potential for resident and resident representative dissatisfaction with their living conditions. Findings include: On 5/22/23 at 9:13 AM, during initial tour, the room of R145 was observed to have a large pool of wet tube feeding formula on the floor and tube feeding pole. The tube feeding formula was observed on the floor and pole at 10:51 AM, 12:56 PM and 3:22 PM. On 5/23/23 at 8:58 AM and 3:40 PM, the large pool of tube feeding formula remained on the floor and tube feeding pole. On 5/24/23 at 8:42 AM, the tube feeding fluid remained on the floor and tube feeding pole. On 5/24/23 at 1:33 PM, the Director of Nursing (DON) was informed of the observations of R145's room, and asked whose responsibility it is to clean up tube feeding fluid off the floor. She explained that it's an all…

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.