Harmony Village of Warren

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one delayed release medication and two extended release medications were not crushed prior to administration and a cranberry tablet dosage was correctly administered out of 33 medications observed, resulting in a medication error rate of 12.12%. Findings include: On 05/07/25 at 9:29 AM, a medication pass observation for R68 was conducted with Licensed Practical Nurse (LPN)C. The following medications were prepared, crushed and placed into applesauce: Aspirin 81 mg (milligrams) tablet one time a day, Megestrol 400 mg/10ml, liquid, 10 ml (milliliters) two times a day; Zunveyl (Benzgalantamine Gluconate) Oral Tablet Delayed Release 10 mg two times a day; Loratadine 10 mg one time a day; Cranberry 400 mg tablet one time a day, (450 mg tablet given); Losartan 100 mg tablet in the morning; Metoprolol succinate 100 mg ER (extended release) tablet; Amlodipine 5 mg tablet in the morning; and Klor-con potassium ER 20 MCG (micrograms) tablet…

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 MI00151378. Based on interview and record review, the facility failed to honor the rights, notify, or obtain consent from a Durable Power of Attorney (DPOA) regarding a resident discharge for one resident (R504) of three sampled residents reviewed, resulting in the released to an unauthorized family member. Findings include: R504 R504's Electronic Medical Record EMR was reviewed on 4/8/25 at 11:30 AM. R504 was admitted to the facility on [DATE] with the diagnosis of Cervical Disc Disorder, Type 2 Diabetes Mellitus, and Carcinoma of the Prostate, in addition to other diagnoses. R504's Brief Interview for Mental Status (BIMS) Score dated 1/15/25, assessed by the facility, was 6/15. A BIMS score of 6 indicates severe cognitive impairment. R504 Minimum Data Set (MDS) assessment dated [DATE] revealed they are frequently incontinent with both bowel and bladder elimination patterns and requires substantial/maximal assistance with Activities of Daily Living (ADLs). A review of R504'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 MI00151133. Based on interview and record review, the facility failed to protect and prevent abuse from occurring for one resident (R504) who was inappropriately touched by another resident (R505) of three residents reviewed for abuse. Findings include: A review of the facility investigation revealed that on 3/3/25 at 3:30 PM. The Activities Director reported witnessing R505 inappropriately touching R504 to the Social Service Director. The incident occurred in the dining room with no staff present. The Activities Director happened to step out of her office door and saw R505 touching R504's breast. The Activities Director called out R505's name. She said that the behavior was unacceptable and immediately separated both residents (R504 and R505). The Social Services Director reported the incident to the Abuse Coordinator. R504 Record review revealed F504 was admitted to the facility on [DATE] with diagnosis of cervical disc disorder with myelopathy, carcinoma of the prostate,…

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 MI00147420. Based on observation, interview, and record review the facility failed to maintain clean and repaired flooring, handrails and furniture items throughout the facility potentially affecting all 126 residents residing there. Findings include: On 11/14/24 at 10:36 AM, observations of the environment were initiated and revealed: The A wing 100 hall shower room had some dried build up of debris on the strainer for the drains in the left hand shower stalls. The toilet bowel had an amount of used tissue which filled the bowl. The six to eight foot long baseboard heater register was observed to have rust scattered across the surfaces, a portion of the cover hung down on one end and multiple tines of the register were dented or mashed. room [ROOM NUMBER] had an unoccupied bed which tilted down at one corner, the mattress did not fit the width of the bed, the bed sheet was soiled with a few tan/brown spots and the sheet rock at the wall side of the bed had a softball size dent…

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 MI00146878 and MI00146890. Based on interview, and record review, the facility failed to ensure physican was timely provided notification off an abnormal blood sugar (glucose) for one resident (R901) of three reviewed for a change in condition. Findings include: A physician order documented, sliding scale insulin order for humalog revised 01/28/24 revealed 401 to 450 give 12 units, greater than 450 call doctor for further coverage orders . The blood glucose results documented for 09/09/24 revealed: - a blood glucose of 450 documented at 9:56 AM, - a blood glucose of 550 documented at 11:57 AM and, - a blood glucose of 550 documented at 3:53 PM. All documented by Licensed Practical Nurse (LPN) A. Further review of the record revealed no notification to the physician for the abnormal 450 blood glucose levels at 9:56 AM and 11:57 AM. A progress note dated 9/9/24, by Licensed Practical Nurse (LPN) A at 16:01 (4:01 PM after third high blood glucose reading): Alert Note Text: 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 This citation petains to Intakes MI00145830 and MI00146169. Based on observation, interview, and record review, the facility failed to implement a plan of care for two residents (R700 and 701) of out of two residents reviewed for quality or care care plans. Findings include: R700 On 08/13/24 at 10:00 AM, R700 was observed sitting up in electric chair listening to music on their head phones. R700 discussed concerns about care of their (indwelling tube inserted into the bladder to drain urine) catheter. A review of R700's medical record revealed they were admitted into the facility on 7/01/24 with diagnoses of Paraplegia; Opioid Independence; Major depressive disorder; and Anxiety disorder. A review of R700's Minimum Data Set (MDS) assessment dated [DATE] revealed, R700's Brief Interview for Mental Status assessment score was a 15 indicating intact cognition. Further review of R700's medical record revealed no care plan with goals or interventions for the care of the catheter. R701 On 08/13/24 at 11:30, R701 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.

This citation pertains to Intake MI00145065. Based on observation and interview the facility failed to provide a safe and functional environment for the facilities census of 133 residents. Findings include: On 7/03/24 at 10:20 AM, the floor tile in the basement were observed to be broken and missing in multiple areas of the basement. On 7/03/24 at 10:30 AM, the Maintenance/Housekeeping/Laundry Director was asked about the basement floor and stated, They are asbestos, corporate knows and we are to not touch it. On 7/03/24 at 11:36 AM, during another observation in the basement the Maintenance/Housekeeping/Laundry Director was asked about the asbestos tile and now stated, I'm not sure if it's asbestos. The Director was asked about the statement prior that it was asbestos and he said that because of how the tile looked and the size of them. The Director was asked if the tile problem was reported to corporate. The Director reported, They don't know, I will tell them today. On 7/03/24 at 1:27 PM, the Nursing Home Administrator (NHA) was asked about the basement floor tile being asbestos.…

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 MI00145065. Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, homelike environment for one (R803) of five residents reviewed for homelike environment. Findings include: On 7/3/24 at 10:15 AM, R803 was observed lying in bed and was asked about their stay at the facility and stated, Yesterday was the first time I got a shower at this new room. I have not had the bed linen changed since getting to this room. R803's was observed with a gown on that material had been worn that cause the gown to be see through. R803 pillowcase was observed stained with a yellow ring around it. R803 reported the facility had a lack of linen. During this same time, observation of R803's bathroom revealed, the toilet was observed with water that dripped to the floor. The floor was observed with black and gray substance that appeared to be mold along the crease of the wall. The bathroom vent was observed with a thick layer of a buildup of dust and debris. On 7/03/24 at 9:15 AM and 10:00 AM, the two linen closets 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.

Based on interview and record review, the facility failed to develop and maintain a QAPI ( Quality Assurance and Process Improvement) program, resulting in the lack of the facility's ability to identify areas needing improvement and enacting a process for correction of those issues, potentially affecting all 136 residents' quality of life. Findings include: During an interview on 03/28/24 at 12:07 PM with the Nursing Home Administrator (NHA), a request was made to review the facility's QAPI Program Plan for the past 6 months. The NHA stated, I have not been able to locate QAPI notes nor information since the last QAPI meeting on 9/25/23. I have only been administrator for two weeks at this facility. Review of the policy titled QAPI Data Colllection Systems revise date 3/24 revealed: It is the policy of this facility to systematically collect data as part of the Quality Assurance Performance Improvement (QAPI) program to ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standards of practice.

Based on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Program that identified, developed, and implemented appropriate plans of action to correct quality deficiencies, which has the potential to affect all 136 residents in the facility. On 3/28/24 at 12:07 PM a meeting was held with the Nursing Home Administrator. When asked about identified plans, concerns or brought to QAPI. The NHA revealed that he was a recent hire two weeks ago and the last QAPI meeting was 9/25/23. When asked about his expectation for QAPI, NHA stated, My expectation are that a full QAPI meeting should be held at least quarterly and monthly monitoring of care concerns and system deficiencies. Review of the policy titled QAPI Data Colllection Systems revise date 3/24 revealed: It is the policy of this facility to systematically collect data as part of the Quality Assurance Performance Improvement (QAPI) program to ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standards of practice.

Based on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. This deficient practice resulted in the potential for ineffective coordination of facility issues and concerns affecting all 136 residents i the facility. On 3/28/24 at 12:07 PM a meeting was held with the Nursing Home Administrator. When asked about the the meeting minutes and sign in sheets for the QAPI meeting. The NHA stated,The last QAPI meeting was 9/25/23. I have not been able to find any sign sheets or minutes since then. When asked about the expectation for the QAPI committe, NHA stated, My expectation are that a full QAPI meeting should be held at least quarterly and monthly monitoring of care concerns and system deficiencies. Review of the policy titled QAPI Data Colllection Systems with the revision date of 3/24 revealed: It is the policy of this facility to systematically collect data as part of the Quality Assurance Performance Improvement (QAPI) program to ensure the 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.

Based on interview and Record review, the facility failed to implement and operationalize an Antibiotic Stewardship Program and failed to ensure accurate monitoring and documentation of antibiotic use resulting in the potential for inappropriate antibiotic utilization and worsening or non-improving infections for all 134 facility residents. Findings Include: On 3/28/2024 at 12:00PM, the Infection Control task was completed with the Director of Nursing (DON). The DON stated that they were acting as the Infection Control (IC) nurse at the time. The DON was asked to provide the antibiotic monitoring and line listing starting from January, February and March 2024. The DON stated that they had not been monitoring antibiotic use for the 2024 year. The DON was asked how the facility is ensuring that antibiotics are being prescribed correctly and there are no adverse effects. The DON stated that it is being managed by the physicians at this time, but the antibiotic stewardship program was not being utilized at the time. A review of a facility policy titled, Infection Prevention and Control…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP-individual who is responsible for assessing, developing, implementing, monitoring, and managing the Infection Prevention and Control Program) completed specialized training in infection prevention and control. Findings Include: On 3/28/2024 at 12:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they were also acting as the IP in the facility. The DON stated they had been in the role for a couple months due to some company changes. The DON stated they had started the Centers for Disease Control and Prevention (CDC) course for infection control, however had not completed it yet. The DON stated they did not have a corporate IP and they had no other training related to IP. A review of a facility policy titled, Infection Prevention and Control Program noted the following, .a. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies…

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 MI00143093. Based on observation, interview, and record review the facility failed to ensure that towels and wash clothes were available for seven confidential group residents of seven residents reviewed for homelike environment, resulting in resident dissatisfaction. Findings include: On 3/27/24 at 10:00 AM, a confidential group meeting was held with seven confidential group residents and the group was asked about their overall level of satisfaction with the care and services at the facility. All seven group members expressed dissatisfaction with the amount of towels and wash clothes they were provided. The group indicated that the facility runs out of towels and wash clothes on the units approximately, Two times a week. On 3/28/24 at 1:28 PM, An observation of the 100 unit linen closet revealed no towels or wash clothes observed in the closet. On 3/28/24 at 1:30 PM, An observation of the 200 unit linen closet revealed no towels or wash clothes observed in the closet. On 3/28/24 at 1:32 PM, an interview was conducted with 200 unit Certified 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 Intakes MI00142583 and MI00142441. Based on interview and record review, the facility failed to protect resident funds for seven residents (R8, R15, R34, R75, R84, R92, and R108) of seven residents reviewed for misappropriation of funds. Findings include: In a complaint, as well as, a facility reported incident (FRI) reported to the State Agency indicated; An audit of the facility's trust fund accounts revealed missing funds. R84 On 03/27/24 at 8:55 AM, R84 was interviewed in their room regarding the alleged misappropriation of funds that was noted in their complaint to the State agency. R84 stated Usually I get my social security check to sign around the second or third day of the month and when it got to be about the 10th of the month (January 2024) and I hadn't seen it. I asked the Business Office Manager (BOM) M (who was covering at the time for BOM N) about my check. (BOM M) came back to me and said they had called Social Security and they were waiting to hear back. I didn't hear…

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 pass and date water for five residents (R7, R11, R16, R84, and R287) of five residents reviewed for hydration. Findings Include: R7 On 3/26/2024 at 2:09 PM, R7 was observed in bed. No water was observed at the bedside. R11 On 3/26/2024 at 11:40 AM, R11 was observed sitting in their room. R11 had no ice or ice water. R11 stated that they never get ice for their pop they have in the room. R11 stated that there is only one ice machine for the whole building and its runs out of ice often. R11 stated that this has been going on for about six months. R16 On 3/26/2024 at 2:02 PM, R16 was observed in the bed. R16 stated that they wanted some ice water. R16 activated their light and told their certified nursing assistant (CNA) that they wanted some water. CNA Q stated that they were waiting for a meeting to conclude in the dining room where the ice machine was and then they could get them some ice water. CNA Q stated that there was only one working ice machine and that if often runs out of ice. R287 On 3/26/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document the education regarding benefits and offering of immunizations (influenza vaccine) for four residents (R287, R91, R84 and R5) of five sampled residents reviewed for immunizations. Findings Include: R287 Review of the medical record revealed that R287 admitted into the facility on [DATE]. During the Infection Control task, the consent or declination related to the influenza vaccine was requested. The facility staff provided a declination dated for 9/22/2022. No further information was provided related to the current influenza season. R91 Review of the medical record revealed that 91 admitted into the facility on [DATE]. During the Infection Control task, the consent or declination related to the influenza vaccine was requested. Provided was a consent dated 9/21/2022. No further information was provided related to the current influenza season. R84 Review of the medical record revealed that R84 admitted into the facility on 5/13/2020. During the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer or document the COVID-19 vaccination to three residents (R287, R91, and R84) out of five reviewed for immunizations and one employee (Licensed Practical Nurse-LPN E) of five employees reviewed for COVID vaccines. Findings include: R287 Review of the medical record revealed that R287 admitted into the facility on [DATE]. During the Infection Control task, the consent or declination related to the COVID-19 vaccine was requested. Provided was a form with the following question, .3. Do you want to receive the COVID-19 Vaccine or Booster (Available per CDC (Center for Disease Control) Guidelines)? Yes or No The area was blank with no response recorded. No further information was provided related to the Covid-19 vaccine. R91 Review of the medical record revealed that 91 admitted into the facility on [DATE]. During the Infection Control task, the consent or declination related to the COVID-19 vaccine was requested. Provided was a form with the following…

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 maintain catheter bag privacy for one (R103) of six residents reviewed for privacy. Findings include: Review of the facility record for R103 revealed an admission date of 12/11/21 with diagnoses that included Dementia, Pulmonary Edema/Hypertension, and Kidney Failure. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 9/15 indicating moderate cognitive impairment. On 03/26/24 at 9:05 AM and 10:08 AM, R103's room door was open and their catheter bag was observed hanging on the side of the bed facing the doorway clearly visible from the hallway. The catheter bag was clear and was not in a privacy bag and staw colored urine was visible in the bag. On 03/26/24 at 10:39 AM, R103's catheter bag remained clearly visible from the hallway, uncovered and containing urine. An interview was attempted as R103 appeared alert and was making eye contact however they were unresponsive to verbal…

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 MI00143520. Based on observation, interview, and record review, the facility failed to ensure that the call light was within reach for one resident (R287) out of two reviewed for call lights. Findings Include: On 3/26/2024 at 9:29 AM, R287 was observed laying in their bed. R287 stated that they were doing okay. R287 call light was noted to be behind them on their nightstand. R287 was asked to try and reach their call light. R287 stated that they were unable to reach their call light. R287 was asked if this happens often and R287 stated that it does. On 3/26/2024 at 10:03 AM, 10:58 AM, and 1:58 AM, R287's call light was observed on the nightstand and still out of reach. On 3/27/2024 at 8:47 AM and 9:14 AM, R287's call light was observed on the nightstand and still out of reach. A review of the medical record revealed that R287 admitted into the facility on [DATE] with the following diagnoses, Metabolic Encephalopathy and Muscle Wasting and Atrophy. A review of the Minimum Data Set…

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 MI00143093. Based on interview and record, the facility failed to report an employee to resident incident of alleged abuse for one resident (R8) of seven residents reviewed for abuse. Findings include: On 3/26/24 at 1:08 PM, during an initial tour of the facility R8 was interviewed about their satisfaction with the care and services that they were receiving at the facility. R8 indicated that Licensed Practical Nurse (LPN) T had twisted her arm. R8 was asked when this had occurred and R8 stated, One or two months ago. R8 was asked if they reported it to anyone at the facility saying, Yes I reported it to (previous Nursing Home Administrator (NHA). R8 stated, Thank you for looking into this. R8's electronic medical record (EMR) was reviewed and revealed that R8 was originally admitted to the facility on [DATE] with diagnoses that included Multiple sclerosis (Autoimmune disease), Bipolar disorder, and Schizoaffective disorder. R8's most recent minimum data set assessment (MDS) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate and protect a resident after an allegation of abuse for one resident (R8) of seven residents reviewed for abuse. Findings include: On 3/26/24 at 1:08 PM, during a tour of the facility R8 was interviewed about their satisfaction with the care and services that they were receiving at the facility. R8 indicated that Licensed Practical Nurse (LPN) T had twisted her arm. R8 was asked when this had occurred and R8 stated, One or two months ago. R8 was asked if they reported it to anyone at the facility saying, Yes I reported it to (previous Nursing Home Administrator -NHA). R8 stated, Thank you for looking into this. R8's electronic medical record (EMR) was reviewed and revealed that R8 was originally admitted to the facility on [DATE] with diagnoses that included Multiple sclerosis (Autoimmune disease), Bipolar disorder, and Schizoaffective disorder. R8's most recent minimum data set assessment (MDS) dated [DATE] revealed that R8 had an intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an update for a preadmission screening (PAS) and resident review (ARR) /Hospital Exempted Discharge for a Level II evaluation was completed for three residents (R12, R65 and R121) of four residents reviewed for PASARR, resulting in the potential for unmet mental health services. Findings include: R12 On 3/26/24 at 9:50 AM, R12 was observed sitting in room watching television. R12 appeared very anxious about not going back home and staying at facility. On 3/27/24 at 1:00 PM, R12 was observed going to dining room and speaking with other residents. A review of R12's medical record revealed the last 3877 was completed on12/20/22 and last level II 2/23/23. A review of the medical record revealed that R12 admitted into the facility on 5/02/19 with the following diagnoses of Major Depressive disorder, Psychosis, Schizophrenia and Adjustment Disorder. A review of the most recent Minimum Data Set assessment dated [DATE] was completed with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one (R103) of four residents reviewed for care plans. Findings include: R103 Review of the facility record for R103 revealed an admission date of 12/11/21 with diagnoses that included Dementia, Pulmonary Edema/Hypertension, and Kidney Failure. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 9/15 indicating moderate cognitive impairment. On 03/28/24 at 3:20 PM, during review of R103's facility record pertaining to their catheter care, it was noted that no care plan was identified that addressed R103's catheter as well as no physician order pertaining to the catheter or related care. On 03/28/24 at 3:41 PM, the facility Director of Nursing (DON) reviewed R103's electronic medical record and acknowledged that there was no care plan or physician order pertaining to R103's catheter. The DON reported the expectation is that any resident with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00143520. Based on observation, interview, and record review, the facility failed to update the fall care plan following a fall for one resident (R15) of two residents reviewed for care plans. Findings include: On 3/26/2024 at 9:29 AM, R287 was observed laying in bed. R287 stated that they had a fall not too long ago and had gone to the hospital. R287 stated that they did not remember how they fell, they just remember being dizzy. A review of the medical record revealed that R287 admitted into the facility on [DATE] with the following diagnoses, Metabolic Encephalopathy and Muscle Wasting and Atrophy. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R287 also required assistance with bed mobility and transfers. A review of the Incident and Accident (I/A) report dated for 3/16/2024 noted the following, Nursing Description: Pt. (Patient) found on floor beside bed. C/O (complained of) hitting…

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 MI00143520. This citation has two deficient practice statements. Deficient Practice Statement #1. Based on interview and record review, the facility failed to implement pre-surgery orders for one resident (R287) out of one reviewed for care and services, resulting in the R287 missing their surgery. Findings include: A review of Intake Called inot the State Agency noted the following, .(R287) is scheduled to have surgery on Tuesday 3/26/2024 and the (surgery) facility has been trying to contact (nursing home) to provide instructions on when to stop medications and confirm transportation and has not been able to make contact. A review of the medical record revealed that R287 admitted into the facility on [DATE] with the following diagnoses, Metabolic Encephalopathy and Muscle Wasting and Atrophy. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R287 also required assistance with bed mobility and…

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

Based on interview and record review, the facility failed to document Nurse Aide Registry Verification for three Certified Nursing Assistants (CNA's J, I, F) of three CNAs reviewed for verification of ability to provide resident assistance. Findings include: On 3/28/2024 at 1:40 PM, the survey team was provided with the personnel files of three certified nursing assistants CNAs J, I, and F. Review of the files failed to reveal Nurse Aide Registry Verifications for all three CNAs. On 3/28/2024 at 5:00 PM, an interview with the Director of Nursing (DON) revealed that no other records were available at the time of the interview. When queried regarding the expectation for file documentation, the DON indicated that the file should be complete including the Nurse Aide Registry Verification. No further records were provided by the facility at the time of exit.

Based on observation and interview, the facility failed to label and date when opened eye medication for two residents (R71 and R98) in two of four medication carts. Findings include: On 3/27/2024 at 1:30 PM, the medication cart located on the 200 Hall revealed two eye medications that were opened and not dated for R98. Two additional eye medications were opened and not labeled for another unknown resident. On 3/27/2024 at 1:40 PM, the second medication cart, located on the 200 Hall revealed two eye medications for R71 without an open date and three eye medications that expired on the following dates, 1/4/2024, 1/25/2024, and 2/4/2024. On 3/28/24 at 2:00 PM an interview with the Director of Nursing (DON) revealed that expired medications should not be in the medication cart and that all medications for multi-use should have an open date and labeled with resident identification. On 3/27/24 at 10:40 AM, the facility policy for the labeling and storage of medication was requested from the facility however, it was not received by the end of survey.

This citation has two deficient practice statements. Deficient Practice Statement #1. Based on observation, interview, and record review, the facility failed to date and label a tube feeding bottle for one resident (R130) out of one reviewed for tube feeding. Findings Include: On 3/26/2024 at 9:15 AM, R130 was observed in the bed. It was noted that they had their tube feeding connected and running. The tube feeding bottle and water were noted to not have a label or date. On 3/26/2024 at 9:19 AM, Licensed Practical Nurse (LPN) E was shown the tube feeding bottle and water. LPN E was queried as to when the bottle was hung. LPN E stated that they were unable to know for sure, but it goes up on the evening shift at 6:00 PM and comes down at 1260CC. LPN E was observed dating the bottle and the water. On 3/28/2024 at 12:00 PM, an interview was conducted with the Director of Nursing (DON). The DON was interviewed regarding the tube feeding not being labeled and dated. The DON stated that the bottle should be labeled and that when it was not, a new bottle should have been put up. Further…

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 MI00142424. Based on interview and record review, the facility failed to maintain complete and accurate medical record for six residents (R237, R54, R90, R107, R108, and R37) of seven records reviewed for complete medical records. Findings include: R237 Review of the March 2024 Medication Administrated Record (MAR) revealed, Nurse H on December 23, 2023, day shift, documented giving R237, 13 medications while the resident was on a Leave of Absence (LOA) from the facility. Review of the medical record progress notes for R237 dated 12/23/2023 at 2:36 AM revealed, Resident on LOA with daughter until 12/24/2023. A subsequent note dated 12/24/2023 at 8:07 PM revealed Received resident back into facility. On 3/26/2024 at 11:00 AM and again at 3:00 PM it was noted that the shower room was filled with equipment near front and door to the room. Upon reviewing the medical record, showers were not documented for seven (R237, R54, R90, R107, R108, R69, and R37) of seven residents for at least 14 days. On 3/28/2024 at 12:00 AM, the shower sheets were requested.…

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: MI00142002. Based on interview and record review the facility failed to update a care plan following a fall for one resident (R909) of one resident reviewed for care plan interventions. Findings include: A review of R909's medical record revealed that they were admitted into the facility on 7/14/23 with diagnoses that include Dementia, Heart Disease, Depression, and Anxiety. R909 was discharged from the facility on 1/5/24. Further review revealed that the resident was severely cognitively intact, and required one person assistance for Activities of Daily Living. Further review of R909's medical record revealed the following fall care plan, I am at an increased risk for falls r/t (related to) blindness to Left Eye/dementia. Date Initiated: 07/15/2023. Interventions: -Assist and stay with me while I am in the bathroom Date Initiated: 07/15/2023 -Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Date Initiated: 07/15/2023 -Ensure that I am wearing non-skid…

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: MI00142002. Based on interview, and record review, the facility failed to complete skin observations weekly for one sampled residents (R909) of one reviewed for skin management. Findings include: A review of R909's medical record revealed that they were admitted into the facility on 7/14/23 with diagnoses that include Dementia, Heart Disease, Depression, and Anxiety. R909 was discharged from the facility on 1/5/24. Further review revealed that the resident was severely cognitively impaired, and required one person assistance for Activities of Daily Living. Further review of R909's medical record revealed the following care plan: Focus: I am at risk for impaired skin integrity r/t (related to) poor safety awareness, risk for moisture d/t (due to) incontinence, dementia, violent behavior. Date Initiated: 08/29/2023 .Interventions: Inspect skin daily with care - Report any concerns to nurse. Date Initiated: 08/29/2023 .Licensed Nurse skin assessment per protocol. Date Initiated: 08/29/2023 . Further review of R909's Weekly Skin Sweeps revealed that 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 Intake: MI00142002. Based on interview and record review, the facility failed to include a 14-day stop date on an as needed (PRN) anti-anxiety medication for one resident (R909) of one reviewed for unnecessary medications. Findings include: A review of Intake MI00142002 called into the State Agency revealed the following, I begin complaining on Thanksgiving Day that [R909] was being over medicated because [R909] came and slept for 12 hours straight and [R909] was in such a deep sleep we could not wake [them], [R909] did not eat dinner or engage . A review of R909's medical record revealed that they were admitted into the facility on 7/14/23 with diagnoses that include Dementia, Heart Disease, Depression, and Anxiety. R909 was discharged from the facility on 1/5/24. Further review revealed that the resident was severely cognitively impaired, and required one person assistance for Activities of Daily Living. Further review of the medical record revealed the following physician orders: Lorazepam Oral Tablet 0.5 MG (milligrams, Lorazepam). Give 1 tablet by…

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 Deficient Practice Statement #1 This citation pertains to Intake M100141178. Based on interview and record review, the facility failed to prevent the verbal abuse by a staff member of one (R903) of six residents reviewed for abuse. Findings include: Review of the facility record for R903 revealed an admission date of 12/08/21 with diagnoses that included Chronic Obstructive Pulmonary Disease, Emphysema and Depression. The Minimum Data Set (MDS) assessment dated [DATE] indicated R903 required supervision to moderate assistance for activities of daily living (ADLs). The Brief Interview for Mental Status (BIMS) assessment score of 15/15 indicated intact cognition. On 01/09/24 at 11:55 AM during an interview, R903 reported that they did recall an incident involving a Certified Nurse Assistant (CNA) named [CNA D]. R903 reported that they have difficulty getting their medication at times and they were having a verbal altercation with CNA D about their medication during which CNA D called them a bitch. R903 admitted…

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 M100141170. Based on observation, interview and record review, the facility failed to respond to door alarms in a manner timely to prevent the elopement for one (R902) out of three residents reviewed for elopement. Findings include: Review of the facility record for R902 revealed an admission date of 05/20/15 with diagnoses that included Cerebral Infarction with Right Hemiplegia and Expressive Aphasia, Schizophrenia and Bipolar Disorder. The Minimum Data Set (MDS) assessment dated [DATE] indicated that R902 was not functionally ambulatory and required supervision for self-propelling their wheelchair up to 50 feet with two turns. The Brief Interview for Mental Status (BIMS) assessment dated [DATE] was scored 14/15 indicating intact cognition. On 01/09/24 at 12:55 PM, Licensed Practical Nurse (LPN) A, who was identified as the first staff to respond to the main entrance door alarm after R902 exited the building, was interviewed via phone call. LPN A reported that they recalled 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 M100141302. Based on interview and record review, the facility failed to provide routine dental services for one (R909) of three residents reviewed. Findings include: Review of the facility record for R909 revealed an admission date of 05/20/15 with current primary diagnoses that included Rhabdomyolysis, Dementia, Schizophrenia and Metabolic Encephalopathy. The Minimum Data Set (MDS) assessment dated [DATE] indicated R909 required set up to moderate assistance with activities of daily living (ADLs). The Brief Interview of Mental Status (BIMS) assessment score of 10/15 indicated moderate cognitive impairment. On 01/09/24 at 10:55 AM, the complainant was interviewed via phone call and reiterated that R909 had recently received assessment for their dental needs due to the complainant's persistent requests but that R909 had not received any routine dental exam or service in approximately four years prior to the recent assessment. They reported that R909 complained of painful and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake: MI00134945. Based on observation, interview, and record review, the facility failed to protect a resident from inappropriate sexual advances for one sampled resident (R901) of three reviewed for abuse, resulting in R901 experiencing inappropriate sexual touching and advances, and the potential for decreased psychosocial well-being. Findings include: A review of Intake MI00134945 revealed the following, Incident Summary: Residents were sitting in dining room. Employee noted that [R902] placed hand in [R901's] pants. Employee intervened and removed [R901] from the dining room . On 9/19/23 at 2:45 PM, R901 was observed lying in bed. Attempts to interview them were to no avail as they refused to speak to surveyor. A review of R901's medical record was reviewed, and revealed that R901 was admitted into the facility on [DATE] with diagnoses that included Dementia, Dysphagia, and Muscle Weakness. Further review revealed a quarterly Minimum Data Set (MDS) assessment dated for 12/13/22…

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 unrestricted, 24-hour visitation for all 146 residents residing in the facility resulting in residents verbalizations of not being able to visit with family, anger, and sadness. Findings include: On 12/15/2022 at 8:45 am, during the initial entry of the facility, signage was posted at the receptionist desk noting the following: May 3, 2022 Attention Families, Guardians and Responsible Parties: ALL visitations are during the times of 12:30 PM-6:00 PM. Each visitor must be out of the building by 6:45PM .There will only be TWO (2) visitors allowed per visitation time and children under [AGE] years of age are not allowed. On 12/20/2022 at 10:25 AM, the resident council was held. Resident (R)130 said, We can only have visitors during 12:30 PM and 6 PM .That makes me so mad because my people work and can't come at that time . R115 said, I'm mad too because my son is six years old and is not allowed in the building .I'm so upset. R43 said,…

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 the resident right to privately and confidentially packages potentially affecting all 146 Residents who reside in the facility, resulting in resident mail and packages being opened by the facility prior to delivery to the resident, and a loss of personal privacy, anger, and independence. Findings include: On 12/15/2022 at 8:45 am, during the initial entry of the facility, signage was posted at the receptionist desk noting the following: May 3, 2022 Attention Families, Guardians and Responsible Parties: ALL visitations are during the times of 12:30 PM-6:00 PM. Each visitor must be out of the building by 6:45 PM .All packages must be inspected prior to resident receiving any items to ensure the items are allowed in the facility . On 12/20/2022 at 10:25 AM, the resident council was held. Resident (R)115 said, I'm mad because (Business Office Coordinator R) opened my social security check .(they) said I need to put it into their bank here, but I have my own bank account .they open our packages too . 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 failed to ensure food items were labeled, dated, and properly store personal items, resulting in the increased potential for foodborne illnesses. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 12/15/2022 at 9:07 AM, an initial tour of the kitchen was conducted. In the food preparation area, the following seasonings and condiment were opened and undated: chopped chives, poultry seasoning, and mustard. In addition, a half loaf of bread was observed opened undated. On 12/15/2022 at 9:30 AM, At least three staff coats were observed hanging on food racks next to food in the storage room. The Director of Nutrition Services was interviewed and asked about the opened and undated seasonings and mustard they said, I will make sure they (seasonings and condiment) are dated .they do not have space in the employee lounge for their coats. A review of the facility's policy Food Storage dated 05/25/07 and revised on 01/2021 noted 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 documentation of at least quarterly meetings held by the Quality assessment and assurance (QAA) committee, affecting all residents residing in the facility, and resulting in the potential for unidentified quality deficiencies with a lack of response and corrective action. Findings include: On 12/21/22 at 11:00 AM, review of the Quality Assurance Performance Improvement (QAPI) task was conducted with the facility's current Nursing Home Administrator (NHA). The NHA indicated she had only been at the facility since September 2022. When asked to review the sign-in sheets for the QAA committee meetings since the last recertification survey (5/5/2021), the NHA stated, The sign-in sheets aren't together. The NHA indicated there have been QAA committee meetings since the last recertification survey, but that she was unable to establish when they were held due to lack of documentation. The facility was afforded multiple opportunities prior to exit to present proof of at least quarterly QAA committee meetings, however,…

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

This citation pertains to Intakes: MI00133281 and MI00133076. Based on observation, interview, and record review the facility failed to prevent staff to resident verbal abuse for one sampled resident (R132), of 11 residents reviewed for abuse resulting in, the potential for emotional distress. Findings include: A review of a complaint to the State Agency revealed the following, .On 12/3/22 the writer received a report from a nurse regarding an incident involving [R132] and a CNA (certified nursing assistant). Per the report [R132] was involved in a verbal altercation with [the] CNA. During the altercation the CNA stated, 'That's why your roommate was about to beat your [expletive] . On 12/15/22 at 11:35 AM, R132 was interviewed regarding the incident related to the verbal altercation with the CNA, CNA H. R132 explained that CNA H came into their room to provide incontinence care. R132 explained that they advised CNA H that they prefer that only women provide care to them. R132 explained that a woman CNA did come to their room however, CNA H came back into the room with them. R132…

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 MI00133052. Based on interview and record review, the facility failed to report an allegation of physical abuse to the state agency for one resident (R4) out of two reviewed for abuse, resulting in the delayed reporting and investigation of abuse allegations. Findings Include: A review of complaint called into the State Agency noted the following, When (R4) is out [their] room too long, a staff member will grab [them] by the arm . A review of R4's progress notes revealed the following, 12/8/2022 at 8:26 PM, Behavior Note: Please describe behavior that was observed and was it distressing to the resident: Every time I give patient inhaler [they] want to struggle to get the inhaler, [R4] said that I hit [them]. I did not hit [R4]. [R4] did swing on me and missed. 12/10/2022 at 5:46 PM, Behavior Note: Please describe behavior that was observed and was it distressing to the resident: [R4] has been saying that I hit [them] across the left side of [their] forehead. [R4] said that they are going to get me fired. [R4's] previous roommate (sic) said 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.

Based on interview and record review, the facility failed to ensure a Level II evaluation was completed for one resident (R40) out of two reviewed for Preadmission Screening and Resident Review (PASARR Screening), resulting in the potential for unmet mental health and psychiatric care needs. Findings Include: A review of R40's PASARR Level I screening dated 12/29/2021 was completed and revealed that Section II, numbers 1,2,3, and 4 were checked and noted the following, Yes with the diagnosis of Mental Illness checked and included a diagnosis of Mood Disorder with mixed features. R40 was also taking antipsychotics at the time. On 12/20/2022 at 9:06 AM, a request was made to for R40's Level II Screening. A reply via email was received stating that R40 did not need a Level II Screening. On 12/20/2022 at 12:32 PM, an interview was completed with the Social Service Tech (SST) V regarding why R40 did not need a Level II screening and if their Level I screening was ever sent to Omnibus Budget Reconciliation Act (OBRA) for an evaluation. SST V stated that they were unsure if it was ever…

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

Based on observation and interview, the facility failed to update a Preadmission Screening and Resident Review (PASARR screening) for on resident (R4) out of two reviewed for PASARR screenings, resulting in the potential for unmet mental health and psychiatric care needs. Findings Include: A review of R4's PASARR Level I screening dated 9/28/2022 was completed and revealed that Section II, numbers 1 and 2 on the form were checked Yes with the diagnosis of Mental Illness checked and included a diagnosis of Schizoaffective Disorder, Bipolar Type. R4 was also taking antipsychotics at the time. The note section of the form noted the following, Note: The person screened shall be determined to require a comprehensive Level II OBRA evaluation if any of the above items are Yes Unless a physician, nurse practitioner, or physician's assistant certifies on form DCH-3878 that the person meets at least on of the exemption criteria. Further review of the PASSAR Level I screening dated 9/28/2022 revealed a hospital exempted discharge were checked and noted the following, Yes, I certify the patient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to revise and update a care plan for one sampled resident (R132) of three residents reviewed for care plans, resulting in an inaccurate plan of care, and unmet care needs. Findings include: On 12/15/22 11:48 AM, an interview was completed with R132 regarding their splints not being worn, as they (the splints) were observed lying on a shelf above the bed. R132 explained that no one puts the splints on for them, and that their hands are feeling tight. R132 was also asked about the verbal altercation with the CNA, CNA H. R132 explained that CNA H came into their room to provide incontinence care. R132 explained that they advised CNA H that they prefer that only women provide care to them. R132 explained that a woman CNA did come to their room however, CNA H came back into the room with them. R132 explained that they asked CNA H if they were undercover a term implying that CNA H was gay (homosexual), and a verbal altercation ensued resulting in…

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 Practice Statements. Based on interview, and record review, the facility failed to provide showers to one resident (R134) out of two reviewed for showers, resulting in feelings of frustration and dissatisfaction with care, based on the reasonable person concept. Findings Include: A review of the medical record revealed that R134 admitted into the facility on 4/22/2022 with the following diagnoses, Cerebral Infarction, Metabolic Encephalopathy, Muscle Weakness, and Muscle Wasting and Atrophy. A review of the Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 9/15 indicating an impaired cognition. R134 also required total two-person dependence with bed mobility and transfers. A review of shower documentation for the last thirty revealed that R134 received only bed baths on the following days, 11/25/22,12/2/22,12/9/22,12/16/22, and 12/20/22. On 12/21/2022 at 1:39 PM, an interview was conducted with the Director of Nursing (DON) regarding when 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 observation, interview, and record review, the facility failed to arrange appointments for vision care for one sampled resident (R125) of one resident reviewed for vision concerns, resulting in inadequate accommodation of vision needs. Findings include: On 12/15/22 at 1:49 PM, R125 was observed in their room sitting on their bed. They were asked about their stay in the facility, and explained that they wore prescription glasses prior to their admission to the facility, and had yet to be seen by an eye doctor. A review of R125's medical record revealed that they were admitted into the facility on 2/17/22 with diagnoses that included Sarcopenia, Diabetes, and Depression. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and was independent for Activities of Daily Living (ADL's). Further review of R125's physician's orders revealed an order dated for 2/17/22 indicating 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 implement pressure ulcer interventions per the plan of care for two residents (R74 and R75) of four reviewed for pressure ulcers, resulting in the potential for worsening of existing pressure ulcers or the development of new wounds. Findings include: Resident #74 (R74) A review of R74's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was initially admitted into the facility on 8/15/22 and re-admitted on [DATE] with medical diagnoses of Diabetes, Hypertension, Neurogenic Bladder, Alzheimer's Disease, Seizure Disorder, Malnutrition, Gastrostomy Status, Psychotic Disorder, and Schizophrenia. Further review revealed that the resident is severely cognitively impaired and totally dependent on staff for all activities of daily living (ADLs). On 12/15/22 at 10:25 AM, R74 was observed lying in bed on their back. A tube feeding pole was next to the bed and the resident was observed to have a urinary catheter. R74 appeared…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to include the PTSD (post traumatic stress disorder) diagnosis and specific interventions in the active comprehensive care plan for one sampled resident (R133) of 31 sampled residents whose care plans were reviewed, resulting in the potential for re-traumatization. Findings include: On 12/15/22 at 10:02 AM, R133 was observed to be dressed and seated in the main dining room. R 133 was calm and answered yes no questions. R133 was asked about their time spent at the facility and expressed no concerns. A review of the facility record for R133 revealed R133 was admitted into the facility on [DATE]. Diagnoses included PTSD, Anxiety Disorder, Bipolar Disorder, Depression and Drug Abuse. The active care plan dated 04/03/22 documented I use anti-depressant medication related to depression .I use anti-anxiety medication due to anxiety disorder . The I use anti-psychotic medications related to Behavior management due to Schizoaffective, PTSD, Date…

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 a physician responded to pharmacist monthly medication regimen reviews (MRR) recommendations timely for one resident (R40) out of one reviewed for MMR's, resulting in the potential for the continuance of unnecessary medications and lack of communication of recommended medication changes. Findings Include: A review of pharmacy progress notes for the year of 2022 revealed, see report for any noted irregularities was checked for the following months, April, June, July, August. A request was made for the MRR irregularity reports for April, June, July, and August (2022). The MRR irregularity report was received for the months of April and July. No other MRR irregularity reports were received by the end of survey. On 12/20/2022 at 2:30 PM, an interview was conducted with the Director of Nursing (DON) regarding MRR's. The DON stated that they could not find the reports for June and August. No further information was provided. A review of a policy titled, Medication Monitoring noted the following, F. Resident-Specific…

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 date insulin pens and inhalers when opened and discard expired medication in three of four medications carts reviewed resulting in the potential for decreased efficacy of medications and the use of expired medications. Findings include: On 12/16/22 at 8:25 AM, the low one hundred unit medication cart had: three Novolog insulin pens, one Humalog insulin pen, and one Basalgar insulin pen, a Serevent diskus inhaler and two glucose strips containers not dated when opened. On 12/16/22 at 12:11 PM, the middle one hundred unit medication cart had an one lantus insulin pen, not dated when opened. A review of the package insert for the Serevent Diskus revealed it should be stored inside the unopened moisture-protective foil pouch and only removed from the pouch immediately before initial use. Discard Serevent Diskus 6 weeks after opening the foil pouch or when the counter reads 0 (after all blisters have been used), whichever comes first. The inhaler is not reusable. Do not attempt to take the inhaler apart. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to arrange appointments for dental care for one sampled resident (R125) of one resident reviewed for dental concerns, resulting in inadequate accommodation of vision needs. Findings include: On 12/15/22 at 1:49 PM, R125 was observed in their room sitting on their bed. They were asked about their stay in the facility, and explained that they hadn't seen a dentist since admission to the facility, and would like to have their teeth cleaned. A review of R125's medical record revealed that they were admitted into the facility on 2/17/22 with diagnoses that included Sarcopenia, Diabetes, and Depression. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and was independent for Activities of Daily Living (ADL's). Further review of R125's physician's orders revealed an order sated for 2/17/22 indicating the following,…

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 four (identified as Certified Nursing Assistant (CNA) W, X, Y, and Z out of five reviewed for required 12 hours of in-service training, resulting in the potential for unmet education needs, unmet resident care needs, and the potential for inadequate care. Findings Include: On 12/21/2022 at 8:00 AM, a request was made for the annual 12-hour training for CNA W, X, Y, and Z. On 12/21/2022 at 11:28 AM, an interview was conducted with the Director of Nursing (DON) regarding the annual 12-hour training. The DON stated that the website they use for the training has been down for the past two weeks, so they are unable to show that the education has been completed at this time. The DON stated that they had communication out to try and get the record of the education. No further information was provided prior to the end of survey.