The Orchards at Warren

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to document the physician's order, consent for use, risk versus benefits, attempted alternatives, and consistently monitor for the use of side rails for two residents (R50 and R89) of two residents reviewed for side rails. Findings include: R50 On 12/1/25 at 12:00 PM, R50 was observed sitting in their wheelchair. An observation of the resident's bed revealed two black side rails approximately 32 inches in length. R50 was asked about the rails and explained they like them there because they make them feel safe. A review of R50's medical record revealed they were admitted into the facility on [DATE] with diagnoses which include Cerebral Infarction, Acute Respiratory Failure with Hypoxia, and Heart Failure. Further review revealed the resident was cognitively intact and required 2-person assist for bed mobility, per their care plan. Further review of the care plan did not address the resident's side rails, and there were no physician orders 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 Based on interview and record review, the facility failed to ensure a prescribed medication (lacosamide-anticonvulsant medication) was available for administration for one resident (R1) of 24 whose medications were reviewed. Findings Include:A review of the record for R1 revealed R1 had an original admission date of 06/06/19 with a readmission on [DATE]. Diagnoses included Seizures, Epilepsy, and Stroke. A review of the active care plan documented, I have a seizure disorder related to Disease process Seizure, Date Initiated: 09/19/2022. Give me my medications as ordered. Observe me for effectiveness and side effects. Date Initiated: 09/19/2022.A review of the medication orders revealed, Lacosamide oral solution 100 mg (milligrams)/ 10 ml (milliliters) Give 20 ml two times a day related to Generalized Idiopathic Epilepsy and Epileptic Syndrome . A review of the December 2025 Medication Administration Record (MAR) revealed the Lacosamide was not documented as given twice daily on 12/01, 12/02, with the morning…

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 oral surgeon consultation was completed timely for one resident (R8) of three whose ancillary services were reviewed. Findings include: On 12/01/2025 at 10:18 AM, R8 was observed to be in their room lying in bed dressed in a hospital style gown. R8 was asked about mouth care and when asked if it was completed daily R8 showed their teeth and shook their head No. The middle upper teeth were missing or appeared broken. The front teeth on the lower jaw were more aligned but with a build of white debris in the spaces between the teeth. R8 shook their head yes when asked if they would like their teeth brushed more often. R8 was observed to have a hand contracture on the left and when asked if they could move their arms lifted them a few inches off the bed and was not able to move beyond that position. R8 reported they would allow staff to brush their teeth. R8 was receiving tube feeding and reported they also received a tray of food…

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 don appropriate personal protection equipment (PPE) when providing care for two residents (R1 and R8) of three observed for Enhanced Barrier Precautions (EBP - use of gloves and gowns for high-contact care activities). Findings include: On 12/02/2025 at 9:27 AM, a medication administration was observed with Licensed Practical Nurse (LPN) I for R1. The room of R1 had a sign on the door which indicated R1 was on Enhanced Barrier Precautions (EBP). LPN I entered the room and donned a pair of gloves. A gown was not worn. LPN I administered the medications separately, via a PEG (percutaneous endoscopic gastrostomy tube - tube inserted externally into the stomach for liquid nutrition). On 12/03/2025 at 8:10 AM, Certified Nursing Assistant (CNA) J was observed to enter the room of R8 with a clear plastic bag of wash towels. CNA J then exited the room. CNA J re-entered the room of R8 and closed the door. The sign on the door indicated both residents residing in the room were on EBP. R8 was observed to have tube…

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: MI00149450. Based on interview and record review, the facility failed to notify the resident's representative of a change in condition for one resident (R901) of one resident reviewed for a change in condition. Findings include: On 1/21/25 at 9:32 AM, Confidential Family Member A was interviewed regarding R901, and explained they were unaware that R901 was showing any signs of a change in condition until another family member went to visit the resident on 1/9/25, and noticed a change in their abilities. Family Member A explained they requested the resident be transferred to the hospital on that day, and was later informed R901's physician had ordered tests to be completed days before the transfer, but wasn't informed of this, as they would have liked to be a part of the decision-making regarding the care of their loved one. A review of R901's medical record revealed they were admitted into the facility on 2/5/24 with diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia, Diabetes, Dementia, and Heart Failure. Further review…

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

This citation pertains to Intake M100147854. Based on interview and record review, the facility failed to complete a comprehensive nutritional assessment in a timely manner for one (R801) of three residents reviewed who were admitted with nutrional at-risk indicators. Findings include: Review of the facility record for R801 revealed an admission date of 10/15/24 with diagnoses including Dysphagia (difficulty swallowing), Diabetes Mellitus, and Dementia. A transfer order from the hospital indicated the resident required a pureed diet. The resident's weights were documented on 10/15/24 (140 pounds) and 11/02/24 (131.7 pounds). R801's Care Plan indicated they required Extensive Assistance for eating. The Nurse Practitioner (NP) progress note dated 10/21/24 stated decreased oral intake, monitor for now. The Change of Condition note dated 11/08/24 indicated decreased appetite. Further review revealed no comprehensive nutritional assessment was completed by the Registered Dietician (RD). On 11/08/24 at 12:06 PM, RD A was interviewed by phone. RD A reviewed R801's record and confirmed 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 Based on observation, interview, and record review, the facility failed to serve food in a palatable manner and at the preferred temperature for one resident (R47) and ten confidential group residents of thirteen reviewed for food palatability, resulting in dissatisfaction during meals. Findings include: On 9/17/24 at 9:25 AM, R47 was met in their room for observation and interview. R47's breakfast was observed to consist of two biscuits, two pancakes, cereal, a small carton of milk, syrup and butter. The only protean observed with R47's breakfast was the carton of milk. R47 was interviewed about the food served to them at the facility and stated, The food is [swear word]. On 9/18/24 at 8:38 AM, a followup visit was conducted with R47 and they were asked how their breakfast was. R47 stated, It tasted like garbage, I had two hard boiled eggs, toast, and cereal. A review of R47's electronic medical record (EMR) revealed that R47 was most recently admitted to the facility on [DATE] with diagnoses that included…

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: MI00146189 Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by eliminating harborage conditions in the kitchen. This deficient practice has the potential to affect all residents in the facility. Findings include: 09/17/24 at 9:15 AM, there was standing, stagnant, slimy water observed on the floor, in the corner underneath the garbage grinder at the 3 compartment sink. In addition, there were cobwebs and numerous gnats observed in the same area. When queried, Dietary Manager (DM) A stated that the pipe for the garbage grinder was small and sometimes over-flows. DM A did not provide an explanation for why the standing water in the kitchen was not cleaned up, in order to prevent a breeding ground for gnats. On 9/17/24 at 9:20 AM, there was standing water on the floor between the coffee maker and the juice dispenser. There were gnats observed flying about in the same area. When queried, DM A was unsure where the water was coming from. Review of the pest control service reports for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident medications were not left at the bedside for four residents (R22, R44, R63 and R71) of four residents reviewed for medication storage. Findings include: R71 On 9/16/24 at 8:40 AM, R71 was observed lying in bed. An inhaler was observed lying on their bedside table. A review of R71's medical record revealed the resident was admitted into the facility on [DATE] with diagnoses included Chronic Obstructive Pulmonary Disease, Alcohol Abuse, and Adjustment Disorder. Further review revealed the resident was moderately cognitively impaired, and required limited assistance with Activities of Daily Living. On 9/17/24 at 12:55 PM, R71 was observed lying in bed awake, inhaler located on their bedside table. On 9/19/24 at 9:19 AM, R71 was observed lying in bed, inhaler lying on their bedside table. R71 was asked about the inhaler, and explained it's their Albuterol recuse inhaler. R71 was asked when was the last time they used it and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor a resident's request to be sent out for a higher level of care for one resident (R33) of one reviewed for self-determination. Findings include: On 9/18/24 at 8:47 AM, R33 was observed lying in bed, and asked to speak to the surveyor. R33 explained that their pain management has not been managed well, specifically with them not receiving their prescribed as needed medications timely. R33 further explained that they have a history of kidney stones, and felt as though they had one last week Wednesday, which was causing excruciating pain. R33 explained that as a result, they asked to speak to the Director of Nursing and their physician as they wanted to be transferred to the hospital. R33 further explained that they never spoke to the DON or the physician, but was told that the nurse spoke to the physician who did not order a transfer to the hospital, and that if they chose to transfer on their own they would have to sign themselves out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration when an extended-release medication was crushed for one Resident (R62) of six residents reviewed for medication administration. Findings include: On 9/18/24 at approximately 9:30 a.m., R62 was observed in their bed with fisted hands, wearing a hospital gown, with Licensed Practical Nurse (LPN) L present. When LPN L was leaving the room, R62 was heard to say they wanted their medications crushed. On 9/18/24 at approximately 9:32 a.m., LPN L started to crush R62's medications. LPN L was asked if R62 should have had their medications crushed, as this was not observed in the physician's orders. LPN L reported R62 sometimes liked their medications crushed and continued to crush R62's medications as follows: -Colace Oral Capsule, 100 mg (milligram). Give 1 capsule two times a day for constipation. -Loratadine Oral Tablet. 10 mg. Give 1 tablet by mouth one time a day for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an assistive communication device for one resident (R35) of five reviewed for communication, resulting in limited communication between R35 and staff. Findings include: On 9/17/24 at 10:30 AM, R35 was met in their room for observation and interview. R35 was unable to answer any questions asked. R35 gave a thumbs up, when asked if they were okay. On 9/18/24 at 9:03 AM, R35's Certified Nursing Assistant (CNA) B was interviewed and asked about how they communicated with R35. CNA B stated, [R35] gestures and gives a thumbs up. CNA B was asked if R35 had a communication board to assist with communication with staff. CNA B stated, No, not that I'm aware of. CNA B indicated it would be helpful for R35 to have a communication board. A review of R35's electronic medical record (EMR) revealed that R35 was most recently admitted to the facility on [DATE] with diagnoses that included Ceberal infraction (stroke) and Type 2 diabetes. R35's most…

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 broken glasses were addressed for one resident (R109) out of one resident reviewed for vision. Findings include: On 9/18/24 at 10:24 AM, R109 was observed in their room wearing glasses which were observed to be missing a section of the frame and the entire lens on the right side. The lens on the left side was observed to be dirty with many specks of unknown particles covering it and smeared with a greasy appearing substance. R109 was asked how long their glasses had been broken. R109 explained they had been broken for quite a while. R109 was asked if they were able to see. R109 stated, I can see but not very well. R109 was asked if the facility was helping them get new glasses. R109 stated no. they said I had to get them myself. A review of R109's medical record revealed they were admitted to the facility on [DATE] with the following diagnosis: Other sequelae of cerebral Infarction; Ataxia following Cerebral Infarction. 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 maintain a splinting program for one (R68) of five residents reviewed. Findings include: On 09/17/24 at 09:56 AM, R68 was asked about a hand splint that was observed laying on the heat register in their room. R68 reported the splint was for their left hand and stated They never put it on anymore. Review of the facility record for R68 revealed an admission date of 12/17/20 with diagnoses including Cerebral Infarction with Left Hemiplegia and Muscle Wasting and Atrophy. The record also indicated R68 required total assistance for dressing tasks. On 09/17/24 at 03:27 PM, R68 was observed laying in bed. The hand splint was observed laying on the heat register. Additional review of R68's record revealed the most recent Occupational Therapy (OT) evaluation dated 06/06/24 and Discharge summary dated [DATE] made no reference to a left hand splint or related interventions. An OT evaluation dated 06/01/21 did reference the left hand splint and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain a physician order for oxygen for one resident (R76) out of two residents reviewed for oxygen. Findings include: On 9/17/24 at 10:15 AM, 9/17/24 at 11:43 AM, 9/17/24 at 1:34 PM, 9/17/24 at 3:36 PM, 09/17/24 04:04, 9/18/24 at 8:46 AM, 9/18/24 at 11:56 AM, and 9/18/24 at 1:42 PM, R76 was observed lying in bed wearing oxygen at four liters per minute via nasal cannula. A review of R76's medical record revealed they were admitted to the facility on [DATE] with the following diagnosis: Cerebral Infarction due to Embolism of Right Cerebellar Artery; Chronic Obstructive Pulmonary Disease; Acute Respiratory Failure with Hypoxia. A review of R76's Brief Interview for Mental status revealed a score of 15 indicating intact cognition. A review of R76's care plan revealed the following: I have altered respiratory status/difficulty breathing in my respiratory status r/t (related to) COPD (chronic obstructive pulmonary disease) Acute respiratory…

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 MI00140309. Based on observation, interview, and record review the facility failed to ensure timely incontinence care was provided to a dependent resident (R902) of three reviewed for activities of daily living (ADLs), resulting in and the potential for the resident in a soiled brief for an extended period of time and or skin irritation. Findings include: On 01/17/24 at 7:39 AM, R902 was observed out in the hallway near the common area on the [NAME] unit. R902 was dressed and seated in a wheelchair. On 01/17/24 at 8:45 AM., 9:45 AM, 11:25 AM, 1:30 PM and at 3:20 PM, R902 was observed sitting up in wheelchair appropriately dressed at a table in the dining room. There was a grey and white toy cat placed on the table in front of R902 that occupied their attention. R902 was not interviewable due to their cognitive ability. At 1:30 PM, R902 was observed in the same spot and had recently finished eating as evident by the food crumbs on their clothing. On 01/17/24 at 8:45 AM., 9:45 AM.,…

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 MI00133113. Based on observation, interview and record review the facility failed to ensure appropriate and/or sufficient staff were available to meet the needs of the residents for 19 residents (R4, R24, R28, R46, R57, R60, R66, R78, R81, R87, R93, R103, R106, R11, R331, R39, R112, R86) of 32 reviewed resulting in unmet care needs. Findings include: R4 A review of the clinical record for R4 revealed R4 was admitted into the facility on [DATE]. Diagnoses included High Blood Pressure, Depression, Anxiety and Insomnia. The Minimum Data Set (MDS) assessment dated [DATE] documented moderately impaired cognition and the need for supervison for most Activities of Daily Living. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Trazodone (for sleep) and Norco (for pain control) were not documented as given. The assessments for pain, anti-depressant side effects, and the vital signs were also not documented as done. The…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: There was a dusty box fan blowing in the direction of the steam table during breakfast service. When queried about the dusty fan, Culinary Director A stated I just bought those. According to the 2017 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. There were 2 clean pitchers on drying rack, sitting upright with the lids on, observed with moisture inside with water pooling at the bottom of the pitchers. When queried, Culinary Director A confirmed the pitchers should be air dried in an inverted position. According to the 2017 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, (B) Clean equipment and utensils shall be stored as specified under (A) 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 observation, interview and record review the facility failed to ensure biologicals were dated when opened in four medication carts resulting in the potential for used of expired medication and decreased efficacy of medications. Findings include: On 08/01/23 at 8:55 AM, a check of the [NAME] one medication cart revealed a Trelegy Ellipta inhaler had not been dated when opened. The patient care information from the manufacturer's web site revealed, Safely throw away Trelegy Ellipta in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler . On 08/01/23 at 9:25 AM, a check of the [NAME] two medication cart revealed one insulin without a date when opened. On 08/01/23 at 2:25 PM, a chcek of the Lavender High medication cart revealed a Combivent inhaler that was undated when opened the manufacuter's insert indicated it was good for three months post after opening. On 08/02/23 at 8:07 AM, a check of the Lavender medication room revealed the tuberculin vial was not dated on vial when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to update a care plan following a change in code status for one resident (R64) of two residents reviewed for advanced directives, resulting the incorrect code status as an intervention. Findings include: A review of R64's medical record noted, progress note, [DATE] 13:07 Social service Quarterly Review: Social worker met with resident in a common area for [R64's] quarterly review. Resident was sitting in [R64's] wheelchair alert . Resident has a guardian who is responsible for [R64's] care decisions and requested for resident to remain a full code and long-term care . Care plan: Focus: CODE STATUS: My Guardian has reviewed my advanced directives with the social worker/physician and wishes for me to receive CPR (full code). My Guardian has consented for all other physician recommended medical or surgical treatments. Goal: My guardians wishes will be honored through the next review date. Interventions: Communicate any change of condition with me and my…

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 MI00132448, MI00137217, and MI00137909. Based on observation, interview and record review, the facility failed to provide timely incontinence care and/or bathing assistance for three resident (R46, R86, R101) of 24 residents reviewed for Activites of Daily Living (ADL) care resulting in resident feelings of poor hygiene, dissatisfaction with care and potential for compromised skin integrity. Findings include: R86 Review of the facility record for R86 revealed an admission date of 04/27/23 with diagnoses that included Acute Lower Extremity Deep Vein Thrombosis, Thrombocytopenia and Hematuria. The Minimum Data Set (MDS) assessment dated [DATE] indicated R86 required maximum assistance for bathing. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. On 07/31/23 at 8:44 AM, R86 reported I haven't had a shower in a week or two. I get a bed bath sometimes but not twice a week. Review of the R86's electronic medical record TASK completion checklist…

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 MI00132448. Based on interview and record review, the facility failed to ensure services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, resulting in the potential for inadequate coordination of care and negative clinical outcomes, affecting all residents currently residing in the facility. Findings include: On 8/2/23 at 2:55 PM, the Nursing Home Administrator (NHA) was asked about Registered Nurse (RN) coverage and stated, We have two, but had three until a couple of weeks ago. A review of staffing for Monday July 31st and Wednesday August 2nd, revealed, the facility did not have an RN that worked other than the Director of Nursing (DON). On 8/02/23 at 3:06 PM, the NHA was asked if the facility had any other RN's that was not the DON in the building that was a RN during the dates of 7/31/23 and 8/2/23. The NHA reported, No.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to consistently provide meals of a palatable taste and temperature for two (R86 and R33) of six residents reviewed for food satisfaction and nine of nine anonymous group members, resulting in resident dissatisfaction with the meal experience. Findings include: On 07/31/23 at 8:44 AM, R86 reported The food is lousy, it just isn't good and it's not hot enough. Review of the facility record for R86 revealed an admission date of 04/27/23 with diagnoses that included Acute Lower Extremity Deep Vein Thrombosis, Thrombocytopenia and Hematuria. The Minimum Data Set (MDS) assessment dated [DATE] indicated R86 required set up assistance for meals. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. On 08/01/23 at 9:11 AM, R86 reported their breakfast was lousy, I think it was something like biscuits and gravy, I'm not sure, but it was cold whatever it was. On 08/01/23 at 9:36 AM, review of Resident Council meeting…

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 MI00132448. Based on observation, interview, and record review the facility failed to ensure hand hygiene was completed, a glucometer (device used to check blood sugar levels), oxygen tubing, and tube feeding pole were cleaned after patient care was completed resulting on the potential for the spread of infection. Findings include: On 8/01/23 at 12:55 PM, staff were observed to assist two residents with feeding. At one point during the meal assistance the two staff members switched residents and were not observed to complete hand hygine. On 08/02/23 at 9:10 AM, Licensed Practical Nurse D was observed to prepare medication for room [ROOM NUMBER]. LPN D administered the medication to the resident and exited the room. LPN D then removed the glucometer from the medication cart and entered the room next door. A blood sugar check was completed and LPN D returned to the medication cart and placed the glucometer in the drawer. LPN D then began to prepare the next resident's medication.…

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