Regency at Waterford

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a splint/ positioning device (palm protectors) and range of motion were implemented for one (R49) of two residents with hand contractures (hardening of the muscles, tendons, and other soft tissues) reviewed for positioning and range of motion(ROM) resulting in the potential for contracture progression, pain, and further decline in range of motion with compromised skin integrity. Findings include: R49 Record review revealed R49 was a long-term resident of the facility. R49 was originally admitted to the facility on [DATE]. R49 was recently admitted to hospital on [DATE] with pneumonia and readmitted to the facility on [DATE]. R49's admitting diagnoses included chronic kidney disease, dysphagia (difficulty with swallowing), anemia, dementia, and heart failure. R49 also had a stage 3 pressure ulcer (Merck manual defines a stage 3 pressure ulcer as a full-thickness skin loss with damage to subcutaneous/fat tissue extending down to [but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to document resident falls in the clinical record, thoroughly investigate the root cause analysis of falls, and immediately implement appropriate interventions after falls for one resident (R63) of two residents reviewed for falls, resulting in the potential for additional avoidable falls. Findings include: On 5/20/25 at 11:36 AM, R63 was observed asleep and snoring in their dialysis chair at the nursing station. At that time, Certified Nurse Aide (CNA) 'AA' was asked why R63 was not taken back to their room to sleep in their chair and they said they kept them up at the nursing station because they were a fall risk. A review of R63's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: stroke, dysphagia, end stage renal disease with dependence on dialysis, atrial fibrillation, depression, diabetes, heart failure, adjustment disorder 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 ensure freedom from unnecessary antibiotic therapy for five residents, (R#'s 92, 16, 6, 20, and 91) of five residents reviewed for unnecessary antibiotic use, resulting in the potential for the development of antimicrobial resistance. Findings include: On 5/22/25 at 10:45 AM, a review of the facility's infection control program for the month of March was conducted and revealed the following: R92's facility acquired infection type on the line listing was documented as, Unknown. The line listing did not indicate any signs and symptoms for an infection or any lab results obtained and further documented they had been put on an antibiotic. A progress note in the record dated 3/20/25 read, .resident started on ABT (antibiotics) .no fever. continue having hematuria . R16's facility acquired infection on the monthly line listing documented they had a urinary tract infection. The only documented sign and symptom was, Dark urine, and there was no evidence of urinalysis/culture and sensitivity lab. The report further indicated R16…

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

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent. Four medication errors were observed from a total of 26 opportunities for three (R11, R120, R124) out of four residents reviewed during medication administration, resulting in an error rate of 15.38%. Findings include: R11 On 5/21/25 at 8:47 AM, a medication observation was conducted with Licensed Practical Nurse (LPN) Q for R11 and was observed providing Midodrine 10 milligram (mg) (medication to treat low blood pressure). LPN Qwas ordered to give one tablet by mouth with meals for hypotension hold if Systolic Blood Pressure (SBP) >105. LPN Q administered this medication with R11's SBP of 122. LPN Q was observed instilling four drops into the right eye and two drops into left eye. The order is to instill Artificial tears Ophthalmic Solution one drop in both eyes two times a day for dry eyes. On 5/22/25 at 10:31 AM, an interview was conducted with the Director of Nursing (DON) and acknowledged LPN L should have given the correct medication as ordered…

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 and interview, the facility failed to ensure proper storage of medications for four of eight medication carts reviewed for medication storage. Findings include: On 5/21/24 at 9:02 AM, an observation of the [NAME] Unit #1 Medication Cart was conducted with Licensed Practical Nurse (LPN) Q. The following medications were observed throughout the cart unpackaged and without patient identifiers: A plastic cup was observed in drawer #4 containing a clear liquid, and a plastic spoon. LPN Q said it was MiraLAX, (laxative solution medication) for another resident and they kept it in there to give it time for it to dissolve. Three Styrofoam cups were observed dented, dirty, with debris at the bottom of each cup. One cup observed storing two loose double AA batteries amongst three packaged antibiotic ointment and packaged syringes. Second Styrofoam cup observed storing a small black flashlight with two packaged Biofreeze (topical analgesic) and three packaged antibiotic ointment packages. Third…

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 reviews the facility failed to ensure meals were maintained and served at a palatable temperature affecting multiple residents, including R284, and three of eight residents from the confidential group interview, resulting in dissatisfaction with meals and the potential for nutritional decline. Findings include: It should be noted that the facility was recently found to be out of compliance with this regulation during an abbreviated survey conducted on 4/10/25 with an alleged compliance date of 5/8/25. On 5/20/25 at 9:43 AM, R284 was observed sitting on their bed. R284 was asked about food at the facility. R284 explained the food was always brought to them cold and they would have to get it reheated, or eat it cold. On 5/20/25 from 11:45 AM-12:43 PM, an observation was conducted of the lunch meal. During this time, Certified Dietary Manager (CDM 'O') was requested to prepare an additional meal tray with the main meal (Chicken Ala King) to include with the last food cart. At 12:43 PM, the last food cart was observed taken from the kitchen to…

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

Based on interview and record review the facility failed to operationalize an antibiotic stewardship program which consistently ensured appropriate clinical indication for us of antibiotic medications. This deficient practice affected multiple residents at the facility when residents who were deemed as not meeting criteria were prescribed on antibiotic therapy, resulting in the potential for increased antibiotic resistance. Findings include: Review of the Center for Disease Control's (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes dated 2015, documented in part, .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics 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.

Based on observation, interview, and record review, the facility failed to ensure assessment and a physician's order for self administration of medications for one resident, (R46), of one resident resident reviewed for self-administration, resulting in the potential for inappropriate medication administration. Findings include: On 5/20/25 at 09:33 AM, R46 was observed lying in their bed. An interview was attempted, however R46 did not verbally respond to the attempt. At that time, a medication cup with a clear liquid was observed present on the bedside table. R46 was observed to take a small sip from the cup and place it back on the bedside table. On 5/20/25 at 9:35 AM, a review of R46's physician's orders and medication administration record (MAR) was conducted and revealed they received lactulose (a liquid synthetic sugar used to treat constipation and/or to reduce ammonia levels in the liver) 15 milliliters. The MAR revealed the medication had been signed off as given on 5/20/25. On 5/20/25 at 9:47 AM, an interview was conducted with Nurse 'Q', (R46's assigned nurse) regarding…

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 promote self-determination for two (R112 and R13) of two residents reviewed for choices. Findings include: R112 On 5/20/25 at 11:14 AM, R112 was observed sitting in a wheelchair in the foyer area with other residents and activity staff. Upon request, staff moved R112 to an area of the foyer away from the other residents. R112 was asked if they enjoyed the activities at the facility. R112 explained they would rather be in their room. Activity Aide (AA) H was informed R112 wanted to go back to their room. AA H explained R112 needed to stay in activities because they were a fall risk. Review of the clinical record revealed R112 was admitted into the facility on 4/15/25 with diagnoses that included: obsessive-compulsive disorder, depression and anxiety. According to the Minimum Data Set (MDS) assessment dated [DATE], R112 scored 12/15 on the Brief Interview for Mental Status Exam (BIMS), indicating moderately impaired cognition. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review facility failed to establish a resident centered comprehensive care plan for one (R49) of one Resident with contractures (hardening of the muscles, tendons, and other soft tissues) reviewed for care plans resulting in unmet care needs. Findings include: R49 Record review revealed R49 was a long-term resident of the facility. R49 was originally admitted to the facility on [DATE]. R49 was recently admitted to hospital on [DATE] with pneumonia and readmitted to the facility on [DATE]. R49's admitting diagnoses included chronic kidney disease, dysphagia (difficulty with swallowing), anemia, dementia, and heart failure. R49 also had a stage 3 pressure ulcer (Merck manual defines a stage 3 pressure ulcer as a full-thickness skin loss with damage to subcutaneous/fat tissue extending down to [but not including] the underlying fascia. The ulcers are crater-like without underlying muscle or bone exposure) on their coccyx (tail bone area) that they had acquired 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.

Based on observation, interview and record review, the facility failed to ensure medications were administered per professional standards for two (R120 and R124) of four residents reviewed for medication administration. Findings include: R120 On 5/21/25 at 8:14 AM, as part of the medication pass task, LPN A was observed to mix 17 grams (g) of Polyethylene Glycol Powder (a laxative) in water in a small cup. LPN A also prepared two oral medications. LPN A entered R120's room, told R120 one of their medications was not available, however LPN A did not tell R120 what the medication was. LPN A then gave R120 the two prepared oral medications, without telling them what they were, then handed R120 the small cup of water with the Polyethylene Glycol Powder mixed into it. R120 put the two oral medications in their mouth, and took two sips of the Polyethylene Glycol Powder mixture, and handed the full cup back to LPN A. LPN A asked R120 if they wanted to finish the cup. R120 explained they only wanted enough to swallow the medication. LPN A then took the full cup with the Polyethylene Glycol…

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 activity of daily living (ADL) care for showers, hair care, nail care, and facial hair care were provided for three residents, (R#'s 103, 53, and 284), of four residents reviewed for ADL care, resulting in verbalized complaints and frustration with personal hygiene and grooming. Findings include: R103 On 5/20/25 at 10:00 AM, R103 was observed in their bed. R103 presented with uncombed hair that had a shiny/greasy appearance. They were further observed to have a full moustache and beard and their nails were observed to have thick brown debris under the nail beds. They were asked if staff assisted them with personal hygiene/grooming and said they did not. They were then asked about their preference for facial hair and said they never liked a beard or a moustache but no one would help them with shaving. On 5/21/25 at 2:39 PM, a review of R103's Minimum Data Set (MDS) assessment dated [DATE] revealed they had intact cognition 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 facility failed to consistently implement pressure ulcer prevention interventions as ordered for one (R49) of two residents (with pressure ulcers) reviewed for pressure ulcer prevention/management. This deficient practice has potential for worsening pressure ulcer and development of new pressure ulcer (s): Findings include: R49 Record review revealed R49 was a long-term resident of the facility. R49 was originally admitted to the facility on [DATE]. R49 was recently admitted to hospital on [DATE] with pneumonia and remitted to the facility on 3/25/25. R49's admitting diagnoses included chronic kidney disease, dysphagia (difficulty with swallowing), anemia, dementia, and heart failure. R49 also had a stage 3 pressure ulcer (Merck manual defines a stage 3 pressure ulcer as a full-thickness skin loss with damage to subcutaneous/fat tissue extending down to [but not including] the underlying fascia. The ulcers are crater-like without underlying muscle or bone…

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 one (R110) resident of one reviewed for Post Traumatic Stress Disorder (PTSD) received appropriate trauma assessment with resident specific interventions for one (R110) of one Resident reviewed for trauma informed care resulting in the potential for trauma triggers and re-traumatization. Findings include: Record review revealed R110 was a long-term resident of the facility, admitted on [DATE]. R110's admitting diagnoses included PTSD, major depressive disorder with severe psychotic symptoms, schizoaffective disorder, delusional disorders, and generalized anxiety disorder. Review of R110's Electronic Medical Record (EMR) revealed a most recent social work assessment tilted social work re-eval dated 4/1/25. The social work assessment included the above diagnoses including PTSD. Further review of R110's EMR did not reveal any PTSD assessment since their admission to the facility. R110 was receiving psychiatry services through the facility'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.

This citation pertains to intake(s): MI00151872 Based on interview and record review, the facility failed to implement the abuse policy that requires a complete background check for newly hired staff for one (Staff C) of three staff members reviewed for background checks/abuse. Findings include: A review of Licensed Practical Nurse (LPN) C was completed during the survey as part of an abuse investigation. LPN C was hired on 3/18/25. Review of their personnel file revealed background screening reports and fingerprint appointment date of 3/20/25. The screening report did not indicate that fingerprints for LPN C had been performed based on the documents that were in the personnel file. An interview with Human Resource (HR) coordinator E was completed on 4/10/25 at approximately 4PM. They were queried about the fingerprints for LPN C. They reported that they had kept the fingerprints on a separate binder, and they would check. Later they came and reported that that they did not have any fingerprints completed for LPN C and they added that the staff member was scheduled to go for their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake(s): MI00151872, MI00151053 Based on interview and record review, the facility failed to timely report allegations of abuse to the abuse coordinator and State Agency for two (R501 and R503) of two residents reviewed for abuse. Findings include: A facility reported incident was submitted to the State Agency on 2/26/2025 at 10:17 AM that revealed on 2/23/25 a family member visiting R503 was notified by R503 that a staff member had thrown a washcloth or towel at them earlier that day. The Family member notified R503's charge nurse of the allegation. The charge nurse failed to notify the abuse coordinator timely resulting in the failure of the Facility to notify the State Agency and initiate an investigation timely. An initial report of this allegation was submitted to the State Agency on 2/26/25, approximately 64 hours after the allegation was reported to the staff member by a family member. Review of the facility investigation report submitted to the State Agency revealed that abuse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake(s): MI00151919 Based on observation, interview, and record review, the facility failed to ensure meals were enjoyable and served at palatable temperatures due to use of disposable Styrofoam containers for three sampled residents (R502, R504, and R505) from a total of three sampled residents reviewed for food palatability. Findings include: A complaint received by the State Agency that read that food served by the facility were not palatable. An initial observation was completed on 4/10/25 at approximately 9 AM in the 100 hallway. The observation was made from the main nursing station in the 100 hallway near rooms (150s). A meal cart was parked in the hallway and staff were observed picking up breakfast trays from resident rooms. The breakfast meal was in Styrofoam boxes placed on the tray. The surveyor opened the cart and observed six breakfast trays with a Styrofoam box on every tray. Later that day staff were observed picking up trays from room [ROOM NUMBER], the trays had…

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 #MI00146351 Based on interview and record review, the facility failed to ensure timely submission of physician/physician extender progress notes for each visit for two residents (R#'s 901 and 902) of two residents reviewed for progress notes. Findings include: R901 A review of R901's closed clinical record was reviewed and revealed the following: A progress note from Nurse Practitioner (NP) 'C' with an effective date of [DATE] at 12:00 AM, entered into the record on [DATE] at 9:34 PM. It was revealed this note was entered into the record after the resident's death on [DATE]. R902 A review of R902's closed clinical record was reviewed and revealed the following: A progress note with an effective date of [DATE] at 12:00 AM, created and entered into the record on [DATE] at 10:37 AM. A progress note with an effective date of [DATE] at 12:00 AM, created and entered into the record by NP 'C' on [DATE] at 10:39 AM. A progress note with an effective date of [DATE] at 12:00 AM, created…

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 report to the Administrator and the State Agency an injury of unknown origin for one (R903) of one resident reviewed for abuse. Findings include: A review of R903's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included, in part: end stage renal failure and heart disease. R903 census notes indicated the resident was discharged to the hospital on 7/29/24 and returned on 8/20/24. A review of the residents Minimum Data Set (MDS) revealed the resident was severely cognitively impaired and required extensive assistance with most Activities of Daily Living (ADLs). Continued review of R903's clinical record revealed, in part, the following: 9/9/24- Nurse Notes: Resident has an <sic> red raised lump on the left side of the back head. Resident is unable to explain the cause, no c/o (complaints) of pain .Resident has been sent out to (name redacted) Hospital for observations . Authored by Nurse D.…

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 #146351. Based on interview and record review, the facility failed to ensure clinical documentation met professional standards for one resident (R901) of two residents reviewed for professional standards. Findings include: A complaint received by the State Agency alleged staff entered late progress notes and documented in the clinical record after a resident's death. A review of R901's clinical record was conducted and revealed a Late Entry progress note for 8/2/24 at 5:19 AM entered into the record on 8/9/24 at 9:38 PM, (seven days later) by Nurse 'B' that read, .Resident observed in bed unresponsive, no pluse <sic> or respirations noted .Hospice Nurse, physician and family notified . Continued review of R901's clinical record revealed Nurse 'B' documented the Effective outcome of as needed pain and anti-anxiety medications at approximately 6 AM, after the documented time of R901's death. On 10/7/24 at 3:17 PM, an interview was conducted with the facility's Director of Nursing regarding when the note regarding R901's death should have been entered…

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 #MI00147067 and MI00147277 Based on interview and record review the facility failed to complete accurate skin assessments, ensure residents were seen in a timely matter by wound staff/practitioners, ensure appropriate treatment and services/interventions were timely implemented for pressure ulcers for two residents (R#'s 902 and 903) of two residents reviewed for pressure ulcers. Resulting in R903 developing a stage 3 pressure ulcer to their sacrum, left heel and worsening of their right heel. Findings include: R903 A complaint was filed with the State Agency (SA) that alleged that R903 obtained wounds on both their heels and coccyx/sacrum while residing at the facility. They further noted that R903 was not turned frequently, and the facility failed to put physician ordered boots on the resident until two days prior to their discharge. Review of R903's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included, in part: end…

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 a dignified dining experience for multiple residents, including (R8, R90, R20 and R79) out of sixteen residents reviewed for dining. Findings include: On 6/10/24 at approximately 12:05 PM, during observations of the large dining room, several residents were observed sitting at various tables. Residents at three different tables were observed being assisted with their meals. Other residents, who had yet to be served their lunch were watching the other residents eat their lunch. At approximately 12:20 PM, several residents who did not receive 1:1 food assistance had still had not received their lunch meals and reported that they were hungry. R8 noted that the delay in receiving food in the dining room happens often. Final food trays were served to residents at approximately 12:30 PM. On 6/11/24 at approximately 12:02 PM, a second dinning observation was conducted. Again, several residents were observed sitting at various tables in the large dining room. There were approximately four residents observed…

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 water and other fluids were available and accessible for one resident (R78) of one resident reviewed for accommodation of needs resulting in the potential for thirst and complications from dehydration. Findings include: On 6/10/24 at 12:40 PM, R78 was observed in their bed with their lunch tray placed over them on the over-bed table. It was observed R78 had a pureed meal and two magic cup supplements on their tray. It was further observed two full cups of thickened orange juice were in the room, but they were placed across the room on the dresser with lids placed over them. A staff member entered the room set up the tray (removed the dome from the entree, opened the magic cups) and exited the room. They were not observed to remove the lids from the juices and place them on the over-bed table, or anywhere within R78's reach. On 6/10/24 at approximately 2:55 PM, R78 was observed in their bed, the juices remained out of reach on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure activity of daily living (ADL) care for two residents (R#39 and 98) of four residents reviewed for ADL care, resulting in the potential for hunger and embarrassment from poor personal hygiene. Findings include: R39 On 6/10/24 at 9:46 AM, R39 was observed lying in their bed. R39 had tube feeding delivered via pump at 60 milliliters per hour and did not respond to any attempts at verbal communication. It was observed R39's nails were long in length and had visible dark debris underneath the nail bed. On 6/11/24 at 9:44 AM and 6/12/24 at 8:25 AM, R39's fingernails were observed to remain long with dark debris under the nail beds. R39 did not respond to any attempts at verbal communication during the observations. On 6/10/24 at 1:21 PM, an observation of the meal service on the Oakland Unit was conducted. At the conclusion of the lunch meal staff were observed placing dirty trays on the cart for return to the kitchen. An observation 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 interview and record review, the facility failed to advocate for legal representation for one resident (R107), of one resident reviewed for a provision of social services, resulting in R107 having no one to legally advocate for them. Findings include: A review of R107's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: epilepsy, traumatic brain injury, hallucinations, and dementia. A review of a Statement of Capacity dated 3/21/23 was reviewed and revealed R107 had been found, To be incapable and unable to make his/her informed medical decisions . A review of scanned documents in R107's medical record did not reveal any documents to indicate R107 had a legal decision maker. 6/11/24 at 10:25 AM, an interview with Social Services Staff 'K' was conducted and they were asked if R107 had a Durable Power of Attorney or Legal Guardian and said they did not. They were asked why, considering R107 had been deemed not competent to make their own medical decisions on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain accurate medical records regarding resident treatment for one (R74) out of one resident reviewed for medical records. Findings include: On 6/10/24 at approximately 10:02 AM, R 74 was observed lying in bed. The resident was alert and able to answer questions asked. R74 reported that they had been at the facility for about two years. The resident noted that they did not get out of bed as they could not stand, they also noted that their right arm was paralyzed and did not work. R74 tried to show the Surveyor that their right hand/arm was not functional. During the observation the resident was not wearing a splint. A review of R74's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: vascular dementia, depression and type II diabetes. Continued review of R74's record noted that the resident was on a Maintenance Splint Program that noted Apply right hand splint up to 4…

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 accepted practices for infection control as it relates to transmission-based precautions (TBP) and contact precautions for six residents, (R#'s 118, 16, 85, 25, 43, and 116) of 10 residents reviewed for infection control, resulting in the potential for the development and spread of infection. Findings include: A review of a facility provided policy titled, Enhanced Barrier Precautions (EBP) was reviewed and read, .Enhanced Barrier Precautions are indicated for residents with any one of the following:2) a wound or indwelling medical devices .Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies .It is the intent of this facility to use Enhanced Barrier Precautions (EBP) in addition to Standard Precautions for preventing the transmission of CDC (Centers for Disease Control) targeted multidrug-resistant organisms (MDROS) .Healthcare personnel caring for residents on Enhanced Precautions…

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 two residents were assessed for the safe self-administration of medication (R12 and R43) of two residents reviewed for self-administration of medications. Findings include: R12 On 6/10/24 at approximately 10:24 a.m., R12 was observed in their room, laying in their bed. R12 was observed to be administering a nebulizer solution treatment by themselves in the room with no Nurse present. On 6/10/24 the medical record for R12 was reviewed and revealed the following: R12 was initially admitted to the facility on [DATE] and had diagnoses including Dementia with mood disturbance, Mild cognitive impairment, and Polyneuropathy. A review of R12's MDS (minimum data set) with an ARD (assessment reference date) of 4/3/24 revealed R12 had a BIMS score (brief interview of mental status) of 11 indicating moderately impaired cognition. A review of R12's Physician orders, comprehensive care plan and assessments did not reveal any indication that R12…

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 nursing services met professional standards for medication administration for one resident (R114) out of one reviewed for professional standards. Findings Include: On 6/11/24, a clinical record review revealed R114 was admitted to the facility on [DATE], with most recent admission with Hospice services on 5/30/24. R114's diagnoses included: COPD (Chronic Obstructive Pulmonary Disease), Atrial Fibrillation (abnormal heart rhythm), hypertension, heart disease, and new onset bladder pain and spasms. Psychiatric history included anxiety and dementia. A Brief Interview for Mentals Status (BIMS) score totaled 5/15 indicating R114 has severe cognitive impairment. On 06/10/24 at 10:17 AM, R114 was observed lying in bed and identified 2 pills lying next to resident (one white tablet and one green capsule). Observation of the environment identified one white tab on the floor in front of the radiator, one cream colored capsule was identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide meaningful, diverse and engaging activities for one (R74) out of two residents reviewed for activities. Findings include: On 6/10/24 at approximately 10:02 AM, R 74 was observed lying in bed. The resident was alert and able to answer questions asked. R74 reported that they had been at the facility for about two years. The resident was watching television. When asked about life at the facility the resident reported that they are bored all the time. The resident noted that they did not get out of bed as they could not stand, they also noted that their right arm was paralyzed, and their legs did not work. When asked if they engage in any activities, R74 reported that all they do is watch TV. When asked if they had been offered any other activities to perform in their room, they reported that they had not. The resident noted that the activity schedule was posted on their armoire, but due to vision problems they could not even see 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 has two (2) deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to perform ongoing, accurate clinical assessments and ensure interdisciplinary team (IDT) collaboration for care for one resident (R116), of two residents reviewed for assessment and care, resulting in prolonged placement of an unused Percutaneous Endoscopic Gastrostomy (PEG) Tube, pain and recurrent infections at the PEG tube site. Findings Include: On 6/11/24 at 11:07, an observation of R116's PEG (a tube surgically placed in the abdomen for the use of artificial nutrition and hydration) site was conducted with Licensed Practical Nurse (LPN) A. The observation revealed a split gauze dressing dated 6/11 placed on the abdomen covering the insertion site. The exterior right side of the gauze was observed with an area of dark red blood. Removal of the dressing revealed moderate amounts of dark red blood, and bright red blood on the gauze surrounding area of PEG insertion. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure physician ordered Liters of oxygen per minute were delivered via concentrator for one resident (R47), of one resident reviewed for oxygen therapy resulting in elevated blood oxygen levels. Findings include: On 6/10/24 at 9:52 AM, R47 was observed in bed asleep with oxygen being delivered via nasal cannula at six Liters per minute. On 6/10/24 at 1:45 PM, 6/11/24 at 9:30 AM, and 1:54 PM and 6/12/24 8:26 AM, observations of R47's oxygen concentrator revealed the settings at six Liters. On 6/10/24 at 1:59 PM, a review of R47's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, (COPD) pneumonia, dependence on oxygen, and generalized anxiety disorder. A review of R47's orders revealed an order dated 5/20/24 that read, .Oxygen saturation of 93-94% (Oxygen 3-4L (Liters)/min (minute) ATC (around the clock) via nasal cannula). Directions: every shift avoid…

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 Physician orders were in place for treatment, monitoring and assessing one resident (R43) who was on hemodialysis of two residents reviewed for dialysis care. findings include: On 6/10/24 at approximately 10:08 a.m., R43 was observed in their room, up in their bed. R43 was queried if they were on dialysis services, and they indicated that they were. R43 was queried if the Nursing staff were assessing their dialysis access site and they indicated that they do not assess it on a regular basis. On 6/11/24 at approximately 10:09 a.m., R43 was observed in their room, laying in their bed. R43 was queried if the nursing staff have recently assessed their dialysis access site and they reported sometimes, not every day or anything. R43 was queried if the staff are wearing gowns when the provide care to them and the indicated that they do not. On 6/10/24 the medical record for R43 was reviewed and revealed the following: R43 was initially…

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 residents did not receive duplicate/unnecessary medication for one (R20) out of five residents reviewed for unnecessary medications. Findings include: A medical record review of R20's drug regimen was conducted. There was an order for Montelukast sodium (a medication generally used to treat asthma like symptoms)10mg (milligrams) oral tab once daily for allergies started on 5/4/24 and another order for Montelukast Sodium 10mg oral tab once daily for hypertension started on 3/15/24. Both orders were currently active and R20 according to the documentation was receiving a total of 20mg a day. On 6/12/24 at 11:00AM the Director of Nursing (DON) was interviewed and asked why did R20 have two orders in for the same medication and is the indication of hypertension appropriate for this drug. The DON replied that she would have to ask the nurse practitioner (NP) if it was supposed to be two orders for the medication and that hypertension was not an appropriate indication for that medication. On 6/12/24 at 12:00PM the DON…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly label and confirm a resident's narcotic medication (Morphine) and ensure medication carts were locked for two of three medication carts reviewed and failed to properly secure one unattended medication cart. Findings Include: On 6/11/24 at 8:47 AM, an observation of the [NAME] medication cart was conducted with Licensed Practical Nurse (LPN) A. The narcotic drawer was observed having 30 syringes (three separate clear bags each containing ten syringes) labeled Morphine Sulfate 10 mg (milligrams)/5ml (milliliters). LPN A acknowledged no resident identifiers were placed on the medication and would have to contact pharmacy. On 6/11/24 at 1:29 PM, the Director of Nursing (DON) indicated pharmacy sent them with no names, was aware of the findings and indicated they were returned to pharmacy. Review of the facilities policy titled; Controlled Substances 10/2023 documented: .When a controlled substance is delivered from the pharmacy, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure adaptive equipment/assistive devices used to assist with eating were provided for one resident (R17) of 19 residents reviewed for dining. Findings include: R17 On 6/10/24 at approximately 12:33 p.m., R17 was observed in the dining room, attempting to eat the lunch meal. R17's meal ticket was observed and indicated R17 was to be provided a divided plate and a two-handed spouted cup. R17 was not observed to have been provided either of the assistive devices. On 6/11/24 at approximately 12:17 p.m., R17 was observed in the dining room, attempting to eat the lunch meal. R17's meal ticket was observed and indicated R17 was to be provided a divided plate and a two-handed spouted cup. R17 was not observed to have their divided plate but still had not been provided the spouted cup. On 6/11/24 the medical record for R17 was reviewed and revealed the following: R17 was initially admitted to the facility on [DATE] and had diagnoses including…

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 MI00142567. Based on interview and record review the facility failed to provide one resident(R502) with a shower resulting in a medically missed appointment due to being unclean. Findings include: A complaint was received by the State Agency that alleged that R502 had missed a dentist appointment because of a missed shower and not wanting to got to an appointment dirty and smelly. A record review revealed that on 1/30/24 a progress noted stated that R502 . has scheduled doctor's appointment. Resident refused to go to his doctor appointment at this time due to the weather and a missed shower . A further review of the record revealed the R502 did miss a shower, no shower was documented on the certified nursing assistant task. On 3/20/24 at 10:00AM an interview was conducted with the Director of Nursing(DON), she was asked why didn't R502 receive a shower prior to the known scheduled appointment, the DON replied, that she was not for sure but she could get the unit manager who was over the unit at the time. On 3/20/24 at 10:10AM an interview with Nurse…

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 Citation for intake MI00142569. Based on observation and interview the facility failed to provide a clean homelike environment, free from avoidable urine odors for two resident (R501 and R506) of two residents reviewed for environment. Findings include: On 3/19/24 at 10:00 AM, an observation of R501's room made with the Director of Nursing (DON), there was a strong urine like odor in the room. An assessment or R501's skin was made to rule out any pressure injuries and upon turning R501, their brief was visibly soiled, the DON then asked could the Certified Nursing Assistant rendering care to R501 to assist with a brief change. On 3/19/24 at 1:00 PM, another observation of R501's room was made and the same strong odor was present. On 3/19/24 at 1:15 PM an observation was made in room [ROOM NUMBER] (R506's room), there was trash and food on the floor, R506 was asked does the room get routine cleaning and R506 stated, No, there was a housekeeper who entered into my room and stated they would be back but normally…

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

This pertains to intake MI00143370. Based on observation, interviews, and record review the facility failed to obtain and follow prescribed orders for the maintenance of a PICC (peripherally inserted central catheter) line for one resident (R501) or one resident reviewed for PICC lines. Findings include: On 3/19/24 at 10:00 AM, R501 was observed in their room lying in bed. A skin assessment was completed. A brief assessment of the skin revealed that R501 had a PICC line in the upper right arm with a dressing dated for 3/15/2024. A record review revealed that there was no maintenance order in to care for the PICC, and or to assess the site. There was also an order in for the removal of the PICC for 3/19/24. On 3/20/24 at 9:30 AM an observation of R501 was made the PICC line was still intact in the resident's right upper arm with a dressing date of 3/15/24. On 3/20/24 at 10:00 AM, an interview with the Director of nursing (DON) was completed. The DON was asked what the policy for PICC line maintenance was, DON explained she would have to pull the policy. The DON was asked if there…

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 #MI00138372 Based on observation, interview, and record review, the facility failed to ensure personal dignity for four residents (R#'s 67, 32, 82, and 2) of 21 residents reviewed for dignity. Findings include: On 7/25/23 at 9:07 AM, a conversation was conducted with Nurse 'A' regarding the breakfast tray delivery. Nurse 'A' said the trays for the, feeders were delivered to the unit before the other trays. On 7/26/23 at 12:00 PM, Nurse 'B' was asked what time the lunch meal arrived to the [NAME]/Telegraph unit. Nurse 'A' was asked what time the lunch trays arrived to the unit and said the feeders trays were due around noon. On 7/26/23 from 12:10 PM to 12:40 PM, an observation of the lunch meal on the [NAME]/Telegraph unit was conducted. R67 was seated with R32, it was observed Certified Nurse Aide (CNA) 'C' was alternately feeding both R67 and R32 simultaneously. R2 was observed in the dining room seated with R82. R82 had been served their meal at approximately 12:10 PM, and 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.

Based on observation, interview, and record review the facility failed to ensure water was within reach for three residents (R#'s 5, 2, and 60) of three residents reviewed for accommodation of needs. Findings include: On 7/25/23 at 10:08 AM, R5 was observed in their bed. R5's bedside table with their drinking water was against the wall approximately four feet away from the bed. On 7/25/23 at 10:58 AM, R2 was observed in their bed asleep. R2's bedside table with their drinking water was observed to be approximately four feet to the left of the bed. On 7/25/23 at 3:32 PM, R60 was observed in their bed asleep. R60's bedside table with their drinking water was observed against the wall on the right side of the bed, approximately five feet away from the bedside. On 7/26/23 at at 11:02 AM, R5 was observed in their geri-chair on the right side of their bed. It was observed their bedside table with their drinking water was on the left side of the bed, several feet out of R5's reach. On 7/26/23 at 3:52 PM and 7/27/23 at 9:34 AM, R60 was observed in their bed. At those times, R60's bedside…

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 resident treatments were documented when completed for nine residents (R11, R31, R41, R45, R53, R72, R92, and R221) of nine reviewed for Nursing standards of practice. Findings include: On 7/26/23 the medical records for R11, R31, R41, R45, R53, R72, R92, and R221 were reviewed and revealed the following treatments were not documented as being completed during the night shift in the July 2023 treatment administration record (TAR) on July 21st. Resident #11-Apply A&D ointment to bilateral lower extremities q (every) hs (night) and prn (as needed) at bedtime for Prevention . Resident #31-Ammonium Lactate External Cream 12 % (Lactic Acid (Ammonium Lactate) Apply to BLE (bilateral lower extremities) topically every night shift for wound Resident #41-Cleanse buttock with normal saline. Apply Chamosyn every shift . Resident #45-Cleanse bi-lat buttock and apply zguard every shift for redness Resident #53-Apply Eucerin Cream to bilateral lower extremities BID (twice daily) every day and night shift and skin prep to right…

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 individualized and meaningful activities for thirteen residents (R#'s 15, 14, 221, 29, 67, 11, 74, 32, 91, 73, 2, 45, and 82) of 47 residents who resided on the [NAME] and Telegraph Units, resulting in the potential for feelings of boredom and decreased quality of life. Findings include: On 7/25/23 at 10:51 AM, R15, R14, R221, R29, and R67 were observed seated in their wheelchairs in the [NAME]/Telegraph Unit common area. Staff were noted to be going about the unit performing their duties. The resident's were not being engaged with by staff, there was no television, radio, reading material, sensory activities or other type of activity supplies in the area. On 7/25/23 at 1:27 PM, R14, R11, R221, R74, and R32 were observed seated in the [NAME]/Telegraph common area. Staff were not observed engaging with residents and no formal activities were observed to be taking place. It was further observed R32 was positioned at a table, facing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications and biologicals were appropriate stored in three of four medication carts, two of two medication rooms, and one of one treatment cart, resulting in the potential for unauthorized entry, misuse, contamination, and diversion. Findings include: On 7/27/23 at 12:40 PM, an observation of the medication room on the [NAME]/Telegraph unit was conducted with Nurse 'F'. The cabinet underneath the hand sink contained a large box of various lab supplies (specimen containers, swabs, alcohol pads, and empty sharps containers). When asked if anything should be stored underneath the sink, Nurse 'F' reported there should not. On 7/27/23 at 12:50 PM, an observation of a medication cart on the [NAME]/Telegraph unit was conducted with Nurse 'F' (not their assigned cart, but had access to keys since that nurse was unavailable). There was a container of blood glucose testing strips that had been opened with no label/date of opening. Nurse 'F'…

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 in part to intake MI00137730 Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, homelike environment for one room (145) and one (R71) of seven residents reviewed for environment. Findings include: On 7/25/23 at 10:28 AM, upon entering room [ROOM NUMBER] there was a foul odor of undetermined origin. The odor was pervasive throughout the entire semi-private room. On 7/25/23 at 12:08 PM and 12:54 PM, the same pervasive odor was present in room [ROOM NUMBER]. On 7/25/23 at 4:14 PM, Licensed Practical Nurse (LPN) S was interviewed and asked about the odor in room [ROOM NUMBER]. LPN S explained she did not know what the smell was, but thought is smelled like Penicillin or some kind of antibiotic or medications. On 7/25/23 at 4:18 PM, Certified Nursing Assistant (CNA) K was interviewed and asked about the odor in room [ROOM NUMBER]. CNA K explained she thought it smelled like an antibiotic or a gas. When asked how long the odor had been 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 observation, interview, and record review the facility failed to ensure that showers were offered, provided, and documented for two residents (R25 and R48) of four residents reviewed for activities of daily living care (ADLs), resulting in feelings of depression, being dirty, and dissatisfaction with care. Findings include: Resident #25 (R25) On 7/25/23 at 2:08 PM, during an initial tour of the facility, R25 was interviewed about their care at the facility and indicated that they had not been receiving their scheduled showers on a consistent basis. R25 indicated that they had not been offered a shower in over a week. R25 stated, I feel depressed and dirty. On 7/27/23 at 9:21 AM, R25's shower schedule was reviewed and their shower documentation was reviewed for the months of June and July 2023. R25's scheduled shower days were scheduled on Mondays and Wednesdays day shift. Documentation of showers offered and provided on R25's scheduled shower days revealed the following, R25 was not offered or provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and services to prevent recurrent urinary tract infections (UTI's) for one (R41) of two residents reviewed for antibiotic use. Findings include: Review of a Centers for Medicare & Medicaid Services (CMS) document titled, State Operations Manual Appendix PP revised 2/3/23 read in part, .Follow-Up of UTIs: The goal of treating a UTI is to alleviate systemic or local symptoms, not to eradicate all bacteria . Continued bacteriruia without residual symptoms does not warrant repeat or continued antibiotic therapy. Recurrent UTIs (2 or more in 6 months) in a noncatherterized individual may warrant additional evaluation (such as a determination of an abnormal post void residual (PVR) urine volume or a referral to a urologist) to rule out structural abnormalities such as enlarged prostate, prolapsed bladder, periurethral abscess, strictures, bladder calculi, polyps and tumors . Review of the facility's antibiotic stewardship program revealed R41 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure medications to treat pain were available for administration for two residents (R19 and R225) of two residents reviewed for pain management resulting in the potential for pain to go untreated. Findings include: Resident #19 On 7/25/23 The medical record for R19 was reviewed and revealed the following: R19 was initially admitted to the facility on [DATE] and had diagnoses including Quadriplegia and Generalized abdominal pain. A review of R19's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/4/23 revealed R19 was on a scheduled pain medication regimen and required assistance from facility staff with all of their activities of daily living. A review of R19's careplan revealed the following: Focus-[R19] is at risk for pain r/t (related to) dx (diagnoses) chronic pain, quadriplegia, htn (Hypertension), anemia . A Physician's order dated 5/22/23 revealed the following: fentaNYL Transdermal Patch 72 Hour 50 MCG/HR…

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.