The Orchards at Canterbury on the Lake

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews the facility failed to ensure an effective system to monitor antibiotic use in the facility for four (R's 145, 14, 8 & 126) of four residents reviewed. Findings include:A review of the facility's Infection Control Logs and the monitoring of antibiotics revealed multiple residents identified to have potentially been prescribed an unnecessary antibiotic. A small sample was identified for review: April 2025- 4/20/25- R8 confusion, urgency, freq (frequency). Incont (incontinence). + dipstick UA (urinalysis). Macrobid.A review of a Nursing note dated 4/2025 at 5:59 PM, documented in part . writer observed resident with confusion. vitals are within normal limits. collected UA by straight cath. positive for leukocytes. Called on call and was given an order to start resident on Macrobid 100mg two times a day for 5 days. Sample was collected at 5:40 PM and placed in the 1st floor refrigerator.The medical record did not identify urgency, frequency or incontinence of urine. Further…

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

Based on observation, interview and record reviews the facility failed to ensure a dignified dining experience for one (R14) of one resident reviewed for dining, which had the ability to affect multiple residents who dined in the second floor dining room. Findings include: On 7/29/25 at 11:50 AM, an observation of the second floor lunch meal was conducted in the dining room area. Initially, 16 residents were observed in the dining room waiting to be served. At 12:20 PM, the first tray was observed being served. Flies were observed flying around the dining room. The first, second, third, fourth and fifth table were observed to have been provided their lunch meals, with the exception of two residents at the second table and R14 from the third table. The two residents from the second table and R14 were observed with no lunch meals to have been provided. At 12:37 PM, the two residents from the second table was provided their meal. One resident was observed to require the assistance of staff to be fed. At 12:39 PM, R14 was observed looking down, while the rest of the residents at table…

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 call lights were within reach for two residents (R#'s 49 and 20), of two residents reviewed for accommodation of needs, resulting in the potential for delayed attention to resident care needs. Findings include:On 7/29/25 at 10:11 AM, R49's room was observed with the right side of their bed against the wall. R49 was in their wheelchair on the left side of the bed and it appeared their foot was wedged between the wheelchair pedal and the bottom of the bed rails. R49 asked for assistance to have their foot unstuck from under the bed. They were asked to activate their call light for staff assistance, and said they did not have their call light. At that time, the call light was observed hanging down from the call light box on the right side of the bed against the wall, not within reach of R49. On 7/29/25 at 10:18 AM, R20's room was observed with the left side of the bed against the wall. R20 was in their wheelchair on the right side of the bed at the foot. An oxygen concentrator was placed on the right side…

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 (R55 and R30) of three residents reviewed for Advance Directives were educated and given the opportunity to formulate an advance directive for their health care wishes. Findings include:R55 On 7/29/25 at 10:45 AM, R55 was observed in bed. R55 had difficulty speaking at times, but appeared to clearly understand the questions being asked. At times, R55 had difficulty verbalizing a word, but explained he understood and knew what to say, but the words did not come out properly (aphasia). On 7/30/25 at 8:25 AM, R55 expressed concerns he had with the care in the facility. R55 said he got out of bed to go to therapy, but otherwise preferred to stay in his room. A review of R55's clinical record revealed R55 was admitted into the facility on 2/11/25 with diagnoses that included: cerebral ischemia (stroke). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R55 had clear speech, with distinct intelligible words, mad…

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

Based on observation, interview and record review, the facility failed to ensure resident equipment was maintained in good repair for one (R8) of three residents reviewed for a homelike environment. Findings include:On 7/29/25 at 10:50 AM, an interview was conducted with R8's Legal Guardian (LG) who was seated in a wheelchair next to the resident who was lying in bed. The wheelchair was observed to have a missing left armrest, and the wheels had no treads and were very worn. When asked about whether that had been provided by the facility or brought in from home, the LG reported that was provided by the facility. When asked how long the wheelchair had been in that condition and if anyone had identified a need to replace or repair the wheelchair, the LG reported the wheelchair had been a wreck for a while and no one from the facility had ever asked about it before.On 7/31/25 at 9:10 AM, an interview and observation of the third floor was conducted with the Maintenance Director (Staff 'R') who has worked at the facility for about four years and in the Director role for about four…

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 observations, interview and record review the facility failed to protect the resident's right to be free from neglect for one (R141) of five residents reviewed for abuse resulting in R141 being left on a bedpan for four hours. Findings include: On 7/29/25 at 9:56 AM, R141 was observed lying in bed. R141 was asked about care at the facility. R141 explained a couple nights before he had to go to the bathroom during the night. the aide put him on a bedpan. she did not come back, he was on the bedpan for four hours, his bottom was hurting bad, his legs and heels still hurt from being on the bedpan that long. then when the aide finally came back, she took the bedpan to the bathroom, he thought she was going to clean him up, but she walked out of the room. he waited to see if she was going to get supplies, but she did not come back, so he pushed his call light again after about 15-20 minutes. the aide came back and asked what he needed, he asked if she was going to clean him up, she told him she had forgotten and would get the supplies. she never came back. the day shift aide 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 protect a resident from exploitation for one (R124) of five residents reviewed for abuse. Findings include: On 7/29/25 at 11:13 AM, R124 was observed sitting in a wheelchair in his room. R124 was asked if he was able to take himself to the bathroom. R124 explained he needed staff assistance.Review of the clinical record revealed R124 was admitted into the facility on 6/25/25 with diagnoses that included: metabolic encephalopathy, multiple fractures of ribs and diabetes. According to the Minimum Data Set (MDS) assessment dated [DATE], R124 had moderately impaired cognition.On 7/31/25 at 12:01 PM, Certified Nursing Assistant (CNA) L was interviewed about a concern with R124's roommate. During this interview, CNA L was asked if on the morning of 7/28/25 R124 and his bed were left wet. CNA L explained when she started her shift that morning, she had been given no report and both R124 and his roommate needed to be cleaned up. CNA L then…

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 stop-date for a PRN (as needed) order for anti-anxiety medication for one resident (R120), of five residents reviewed for unnecessary medications. Findings include: On 7/31/2025 at 11:02 AM, a review of R120's clinical record revealed they most recently re-admitted to the facility on [DATE] with diagnoses that included: heart disease, protein calorie malnutrition, adjustment disorder, anxiety disorder, falls, delirium, depression, and dementia with behaviors. R120's physician orders were reviewed and revealed a current, active order originating 12/20/24 for Ativan 0.5 mg (milligrams) to be given every four hours as needed. It was noted the medication had been re-ordered on 3/13/25 and 6/9/25 with the same instructions, to be given every four hours as needed with no duration of time for use defined. A review of R120's monthly medication regimen review reports prepared by the facility's pharmacist and reviewed and signed by the attending…

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 #1227216 Based on interview and record review the facility failed to report an allegation of neglect and an injury of unknown origin to the State Agency for two residents (R138 and R141) of five residents reviewed for abuse, neglect and mistreatment. Findings include: On 7/29/25 a complaint that was submitted to the State Agency was reviewed that alleged R138 had a head wound from an unknown origin. On 7/29/25 the medical record for R138 was reviewed and revealed the following: R138 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Brief Psychotic disorder and was discharged to the hospital on 6/16/25. A review of R138’s MDS (minimum data set) with an ARD (assessment reference date) of 6/5/25 revealed R138 needed supervision from facility staff with most of their activities of daily living. A review of R138's progress notes revealed the following: 6/14/2025- Noted new skin issue observed by CNA (Certified Nursing Assistant). Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #1227216Based on interview and record review the facility failed to complete and document a thorough investigation into an injury of unknown origin for one resident (R138) of five residents reviewed for abuse/neglect/mistreatment. Findings include: On 7/29/25 a complaint that was submitted to the State Agency was reviewed that alleged R138 had a head wound from an unknown origin. On 7/29/25 the medical record for R138 was reviewed and revealed the following: R138 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Brief Psychotic disorder and was discharged to the hospital on 6/16/25. A review of R138's MDS (minimum data set) with an ARD (assessment reference date) of 6/5/25 revealed R138 needed supervision from facility staff with most of their activities of daily living. A review of R138's progress notes revealed the following: 6/14/2025- Noted new skin issue observed by CNA (Certified Nursing Assistant). Resident observed with…

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 Minimum Data Set (MDS) Assessments was completed accurately for one (R120) of three reviewed for the resident assessment task. Findings include:On 7/29/25 at 10:05 AM, R120 was observed lying in bed and a visitor was conducting a clinical assessment. Upon exit from the room, the visitor reported they were a Hospice Nurse (Nurse 'U') as R120 was on their services.Review of the clinical record revealed R120 was initially admitted into the facility on 6/24/24 and readmitted on [DATE] with diagnoses that included: atherosclerotic heart disease of native coronary artery without angina pectoris, moderate protein-calorie malnutrition, paroxysmal atrial fibrillation, and encounter for palliative care.Review of the physician orders revealed R12 had signed onto hospice services on 11/14/24 and as this review, remained on hospice.Review of the Minimum Data Set (MDS) assessments included a significant change MDS assessment dated [DATE] and quarterly 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 the facility failed to ensure a comprehensive resident centered care plan was developed and implemented for an anxiety disorder for one (R30) of five residents reviewed for unnecessary medications. Findings include: On 7/29/25 at 11:17 AM, R30 was observed lying down on their back in bed. A brief interview was conducted with the resident at that time. A review of the medical record revealed R30 was admitted to the facility on [DATE] with diagnoses that included an anxiety disorderA review of R30's physician orders revealed . Alprazolam oral tablet 0.5 mg (milligram). Give 1 tablet by mouth every 8 hours as needed for anxiety or panic related to anxiety disorder. A review of the care plans revealed no documentation of a care plan implemented for the resident's anxiety disorder or interventions to help the resident manage their anxiety before the use of medication. On 7/30/25 at 2:19 PM, the Director of Nursing (DON) was interviewed and asked who responsibility it…

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 #1227212Based on observation, interview, record review the facility failed to consistently provide bathing assistance/services for one (R63) of seven residents reviewed for Activities of Daily Living (ADL). Findings include: On 7/29/25 at 11:59 AM, R63 was observed sitting in their wheelchair in the dining room. When asked, R63 explained they were supposed to get showers twice a week on Tuesdays and Fridays, however stated the staff had only been giving them a shower once a week. R63 stated last week they did not receive their Tuesday shower and today (Tuesday 7/29/25) they were supposed to receive a shower and had not. R63 stated they were unsure if they would receive their shower later in the day. On 7/30/25 at 1:36 PM, R63 was observed sitting in their wheelchair in their room. When asked if they received their Tuesday 7/29/25 shower, R63 replied . No, I had to gather what I could. and try to do a sponge bath in my bathroom. At this time, a record review was completed 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 ensure bed mobility was performed in a safe manner for one (R105) of three residents reviewed for accidents. Findings include: On 7/29/25 at 10:14 AM, R105 was observed lying in her bed. R105 was asked about care at the facility. R105 explained the day before, a Certified Nursing Assistant (CNA) had rolled her over in the bed not realizing the bed was away from the wall, she fell between the bed and the wall and hurt her foot. this was the second time they had taken x-rays of her foot because it was still hurting. R105's bed was observed to have the right side of the bed against the wall. R105 was asked if her bed was always in that position. R105 explained since the call light was located on the wall, staff were always moving her bed away from the wall so they could turn the light off and neither her nor the CNA had realized it was away from the wall when the CNA rolled her over, she just rolled off the bed.Review of the clinical record…

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 reviews the facility failed to ensure timely reviewal of the pharmacist recommendations, physician review/documented response of the pharmacist recommendations, maintain documentation of the pharmacist recommendations in the medical record and establish and implement a facility policy for drug regimen reviews for two (R's 30 & 121) of five residents reviewed for unnecessary medications. Findings include: R30On 7/29/25 at 11:17 AM, R30 was observed lying down on their back in bed. A brief interview was conducted with the resident at that time. A review of the medical record revealed R30 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia (difficulty speaking) and an anxiety disorder. A review of the medication regime review completed by the facility's pharmacist consultant revealed irregularities noted on the 5/3/25, 5/20/25 & 6/29/25 reviews. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for one (R96) of one residents reviewed for medical records. Findings include: On 7/29/25 at 10:11 AM, R96 was observed lying in her bed. R96's Family Member (FM) GG was also in the room and explained due to R96's aphasia (language disorder that affects communication) she was trying to get a Power of Attorney (POA) because her lawyer had told her not to get Guardianship because R96 was not incompetent.Review of the clinical record revealed R96 was admitted into the facility on 7/9/25 with diagnoses that included: stroke, aphasia and heart disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R96 had severely impaired cognition.Review of R96's progress notes revealed a Social Services note dated 7/19/25 at 8:45 AM by Social Services (SS) N that read in part, An admission assessment was completed with a reference date of 7/14/25. The resident is A&Ox3 (alert and orientated times 3 -…

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 facility staff had a clear understanding of the Binding Arbitration agreement and residents received a clear explanation of the agreement prior to signing a legal document for two (R84 and R80) of three residents reviewed for the Arbitration Task. Findings include: During the entrance conference the facility explained a Binding Arbitration agreement was offered to all residents admitted into the facility. The facility provided a list of residents that had agreed to the Binding Arbitration agreement that included R84 and R80.Review of the facility's document titled, Agreement To Resolve Legal Disputes Through Arbitration undated read in part, .Any legal controversy, dispute, disagreement or claim of any kind now existing or occurring in the future between the parties arising out of or in any way relating to this Arbitration Agreement or the Resident's stay. shall be settled by binding arbitration. THIS ARBITRATION AGREEMENT WAIVES THEIR RIGHT TO A TRIAL IN COURT AND A TRIAL BY A JURY FOR ANY LEGAL CLAIMS THEY MAY HAVE…

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 #MI00152409. Based on interview and record review the facility failed to address grievances for one resident, (R702) of two residents reviewed for grievances, resulting in verbalized frustrations with quality of care. Findings include: A complaint received by the State Agency alleged the facility failed to address multiple instances of resident/family grievances. On 5/15/25 at 12:58 PM, a review of a facility provided investigation file was conducted. The file contained a typed document prepared by Social Worker 'A' that read, During my phone call with (R702's family member) some concerns were expressed .(R702's family member) stated that during her visit yesterday (R702's) nurse was rude and she got into a, 'back-and-forth' with the nurse .(R702's family member) also reported that every time she has come to visit her mother, (R702) is soiled, sometimes to the point that her bedding is soaked . Continued review of the file included a Concern Form initiated by Social Worker 'A' and completed by the facility's Administrator. The section headed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00151836. Based on observation, interview, and record review, the facility failed to thoroughly investigate multiple falls to determine the root cause and implement effective interventions that included adequate supervision for one (R805) of two residents reviewed for falls, who had repeated falls, resulting in the resident falling 15 times in three months and sustaining a head injury and forehead laceration. Findings include: On 4/10/25 at 4:05 PM, R805 was observed in bed with eyes closed. R805 woke up upon entrance into his room. R805's water cup was observed on an over bed table that was not within reach of the resident. A wound of some sort was observed on R805's forehead. R805 did not participate in a conversation when addressed. A review of R805's clinical record revealed R805 was admitted into the facility on 1/8/25 and readmitted on [DATE] with diagnoses that included: dementia, psychotic disorder with delusions, and insomnia. A review of a Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00151890. Based on interview and record review, the facility failed to report an allegation of misappropriation of property to the Administrator and/or State Survey Agency for one (R802) of three residents reviewed for abuse. Findings include: A review of a complaint submitted to the State Survey Agency revealed allegations that included, Someone at the nursing home has been taking money from (R802) .There was a cell phone bill for $2000 from calls being placed to [NAME]. There was $400 used at (name of grocery store) up the street from the nursing home. Someone was using (R802's) cell phone to make purchases through account .Over the past several months there had been charges for (name of ride share company) rides, (name of grocery store) and (name of drug store). Someone has been purchasing gift cards using the money out of (R802's) account. The gift cards were purchased in (name of city) and (name of city) with her debit card. There have been thousands of dollars…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00151836. Based on observation, interview, and record review, the facility failed to ensure medications were stored properly and discarded by the expiration date for two of two medication carts reviewed. Findings include: On 4/10/25 at 8:36 AM, an observation of the [NAME] Unit was conducted. A medication cart was observed unlocked and unattended to. When the top drawer was opened, a plastic cup contained one small, round, clear, yellow pill. On 4/10/25 at approximately 8:40 AM, an interview was conducted with Licensed Practical Nurse (LPN) 'C'. LPN 'C' reported the medication cart should have remained locked when not attended to. When queried about the loose pill in the cart, LPN 'C' reported it was left there from midnight shift, but identified the pill as bezonatate (a medication to relieve coughing). LPN 'C' explained all medications should remain in their package and/or bottle until ready for administration. On 4/10/25 at 9:10 AM, an observation of the 3rd floor…

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 #MI00149313. Based on interview and record review the facility failed to ensure regularly scheduled bathing was provided for one resident (R902) of two residents reviewed for activities of daily living (ADL's). Findings include: On 3/5/25 a concern submitted to the State Agency was reviewed that alleged R902 was not receiving regular bathing. A grievance form dated 1/6/25 was reviewed and revealed the following: [R902] did not receive his shower on 1/2 . On 3/5/25 the medical record for R902 was reviewed and revealed the following: R902 was initially admitted on [DATE] and was discharged on 1/22/25. R902 had diagnoses including Heart failure and Weakness. A review of R902's MDS (minimum data set) with an ARD (assessment reference date) of 11/22/24 revealed R902 needed assistance from facility staff with bathing. A review of R902's comprehensive careplan revealed the following: Focus-I need assistance with my ADL's. Date Initiated: 11/17/2024 . A Physician's order dated 11/18/24…

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 #MI00147486. Based on observation, interview and record review the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act resulting in a delay in notification of the allegation to the abuse coordinator and delay in reporting the allegation to the State Agency for one resident (R901) of two residents reviewed for abuse/neglect/mistreatment. Findings include: On 10/28/24 a complaint submitted to the State Agency (SA) was reviewed that alleged R901 was physically and verbally abused by CNA C on 10/12/24. On 10/28/24 an initial FRI (facility reported incident) was reviewed in the State of Michigan reporting system that indicated the initial report of the allegation was submitted on 10/12/24 at 8:56 a.m., by the Director of Nursing (DON). On 10/28/24 at approximately 8:57 a.m., 8:57 a.m., during a conversation with the facility Administrator (who is also the 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 MI001146438, MI00146642, and MI00146819. Based on observation, interview, and record review facility failed to provide sufficient nursing staff to meet the needs of residents, including four (R802, R804, R805, and R806) of four residents reviewed for sufficient nursing staff. This deficient practice has the potential to affect all residents that reside at the facility. Findings include: Review of multiple concerns reported to the State Agency included allegations that residents were left for long periods of time in wet/soiled briefs, not provided with feeding assistance per plan of care, and were not being supervised adequately. R802 On 9/17/24 at 9:10 AM, R802 was observed lying in bed. R802 was asked about the care at the facility. R802 explained staffing had been a great issue lately; on the 2nd floor, there were only four CNA's scheduled, and usually at least one called in, so there would only be three CNA's to care for all the residents. When asked how many nurses were 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 interview and record review the facility failed to ensure the facility assessment was reviewed and revised in accordance with current regulatory requirements including changes in resident care needs (R805) and administrative changes, resulting in insufficient resources to provide for resident care and emergency/disaster needs for all 97 residents. Findings include: According to the Centers for Medicare & Medicaid Services (CMS) memo: QSO (Quality Safety & Oversight)-24-13-NH, dated 6/18/2024, revised Facility Assessment requirements effective 8/8/2024 included: .The facility assessment must address or include the following .The care required by the resident population .consistent with and informed by individual resident assessments as required under 483.20 .In conducting the facility assessment, the facility must ensure .Direct care staff, including but not limited to, RNs (Registered Nurses), LPNs/LVNs (Licensed Practical Nurses/Licensed Vocational Nurses), NAs (Nurse Aides), and representatives of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00146443. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident between two (R803 and R804) of 11 residents reviewed for abuse. Findings include: Review of a Facility Reported Incident (FRI) revealed there was a resident to resident incident that resulted in injury. On 9/16/24 at 10:00 AM, R803 was observed reading while seated in wheelchair next to their bed. When asked about the incident that occurred with R804 on 8/4/24, R803 pointed to the top of their right wrist and stated the scratch there won't go away. There was a linear scab approximately three inches in length to the top right wrist area. The resident reported R803 just came into their room and when they asked R803 to get out, that resident started beating them in the head and arm. Further review of the facility's investigation into the incident on 8/4/24 documented: [R803] has been a resident at the facility since…

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: MI00146438, MI00146642, and MI00146819. Based on observation, interview, and record review, the facility failed to provide one-to-one feeding assistance for one resident (R806) of three residents reviewed for activities of daily living. Findings include: Review of multiple complaints reported to the State Agency alleged residents were not being offered feeding assistance per their plan of care. The facility was previously determined to be out of compliance for concerns with provision of Activities of Daily Living (ADLs) during the recertification survey conducted on 7/17/24 with an alleged compliance date of 8/20/24. On 9/16/24 at 9:45 AM, R806 was observed in their room, laying in a reclined position in a gerichair. Their meal tray was observed placed on an overbed tray table directly in front of them that contained a Styrofoam container and a Styrofoam cup with a straw. R806 did not have a clothing protector on and was observed to have scrambled egg in the front of 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: MI00146642 and MI00146819. Based on observation, interview, and record review, the facility failed to provide drink and adaptive utensils per assessment and individualized care plan for one (R806) of three residents reviewed for dining. Findings include: Review of multiple complaints reported to the State Agency alleged residents were not being provided with food and drink per their plan of care. On 9/16/24 at 9:45 AM, R806 was observed in their room, laying in a reclined position in a gerichair. Their meal tray was observed placed on an overbed tray table directly in front of them that contained a Styrofoam container and a Styrofoam cup with a straw. R806 did not have a clothing protector on and was observed to have scrambled egg in the front of their neck and clothing. Upon approach, R806 reported they were upset since they usually were brought to the dining room for meals, but this morning they were not because they said it was due to a covid outbreak. When asked about if…

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 enough kitchen staff were available to prepare and serve meals in a timely manner. This deficient practice had the ability to affect multiple residents who received meals at the facility, including but not limited to R5, R28 and R64. Findings include: R5 On 7/15/24 at approximately 11:57 AM, R5 was observed sitting in a chair in their room. The resident's family member was present as well. R5 was alert but not able to answer all questions asked. R5's family member was interviewed at that time. The family member reported that R5 had been in the facility for about seven months and noted that their biggest concern was with staffing, specifically related to food services. The family member reported that on Saturday (7/13/24), R5 did receive their lunch very late (approximately 1:30 PM) and stated that the meal was incorrect and by the time they corrected it was about 15-20 minutes later. The family member noted that it was not the first…

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 sanitary kitchen, maintain equipment in good repair, and safely store and handle food, resulting in an increased risk of foodborne illness, affecting all residents in the facility. Findings include: On 7/15/24 at 9:18 AM, during an inspection of the kitchen, the following observation were made: 9:18 AM, a container of cooked eggs, tomato sauce, cheese, sliced ham, shrimp, deli meat, and chicken salad were observed to be stored in the walk-in cooler with no date marking to identify the discard date. Additionally, the floor in the walk-in cooler was observed to be soiled with dried spills and food debris. According to the 2017 FDA Food Code Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more…

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 observations, interview and record review, the facility failed to ensure all staff followed proper infection control practices and protocols including transmission-based precautions and Enhanced barrier precautions for five (R7, R18, R49, R63, R298) of five residents reviewed for Infection Control. Findings include: Prior to entering R7's room at approximately 9:47 AM on 7/15/24, an Enhanced Barrier Precaution (EBP) sign was observed near the resident's door. There was no personal protective equipment (PPE) in or near the resident's room, multiple staff members were observed entering and exiting the room without any PPE on or performing hand hygiene. Upon entering the room no PPE was noted to be disposed of in the trash can. R7 was observed to be lying on their back. On 7/15/24 at 12:17 PM, LPN L was observed outside of R7's room with the medication cart. LPN L was observed to have came out of the room with a used medication syringe. When asked which resident was on EBP they stated that they believed it…

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: MI00145365. Based on observation, interview, and record review the facility failed to protect the rights of one resident (R26) to be free from resident-to-resident verbal and physical abuse by R67 resulting in continued abuse to have occurred. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) documented in part . On May 31, 2024, (nurse name) observed (R67 name) and (R26 name) in the hallway. While approaching them (nurse) observed (R26) call (R67) a derogatory term. (R67) then proceed to hit (R26) with his walker. He hit her in her left shin. (R26) grabbed her leg and yelled out in pain. (nurse) immediately intervened and separated and redirected both residents back to their room. Review of the medical records for R's 26 & 67 documented this event to have occurred on 5/27/24, not 5/31/24 as submitted to the SA. On 7/15/24 at 9:30 AM, R26 was observed sitting in their wheelchair outside the nurses station. When asked about 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 deficient practices (DPS). DPS #1 Based on observation, interview and record review the facility failed to implement Physician treatment orders in a timely manner for one resident (R28) of three residents reviewed for pressure ulcers. Findings include: On 7/15/24 at approximately 10:11 a.m., R28 was observed in their room, laying in their bed. R28 indicated they were in pain and had wounds on their backside. R28 was queried if the staff were completing their wound dressings and they reported that sometimes dressings do not get changed. On 7/16/24 the medical record for R28 was reviewed and revealed the following: R28 was initially admitted to the facility on [DATE] and had diagnoses including Bipolar disorder and Cerebral Infarction. A review of R28's MDS (minimum data set) with an ARD (assessment reference date) of 4/20/24 revealed R28 needed assistance from facility staff with most of their activities of daily living. R28's BIMS (brief interview for mental status) score was 13 indicating…

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

Based on observation, interview, and record review, the facility failed to provide timely meals, resulting in late meal times outside of resident preferences and needs, affecting residents on the 2nd floor and in resident council. Findings include: On 7/16/24 at 9:30 AM, the breakfast meal time was observed to still be in progress. During an interview on 7/16/24 at 12:06 PM, Dietary Staff W confirmed that meals are often served late due to staffing issues. On 7/16/24 at 1:30 PM, the last meal tray was observed to be delivered on the 2nd floor. During an interview on 7/16/24 at 1:33 PM, LPN K was queried on the lunch times and stated that lunch usually finishes around 1:00PM to 1:30 PM. According to the Meal Times, document posted at each dining room, it notes, Breakfast: 1st Floor Pavilion: 7:30 AM, 2nd Floor Pavilion: 8:00 AM, 3rd Floor Pavilion: 7:30 AM Lunch: 1st Floor Pavilion: 11:30 AM, 2nd Floor Pavilion: 12:00 PM, 3rd Floor Pavilion: 11:30 AM Dinner: 1st Floor Pavilion: 5:30 PM, 2nd Floor Pavilion: 6:00 PM, 3rd Floor Pavilion: 5:30 PM On 7/16/24 at approximately 10:42 a.m.,…

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

Based on interview and record review, the facility failed to ensure the Infection Control Preventionist attended the QAPI (Quality Assurance and Performance Improvement) meetings at least quarterly, resulting in the potential for lack of coordination of resident care policies and overall medical care that could affect all 101 residents residing in the facility. Findings include: On 7/17/24 at 2:44PM, a review of the facility's QAPI program was conducted with the Nursing Home Administrator (NHA). Upon review of the sign-in sheets for the QAPI meetings held in 2024, it was noted that the infection control preventionist did not sign in at the January through June 2024 QAPI meetings. This was confirmed by the NHA, who stated she was not present at all meetings and there was no sign in for her but she should have signed if she was present. The Director of Nursing(DON) stated that the infection Control Preventionist joined the meetings via zoom. She was asked does she have any proof that they hold zoom QAPI meetings. The DON stated there was no way to show a zoom meeting. At 3:20PM, the…

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

Based on interview and record review, the facility failed to implement an antibiotic stewardship program that consistently identified signs and symptoms of infection and failed to provide clinical justification for the use of antibiotic medications with the potential to affect all residents (including R88) requiring antibiotics in the facility. Findings include: On 7/16/24 at 2:13 PM an email was sent to the Nursing Home Administrator (NHA) requesting the infection control logs/books for the past six months. On 7/16/24 at 3:06 PM NHA replied via email, stating that Infection Preventionist (IP) Nurse A would be available on 7/17/24 at 2:30 PM. On 7/16/24 at 3:11 PM an email was sent to NHA stating If at all possible, we will need to have access to this information to review much sooner as there is A LOT of information to review. Is there anyone else that can assist with it? On 7/16/24 at 3:33 PM NHA replied via email stating IP nurse A (name redacted) will have the books ready for you tomorrow morning and will be back at 2:30pm tomorrow for questions. On 7/17/24 at 9:39 AM email…

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 accurate advance directive information, including social service assessment and a physician order for a Do-Not-Resuscitate (DNR) was in place for one (R83) of five residents reviewed for advance directives. Findings include: Review of the facility's advance directive form signed and dated by R28 and Physician 'G' on 2/13/24 documented R83's code status was to be a DNR. Review of the current advance directive (AD) order that was active since 8/19/23 read, AD: Full Code. On 7/15/24 at 11:00 AM, R83 was asked about their code status and reported they wanted to be a DNR and had completed that paperwork. Further review of the clinical record revealed R83 was admitted into the facility on 8/19/23 with diagnoses that included: congestive heart failure, permanent atrial fibrillation, adjustment disorder with depressed mood, and chronic respiratory failure with hypoxia. According to the Minimum Data Set (MDS) assessment dated [DATE], R83 had intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete an annual OBRA (Omnibus Budget Reconciliation Act) Level I evaluation to determine if a Level II Evaluation was needed, or if exemption was identified for one (R31) of one resident reviewed for PASARR (Preadmission Screen and Resident Review). Findings include: A review of R31's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: psychotic disorder, Lewy Body Dementia and Parkinsonism. A review of the Minimum Data Set (MDS) noted a Brief Interview for Mental Status (BIMS) score of 4/15 (severely cognitively impaired). Continued review of R31's clinical record revealed a document titled PASRR Level 1 (DCH-3877). Section 1 was completed documenting the resident's personal information and information about their legal representative. Section II documented Yes to four questions that noted the resident had diagnoses of both mental illness and dementia and listed the antipsychotic medications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a care plan for oxygen use and specific transmission-based precautions for one (R18) of 25 residents reviewed for comprehensive care plans. Findings include: On 7/15/24 at 11:18 AM, R18's call light was observed activated (lit up in hallway outside of the room). There was signage posted outside the door that identified R18 was on transmission-based precautions, specifically contact precautions. Upon entry into the resident's room, oxygen was observed in use via nasal cannula. R18 was unable to respond to simple questions asked. Review of the clinical record revealed R18 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: metabolic encephalopathy, cognitive communication deficit, other pericardial effusion, and epilepsy. According to the Minimum Data Set (MDS) assessment dated [DATE], R18 had severely impaired cognition, and did not receive oxygen. Further review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a shower for one (R349) of three residents reviewed for activities of daily living. Findings include: On 7/15/24 at 10:27AM, R349 was observed in their room visiting with family. When asked how was the care that they received, R349 and a family member both stated that the facility was fine but they did not know any schedules and would like to receive a shower. The family member was then asked how many showers have they received and they stated one on Saturday (7/13/24). They further stated the only reason they (facility staff) gave R349 one was because they came up to the facility ready to give them a bath themselves. R349 then stated, I ask for a shower all the time but I just don't know when I should get one and I was supposed to get one on this passed Wednesday, but something happened and I didn't get it. A review of the record revealed that R349 was readmitted to the facility on [DATE] with diagnoses that included: effusion…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident was transferred appropriately to prevent injury and ensure a thorough investigation was completed for one (R26) out of three residents reviewed for accidents/falls. Findings include: On 7/15/24 at approximately 9:30 AM, R26 was observed in their wheelchair outside the nurse's station. The resident was alert, but not able to accurately answer most questions asked. A review of R26's clinical record revealed the resident was originally admitted to the facility on [DATE] with diagnoses that included: heart failure, diabetes type II, dementia and bipolar disease. A review of the Minimum Data Set (MDS) dated [DATE] noted that the resident had a Brief Interview for Mental Status (BIMS) score of 5/15 (severe cognitive impairment). The resident's care plan (5/30/24) noted the resident was a two-person assist for transfers utilizing a [NAME] sit-to-stand machine. Continued review of R26's clinical record documented, in part, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medication regimen reviews were conducted by the consultant pharmacist monthly for one (R18) of five residents reviewed for medication regimen reviews. Findings include: Review of R18's monthly medication regimen reviews from August 2023 to July 2024 revealed there were no monthly regimen reviews documented in the clinical record for August 2023, December 2023, and March 2024. Further review of the clinical record revealed R18 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: metabolic encephalopathy, cognitive communication deficit, other pericardial effusion, candidal stomatitis, bacteremia, dysphagia, epilepsy, osteoarthritis, cerebral ischemia, urinary tract infection,benign paroxysmal vertigo bilateral, presence of neurostimulator, major depressive disorder recurrent, moderate, insomnia, bipolar disorder, unspecified severe protein-calorie malnutrition, essential hypertension,…

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, & record reviews the facility failed to ensure residents were free from significant medication errors in regard to seizure medications for two (R18 and R88) of two residents reviewed for medication errors, resulting in delayed administration, delayed physician notification, and increased seizure risk. Findings include: R18: On 7/15/24 at 11:28 AM, Nurse 'H' was observed across the hall from R18's room. When asked about whether the resident had received their morning medications, Nurse 'H' reported they had not and were currently trying to cover as there was a call-in. 07/15/24 12:26 PM, review of R18's Medication Administration Records (MARs) revealed they had not yet received their morning medication as prescribed by the physician. Further review of these medications included the following anti-seizure medication: Clobazam Oral Tablet 10 MG (Milligram)- give 2 tablet by mouth two times a day for anticonvulsant (ordered to be given at 9:00 AM and 9:00 PM). The last documented…

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 timely notify the physician of abnormal laboratory results for one (R26) of two reviewed for laboratory services. Findings include: On 7/15/24 at approximately 9:30 AM, R26 was observed in their wheelchair outside the nurse's station. The resident was alert, but not able to accurately answer most questions asked. A review of R26's clinical record revealed the resident was originally admitted to the facility on [DATE] with diagnoses that included: heart failure, diabetes type II, dementia and bipolar disease. A review of the Minimum Data Set (MDS) noted that the resident had a Brief Interview for Mental Status (BIMS) score of 5/15 (severe cognitive impairment). Continued review of R26's clinical record noted the following: Behavior Note (7/8/24): R26 continues to yell help repeatedly, again tonight .She is not sleeping and has not had any quiet rest periods for more than few minutes at a time tonight .continues to lay in bed yelling 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 This citation pertains to intake #MI00145467. Based on observation, interview and record review, the facility failed to ensure resident food preferences were honored for six residents (R28, R36, R49, R56, R72, R74, and R78) as well as multiple attendees at the confidential resident council meeting, resulting in verbalized complaints and dissatisfaction with meals. Findings include: Review of a complaint reported to the State Agency alleged ongoing issues with the facility's food and read, .The facility has been out of a lot of different foods since last week .Residents are getting cold food and don't have many options for meal choices .the residents are being served peanut butter & jelly sandwiches for meals. According to the facility's policy titled, Food Preferences dated 5/2023: .Resident food and beverage preferences will be obtained upon admission and periodically as needed to assist the Food & Nutrition Services department in providing preferred food and beverages to enhance/maintain quality of life and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake(s): MI00144553 & MI00144307. Based on observation, interviews, and record reviews the facility failed to document follow-up and addressed concerns per the facility's Concern/Complaint Policy and Procedure for two (R's 901 & 902) of two residents reviewed for quality of care. Findings include: R902 Review of a complaint submitted to the State Agency (SA) documented concerns regarding the resident food preferences to not be honored, non-edible overcooked food and not being offered ice water. On 6/3/24 at 11:30 AM, R902 was observed in their room sitting in their electronic wheelchair. When asked, R902 stated the facility's food service and delivery was not consistent. R902 stated sometimes the meat is so hard they can't bite into it and staff are unable to cut it. R902 stated the facility didn't have milk for a few days recently and complained about the facility's staff not honoring their meal selections. R902 stated that they met with the Ombudsman to talk about these concerns…

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 #MI00143969. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, safe, and homelike environment, as evidenced by offensive odors, soiled floors, walls, and trash/debris left in the main dining rooms. This deficient practice has the potential to affect multiple residents throughout the facility. Findings include: Review of complaints filed with the State Agency included allegations that the facility was not clean. The following observations were conducted from 4/29/24 - 4/30/24: On 4/29/24 at 11:15 AM, upon exiting the elevator to the third floor there was a strong, lingering urine odor that was pervasive throughout the entire floor. At 4/29/24 at 2:40 PM, the strong urine odor remained. On 4/29/24 at 11:24 AM, upon entering the second-floor dining room, the floor was observed to have scattered debris and was very sticky (this Surveyor's shoes stuck to the floor when attempting to walk). The flooring throughout the satellite kitchen within this dining room was soiled and had small papers discarded…

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 #MI00143969. Based on observation, interview, and record review, the facility failed to ensure infection control protocols (handwashing and/or use of hand sanitizer) were followed for a resident on enhanced barrier precautions (EBP) for one (R904) resident reviewed for infection control. Findings include: Review of complaints filed with the State Agency included an allegation that the facility filed to follow proper infection control protocols. According to the facility's, Pavilion Enhanced Barrier Precautions Protocol dated Revised on 3/31/2024: .Enhanced Barrier Precautions (EBP) refer to the use of additional personal protective equipment (PPE) and infection control measures to prevent the transmission of infectious agents, particularly in individuals with MDRO (Multi-Drug Resistant Organism) infection or colonization, indwelling devices, and wounds/chronic wounds .Practice hand hygiene by thoroughly washing hand for at least 20 seconds . On 4/29/24 at 12:42 PM, there was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews/record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one (R900) of one resident reviewed for abuse. Findings include: On 4/29/24 at 11:30 AM, an interview was conducted with R900 (resident named in the complaint). R900 reported CNA (certified nursing assistant) T came into his room to change his brief and when CNA T turned him on his right side they were rough and injured his left knee (swelling and pain) and his left hand (skin tear), R900 reported that he had a prior injury to the same knee and that the incident further aggravated it. On 4/49/24 at 2:49 PM DON (director of nursing) was queried regarding their investigation process for the potential abuse of R900 by CNA T. The DON reported that they were notified about the incident on the weekend. It was reported that the CNA T was rough with the resident, CNA T was immediately suspended, incident…

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

Based on observation, interview, and record review, the facility failed to ensure resident dignity for 10 residents (R#'s 58, 6, 82, 73, 52, 56,68,64, 307, and 11) of 10 residents reviewed for dignity, resulting in the potential for embarrassment and decreased feelings of self worth. Findings include: A review of a facility provided policy titled, Quality of Life-Dignity was conducted and read, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . A review of a second facility provided policy titled, Dining Policy was conducted and read, .8. For those residents that require assistance with feeding, staff will be seated so that they are at the level of the resident to ensure a dignified dining process . On 7/18/23 from 11:40 AM until 12:33 PM, an observation of the third floor dining room was conducted. During the observation R58, R6, R82, and R73 were observed seated together at a table. R6 and 73 were observed eating their lunch meal, however; R58 and and R82 had not been served their lunch. At 11:55 AM, R58…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, and homelike environment for four residents, (R#'s 52, 58, 82, and 10) of four residents reviewed for physical environment. Facility also failed to maintain a clean comfortable home like environment in the dining room on the second floor that had the potential to impact all residents who were using the dining room for their meals and other activities. Findings include: On 7/18/23 at 9:52 AM, the material on the left side padded armrest of R82's wheelchair was observed to be cracked and peeling away from the padding. On 7/18/23 at 10:06 AM, R52 was observed in the common area of the third floor engaged in a group activity. At that time the right side padded armrest was observed to have duct tap securing the material to the armrest. At that time, R58 was also observed engaged in the group activity and it was observed the material on both the right and the left armrests was cracked and peeling. On 7/19/20 at 2:00…

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 annual competencies/performance reviews for five of five Certified Nurse Aides (CNA's) reviewed for annual competencies. This deficient practice had the potential to affect all residents. Findings include: 07/20/23 12:57 PM, a review of Certified Nurse Aide 'D' 'E', 'F', G' and 'U's 12-hour in-service education records, CNA certifications, and annual competency/performance review evaluations was conducted. It was discovered there were no annual competency evaluations for those staff members. On 7/20/23 at 1:07 PM, an interview was conducted with Staff Development Manager, Nurse 'L' regarding the competencies/performance reviews. They said they did not have them and didn't think any had been done since before the start of the COVID-19 pandemic. A review of a facility provided policy titled, In-Service Training Program, Nurse Aide was conducted and read, .2. The facility will complete a performance review of nurse aides at least every 12 months. In-service training will be based on the outcome of the annual…

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 report an allegation of abuse to the Abuse Coordinator and/or State Agency for one (R86) of two residents reviewed for abuse. Findings include: On 7/18/23 at 11:32 AM, R86 was observed lying in bed. R86 was asked about care at the facility. R86 explained she had been humiliated by a couple of Certified Nursing Assistants (CNA's) a couple of days previous. When asked if she had told anyone at the facility about the incident, R86 explained she had told the Supervisor. Review of the clinical record revealed R86 was admitted into the facility on 5/29/23 and readmitted [DATE] with diagnoses that included: mysthenia gravis, stroke and fracture of left lower leg. According to the Minimum Data Set (MDS) assessment dated [DATE], R86 was cognitively intact and required the extensive assistance of staff for all activities of daily living (ADL's). On 7/19/23 at 10:12 AM, the Administrator was asked for grievance forms and/or investigations for R86.…

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 updated/revised plan of care was in place for a contracture for one resident (R38) of four residents reviewed for range of motion/positioning. Findings include: On 7/18/23 at approximately 12:45 p.m. R38 was observed in their room, sitting in their chair. R38 pointed at their left hand that appeared to be contracted. No splint or protective roll was observed in the hand and R38's fingernail appeared to be long and pointed in towards the center of the palm. On 7/20/23 at approximately 8:28 a.m. R38 was observed in their wheelchair in the dining room. R38's left hand still appeared to be contracted with no protective devices or interventions applied. R38's fingernail was still observed to be long and pointed into the palm of the hand. On 7/18/23 the medical record for R38 was reviewed and revealed the following: R38 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Age-related Osteoporosis…

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 timely and appropriate assistance with Activities of Daily Living (ADL) for two (R6 and R8) of six Residents reviewed for ADL care with potential for negative physical, psychosocial outcomes, and potential loss of dignity for residents who are dependent on staff for assistance. Findings include: R8 R8 was admitted to the facility on [DATE]. R8's admitting diagnoses included congestive heart failure, diabetes, polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body) and paraplegia (paralysis of the legs and lower body). R8 was receiving hospice services as of 7/11/23. R8 had a Brief Interview of Mental Status (BIMS) score of 11/15, indicative of moderate cognitive impairment. R8 was dependent on staff assistance to get in and out of their bed. An initial observation was completed on 7/18/23, at approximately 2:30 PM. Staff were assisting R8. R8 reported that they would like to get out of bed every day…

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 up timely with the physician and/or to transfer a resident who had a change of condition to an acute care setting for one (R355) of one reviewed for change of condition resulting in the potential for a decline in health. Findings include: A record review revealed that R355 was originally admitted to the facility on [DATE] and most recently readmitted after hospitalization on 7/7/23. R355's admitting diagnoses include seizures, urinary tract infection, dementia, encephalopathy (any disease that affects the whole brain and alters its structure or how it works, and causes changes in mental function), and osteoarthritis. R355 had a Brief Interview of Mental Status (BIMS) score of 14/15, based on Minimum Data Set assessment completed on 5/17/23. R355 was recently admitted to hospital on [DATE] due to worsening edema, drowsiness and weakness and they were readmitted to the facility on [DATE]. Based on R355's nursing admission assessment…

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 properly transfer one resident (R6) who required a mechanical lift of four residents reviewed for accidents. Findings include: A review of a facility provided policy titled, Lifting Machine, Using a Mechanical was conducted and read, .1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift .Steps in the Procedure 1. Before using a lifting device, assess the resident's current condition, including: a. Physical: (1) Can the resident assist with transfer? (2) Is the resident's weight and medical condition appropriate for the use of a lift . On 7/19/23 at 8:31 AM, Certified Nurse Aide (CNA) 'A' was observed transferring R6 from a reclining chair to their Broda (specialized) wheelchair. CNA 'A' was observed to grab R6 around the waist, pull them up, pivot them, and place them in their Broda Chair. CNA 'A' was then observed to pull R6 back…

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 ensure assistance with eating was provided to one resident (R60) of five residents reviewed for Nutrition. Findings include: On 7/19/23 at approximately 1:13 p.m., R60 was observed in the dining room on the 2nd floor with their lunch meal in front of them. R60 was observed to have spilled milk on the floor and table with their head bowed down on the table. No staff member was observed assisting R60 with the lunch meal. R60 had approximately 50% of the meal remaining on their plate. On 7/20/23 at approximately 8:33 a.m., R60 was observed being served their breakfast meal in the dining room. R60 was observed to start eating the meal with their bare hands. R60 was not observed to have any assistance from facility staff with eating their breakfast meal. On 7/20/23 at approximately 9:03 a.m., during a second observation, R60 was still observed to be slowly eating their breakfast…

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 resident who was prescribed as needed (PRN) psychotropic medication had adequate behavior monitoring and identification of the resident specific targeted behaviors and non-pharmacological approaches at the time of medication administration for one (R5) of five residents reviewed for unnecessary medication Findings include: A review of a facility provided policy titled, Psychotropic Medication Policy was conducted and read, .Physicians and mid-level providers will use psychotropic medications appropriately working with the Interdisciplinary Team to ensure appropriate use, evaluation, and monitoring .Standards 3. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident .Responsible Party-Actions Required: Primary Care…

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