Marvin & Betty Danto Health Care Center

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, homelike environment for for five residents, (R#'s 105, 46, 16, 17, 58, 84, and 30) of five residents reviewed for a homelike environment, and for 11 residents (who wished to remain anonymous) from the group meeting, resulting in verbalized complaints regarding the environment, housekeeping, and laundry services. Findings include: On 1/7/25 at 9:40 AM, the tube feeding pole in room [ROOM NUMBER] was observed to have dried up tube feeding formula staining the length of the pole and on the braces holding the wheels. On 1/7/25 at 9:55 AM the wall behind R16's bed was observed with a large area of missing paint and numerous long and deep gouges in the drywall. On 1/7/25 at 10:05 AM, room [ROOM NUMBER]-W (bed at the window side of room) was observed to have dirty clothing, crumbs, empty food and beverage packaging, food and paper debris, and empty pistachio shells strewn about the floor. It was further observed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medication were administered and documented per professional standards for two residents, (R#'s 47 and 104) of five residents reviewed for professional standards with medication administration and documentation resulting in verbalized complaints of not receiving as needed pain medications on time and inaccurate medical record keeping. Findings include: R47 On 1/7/25 at 10:47 AM, an interview was conducted with R47. They said they did not believe the nursing staff were accurately recording the times they received their as needed narcotic pain medication resulting in them experiencing a delay of receiving their next as needed doses. On 1/8/25 at 2:23 PM, a review of R47's clinical record revealed they admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included: heart failure, diabetes, and chronic kidney disease. R47's most recently completed Minimum Data Set assessment revealed R47 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 Based on observation, interview, and record review, the facility failed to ensure Hospice services were provided per plan of care for one resident, (R4) of one resident reviewed for Hospice, resulting in R4 not receiving Hospice services per the provisions. Findings include: On 1/7/25 at 10:25 AM and 1:05 PM, R4 was observed in their bed asleep. On 1/8/25 at 11:25 AM, a review of of R4's clinical record revealed they admitted to the facility on [DATE], and most recently re-admitted on [DATE] with diagnoses that included: multiple sclerosis, pressure ulcers, osteomyelitis (bone infection, anxiety disorder, dementia, and contractures. R4's most recent Minimum Data Set assessment revealed R4 had moderately impaired cognition and required assistance from staff for activities of daily living. On 1/7/25 at 12:54 PM, continued review of R4's record revealed they signed on for Hospice services on 10/14/24. A review of the Hospice plan of care and orders for the benefit period of 10/14/24 thru 1/11/25 was conducted 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 and interview, the facility failed to ensure proper storage of medications for four of four medication carts reviewed for medication storage. Findings include: On 1/8/2024 at 8:52 AM, an observation of the 700-1 Medication Cart was conducted with Licensed Practical Nurse (LPN) B. The following medications were observed throughout the cart unpackaged and without patient identifiers. 1 WHITE ROUND TAB 1 1/4 TAB 1 WHITE OVAL 1 SMALL WHITE ROUND 1/Z 1 ROUND WHITE R/196 1 WHITE ROUND 1 PEACH ROUND EP102 2 OBLONG YELLOW NVR/17 3 PINK OBLONG 894/5 1 PEACH EP102 Insulin Pen (Humalog) observed with no patient identifier, only room [ROOM NUMBER] D written in black marker. On 1/8/2024 at 9:18 AM, an observation of the 600 Medication Cart was conducted with LPN C. The following medications were observed throughout the cart unpackaged and without patient identifiers. 1/2 WHITE TAB 3 PEACH ROUND EP102 1 WHITE ROUND AC41 2 ROUND WHITE EP116 1 OBLONG GREEN 45E1 1 WHITE ROUND 128C 3 YELLOW OBLONG 88H 1 WHITE…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to obtain an assessment and physician's order for self-administration of medications for one (R98) of one resident reviewed for self-administration of medication/treatments. Findings include: On 1/7/25 at approximately 10:20 AM, R98 was observed lying in bed. The resident was alert and able to answer questions asked. During the interview, several medical ointments/treatments were observed on the resident's shelf and on their tray table next to their bed. Observations included the following: Hydrocortisone 1%, Antibiotic creams, Icy hot and Bio freeze. When asked about the medications, R98 reported that they can put some of them on themselves or staff can put them on as well. On 1/8/25 at approximately 11:50 AM, R98's room was observed. The medications remained in the room on the resident's shelf. At approximately 12:00 PM, Nurse 'D who was assigned to the hall where R98 resided,entered the room with the Surveyor and noted the 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 ensure timely and accurate advanced directives information was in place and ensure resident wishes were timely implemented for two R66 and R2 out of four residents reviewed for Advanced Directives. Findings include: R66 On [DATE] at approximately 10:30 AM, R66 was observed lying in bed. The resident was alert, but not able to answer any questions asked. A review of R66's clinical record noted the resident was initially admitted to the facility on [DATE] with diagnoses that included: dementia, chronic kidney disease and anxiety. A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was severely cognitively impaired. The top of the resident's electronic face sheet indicated the resident was a FULL CODE. Continued review of R66's clinical record noted a form titled, Advance Directives/Medical Treatment Decisions ([DATE]) that documented: This is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess a resident for alternative or augmentative communication methods to ensure functional communication for one Resident (R91) of one resident reviewed for activities of daily living. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 9/26/24, revealed R91 was admitted to the facility on [DATE], with diagnoses including stroke, aphasia (difficulty speaking), hemiplegia or hemiparesis (paralyzed or weak limbs), seizure disorder, and depression. The sensory assessment revealed R91 had adequate hearing and vision, was non-verbal, and showed they could rarely communicate their needs. The Brief Interview for Mental Status (BIMS) assessment revealed R91 could not participate. The activities of daily living assessment showed R91 could eat independently without set-up. On 1/07/25 at 12:10 p.m., R91 was observed in their bed eating their lunch. R91 pointed angrily at their meal card ticket with their left hand and held 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 Based on observation, interview, and record review the facility failed to ensure an order for supplemental oxygen for one resident (R17) of one resident reviewed for oxygen. Findings include: On 1/7/25 at 10:40 AM, R17 was observed up in their wheelchair. An oxygen concentrator powered on was observed at the the bedside with the nasal cannula tubing draped over the top of the concentrator. It was observed the concentrator delivery rate was set at two liters. An interview was attempted, however; R17 was did not respond to attempts at verbal communication. During the observation, staff were observed to enter the room and place the nasal cannula delivering oxygen on R17. On 1/7/24 at approximately 12:50 PM and 2:35 PM, R17 was observed up in their wheelchair at the bedside with two liters of oxygen being delivered via nasal cannula from the concentrator. On 1/8/25 at 9:00 AM, 11:04 AM and 1:06 PM, R17 was observed in their bed with two Liters of oxygen being delivered via nasal cannula from the concentrator. 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 provide appropriate interventions to prevent triggers for one Resident (R8) of one resident reviewed for trauma-informed care and Post Traumatic Stress Disorder (PTSD). Findings include: Review of R8's Minimum Data Set (MDS) assessment, dated 9/27/24, revealed R8 was admitted to the facility on [DATE], with current diagnoses including heart failure, depression, anxiety, and PTSD (Post Traumatic Stress Disorder). R8 had no physical, verbal, or other behaviors towards others. R8 required supervision or touching assistance with bed mobility and transfers, and minimal assistance for toileting. The depression assessment (PHQ-9) showed a score of 19/27, which revealed moderately severe depression. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, showing R8 was cognitively intact. On 1/08/25 at 11:24 a.m., R8 was observed in their bariatric hospital bed. R8 reported they were struggling to adjust to being a long-term 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a medication error rate less than five percent when three medication errors were identified from a total of 41 opportunities for one resident (R104) of five residents observed during medication administration, resulting in a medication error rate of 7.32%. Findings include: Clinical record review revealed R104 was admitted to the facility on [DATE] with medical diagnoses including hypertension, heart failure, prostate cancer, thyroid disorder, and renal Insufficiency. Brief Interview of Mental Status (BIMS) scored 15/15 indicating R104 was cognitively intact. On 1/8/25, at 10:34 AM, Licensed Practical Nurse (LPN) A was reviewed for medication administration and was observed inaccurately measuring ordered 17 grams MiraLAX (a laxative medication) resulting in R104 receiving a lesser dose than ordered. On 1/8/25 at 4:12 PM, A medication reconciliation was conducted for R104 and revealed LPN A administered Metoprolol (heart failure,…

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 #MI00146798. Based on observation and interview, the facility failed to provide an environment that promoted and enhanced residents' dignity for three (R805, R806 and R807) of seven residents reviewed for dignity and respect. Findings include: Review of complaints reported to the State Agency included allegations that residents were not being treated with dignity and respect. On 11/19/24 at 9:37 AM, the call lights were observed activated and sounding at the nursing desk for the rooms occupied by R805, R806 and R807. On 11/19/24 at 9:38 AM, Certified Nursing Assistant (CNA 'A') was observed coming from a resident room while carrying a meal tray and entering into the room occupied by R806 and R807 without announcing themselves, or knocking before entering. CNA 'A' was then observed to go to R807's side of the room and asked in a gruff, rushed tone, What do you want?. Upon CNA 'A' exiting R806 and R807's room, they were asked to answer a few brief questions. During the interview, CNA 'A' began to make statements about why the call lights were on, 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: MI00145092. Based on observation, interview, and record review the facility failed to timely implement effective wound interventions/treatments and ensure physician follow-up, assessment, and monitoring of a worsening wound for one (R502) of two residents reviewed for skin concerns. Findings include: Review of a complaint submitted to the State Agency documented concerns of the facility's failure to prevent worsening of R502's pressure ulcers. On 6/26/24, R502 was observed in their room sitting in their wheelchair. Blue inflated boots were observed on the resident's bed. R502 requested to be assisted to the community room to conduct the interview. R502 was assisted by staff to the community room and an interview was conducted with R502. R502 was asked if they had any wounds on their body and R502 said they had one on their buttocks and one on each heel. When asked if they ever refused to be turned and repositioned in bed or to wear the inflated blue boots observed on their bed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00145236 Based on observation, interview, and record review, the facility failed to ensure freedom from physical restraints for one resident (R503), of one resident reviewed for restraints, resulting in staff reported observations of the resident's feet and legs tied in a knot with blankets and multiple staff reports of having received an in-service education on restraints. Findings include: A complaint was received by the State Agency that alleged a resident had been physically restrained on the afternoon shift of 6/17/24. On 6/27/24 at 9:45 AM, R503 was observed in the dining area between the 500 and 600 unit seated in their wheelchair. An interview was attempted, however; R503 did not respond appropriately. A review of R503's clinical record revealed they admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included: moderate protein calorie malnutrition, heart disease, adjustment disorder with anxiety, falls, and dementia. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00145236 Based on observation, interview, and record review, the facility failed to ensure abuse was immediately reported to the abuse coordinator and reported to the State Agency for one resident, (R503) of two residents reviewed for abuse. Findings include: A complaint was received by the State Agency that alleged a resident had been physically restrained on the afternoon shift of 6/17/24. On 6/27/24 at 9:45 AM, R503 was observed in the dining area between the 500 and 600 unit seated in their wheelchair. An interview was attempted, however; R503 did not respond appropriately. A review of R503's clinical record revealed they admitted to the facility on [DATE] and most recently readmitted [DATE] with diagnoses that included: moderate protein calorie malnutrition, heart disease, adjustment disorder with anxiety, falls, and dementia. Further review of the record revealed R503 received Hospice services. On 6/27/24 at 10:45 AM, an interview was conducted with Certified Nurse Aide…

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 #MI00142694 Based on observation, interview and record review the facility failed to ensure an oxygen dependent resident was provided continuous oxygen per Physicians order for one resident (R802) of one residents reviewed for respiratory care. Findings include: On 2/21/24 a complaint submitted to the Stage Agency was reviewed which indicated R802's oxygen tank ran out of oxygen, resulting in R802 having a lower oxygen saturation rate. On 2/21/24 at approximately 1:11 p.m., R802 was observed in their room, up in their wheelchair. R802 was observed to be having oxygen therapy administered via their tank on the back of the wheelchair at 6L (liters) per minute. R802 was queried how they were breathing and they indicated that it was ok but that the staff wanted them on eight LPM (liters per minute) but they were ok at six LPM. R802 then reported that they had an issue about 1.5-2 weeks ago in which the facility had forgot to provide them with a new oxygen tank and they ran out 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 This citation pertains to intake #MI00138332 and MI00138733. Based on observation, interview and record review, the facility failed to ensure four residents (R20, R21, R62 and R81) of six residents reviewed for dignity were treated in a dignified manner. Findings include: According to the facility's policy titled, Quality of Life-Dignity dated 3/2021: .Residents shall be treated with dignity and respect at all times .Demeaning practices and standards of care that compromise dignity are prohibited . R21 On 12/12/23 12:31 PM, R21 was observed seated in their geri-chair being assisted with their lunch meal by CNA 'N'. CNA 'N' was observed sanding at the side of the geri-chair over top of R21 feeding them the meal. On 12/12/23 at 2:02 PM, R21 was observed laying in bed while yelling out Oh, oh, help me my butt and repeatedly yelling out and moaning. In the room next door to R21, Housekeeper 'G' was observed laughing and making jerking movements every time R21 would yell out, in which the other resident in the room…

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 equal choices of dining for seven of nine residents that attended the confidential resident council, and two (R42 and R55) of six residents reviewed for resident rights, resulting in expressions of frustration, feelings of isolation, and decreased fulfillment of personal autonomy and personal choices. Findings include: According to the facility's policy titled, Resident Rights dated 2/2023: .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .self-determination .exercise his or her rights as a resident of the facility and as a resident or citizen of the United States .exercise his or her rights without interference, coercion, discrimination or reprisal from the facility .be informed about his or her rights and responsibilities .be informed of safety or clinical restriction or limitations of visitation . On 12/13/23 at 11:15 AM, a confidential resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to protect Protected Health Information (PHI) for four (R4, R17, R79 and R102) residents from being displayed in a manner viewable to anyone that passed by the nursing station. Findings include: According to the facility's policy titled, Resident Rights dated 2/2023: .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .privacy and confidentiality . Observations from 12/12/23 to 12/14/23 revealed a white-board that hung from a center wall facing out of the nursing station to anyone passing by contained information in large lettering that identified R4, R17, R79 and R102 were on dialysis, including what time they were to be picked up. R4 Review of the clinical record revealed R4 was admitted into the facility on [DATE] with diagnoses that included: end stage renal disease and dependence on renal dialysis. R17 Review of the clinical record revealed R17 was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00134994 Based on observation, interview and record review, the facility failed to provide a clean, comfortable, safe and home-like environment to ensure that hallways, ceilings, lights, shower rooms, and equipment used for multiple residents were clean and in good repair affecting multiple residents (including R57, R86 and R63) as well as seven of nine that attended the confident resident council meeting, resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness and upkeep. Findings include: According to the facility's policy titled, Quality of Life - Homelike Environment dated 2/2023: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting .Clean, sanitary 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 proper storage, labeling, and discarding of drugs and biologicals, resulting in the potential for misuse, contamination, and medication administration errors. Findings include: On 12/13/23 at 1:18 PM, upon walking through the 700 hallway a treatment cart was observed in the hallway outside room [ROOM NUMBER]. The treatment cart was unlocked and there was no nursing staff observed in the hallway and/or in direct supervision. The treatment cart drawers were accessible due to being unlocked and observed to contain multiple residents treatment supplies and biologicals. Next to this treatment cart was a medication cart that contained an insulin pen and an inhaler for a resident. Placed just next to the medication cart was an over-bed tray table that contained two uncovered clear cups of a pink cream substance. On 12/13/23 at 1:20 PM, a nursing assistant was at a computer behind the nursing station and when asked about who the Nurse 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.

Based on observation, interview, and record review, the facility failed to ensure resident food items were labeled, dated, and discarded when expired, and failed to maintain the resident popcorn machine in the activity room in a sanitary manner. This deficient practice had the potential to affect all residents that store food in the resident refrigerator and consume popcorn from the activity room. Findings include: On 12/12/23 at 10:00 AM, the resident refrigerator located in family dining room was observed with the following: An undated foil container of an unknown food item. An undated small plastic container of an unknown food item. An undated container of soup. An undated plate of an unknown food item. An undated deli sub sandwich. An undated Greek salad. An undated container of potato salad. 3 containers of soup dated 11/17. An opened, undated container of deli turkey (with a manufacturer's best by date 11/3/23). An opened, undated jar of miracle whip. There was a sign on the refrigerator that noted, All containers must be labeled and dated. On 12/12/23 at 1:00 PM, when queried…

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 consistently provide translator services in a language that could be understood for two residents (R7 and R99) of two residents reviewed for communication and understanding, resulting in the potential for inaccurate assessments, unmet care needs and the potential for the resident to not participate in their care. Findings include: On 12/12/23 at 11:03AM, R7 was observed in room sitting in bed, an interview was attempted. R7 was asked how everything was going and R7 replied, I don't understand, I don't understand. With further observation, R7's eye was crusted shut. R7 pointed to their eye and gestured. R7 replied, It happened long time ago in English, and then finished the conversation in a different language. Record review revealed that R7 was admitted to the facility on [DATE] with a diagnosis of dementia, insomnia and delirium with a brief interview for mental status(BIMs) score of 00. On 12/12/23 at 11:23 AM, R99 was observed in 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 Based on observation, interview and record review the facility failed to ensure two (R31 and R84) of two residents reviewed for medication were assessed for the safe self-administration of medication and to have medication kept at bedside. Findings include: On 12/12/23 at 9:32AM, R31 was observed lying in bed with their eyes closed, on the bedside table was a nasal solution (Oxymetazoline HCL Nasal Solution 0.05%). A record review revealed that R31 was admitted to the facility with an original date of 8/28/23 with a diagnosis of acute respiratory failure with hypoxia, anemia and pulmonary hypertension with a Brief Interview for Mental Status(BIMs) score of 13 (indicating an intact cognition). On 12/12/23 at 2:34 PM, R31 was observed sitting up in bed watching tv. R31 was interviewed about the nasal spray located on bedside table, R31 stated their nose had been bleeding for a couple of days, so the spray was used for the dryness in their nose. Further interview revealed that the nasal spray is kept in the room…

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 #MI00138733 Based on observation, interview, and record review, the facility failed to ensure the resident's right to private and confidential mail delivery for one resident (R62) of one residents reviewed for private communications, resulting in resident mail being opened by the facility prior to delivery to the resident and violation of their privacy. Findings include: On 12/12/23 at approximately 10:46 a.m. R62 was observed in their room, laying in their bed. R62 was queried if they had any concerns regarding their care in the facility and they indicated they had an issue with facility staff opening up their mail that is delivered to the facility and receiving it already opened. R62 reported CNA N had just brought them one of their packages that was already opened. R62 reported they thought their packages should be private and not opened before they get delivered to them. On 12/14/23 at approximately 10:04 a.m., CNA N was queried regarding the allegation of them opening R62's mail before it had been delivered to them and they reported that they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Deficient practice is linked to intake MI00140318. Based on interviews and record review, the facility failed to protect the resident's(R255) right to be free from physical abuse by R99. Findings include: A record review revealed that R255 was admitted to the facility on [DATE] and was discharged on 10/4/23 with a diagnosis of Morbid obesity, sarcopenia and muscle wasting and atrophy. R255 had a Brief Interview for Mental Status(BIMs) score of 13. On 10/2/23 according to the investigation the facility conducted on the allegations that another resident hit R255; R255 stated, [R99] wanted to remove the wheelchair, she was not able to, she hit me with her hands, grabbed my hands and dug her nails into my skin with a lot of force. I started calling for help then she took the stick from my hand and tried to hit me, the person who showed up grabbed the stick before she hit me. On 12/12/23 at 11:23 AM, R99 was observed in their room sitting in bed, an interview was attempted. R99 was waving their hands and shaking…

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 policies and procedures for ensuring an allegation of neglect/mistreatment was reported to the State Agency in accordance with section1150B of the Act for one resident (R62) of one residents reviewed for abuse/neglect/mistreatment. Findings include: On 12/12/23 at approximately 10:46 a.m., R62 was observed in their room, laying in their bed. R62 was queried if the facility staff had been treating them with dignity and respect and they indicated they had an issues with a few aides that had given them care. R62 reported that on multiple occasions they had been left wet/soiled in their bed for hours and that they have had some bad aides and they were unsure if management had done anything about it. On 12/12/23 the medical record for R62 was reviewed and revealed the following: R62 was initially admitted the facility on 5/14/22 and had diagnoses including Severe obesity, Osteoarthritis unspecified hand and Disorder of muscle. A review of R62's MDS (minimum data set) with an ARD (assessment reference date of 10/20/23…

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 complete a thorough investigation of an allegation of neglect/mistreatment for one resident (R62) of one residents reviewed for abuse/neglect/mistreatment resulting in the increased potential for retaliation and continued mistreatment. Findings include: On 12/12/23 at approximately 10:46 a.m., R62 was observed in their room, laying in their bed. R62 was queried if the facility staff had been treating them with dignity and respect and they indicated they had an issues with a few aides that had given them care. R62 reported that on multiple occasions they had been left wet/soiled in their bed for hours and that they have had some bad aides and they were unsure if management had done anything about it. On 12/12/23 the medical record for R62 was reviewed and revealed the following: R62 was initially admitted the facility on 5/14/22 and had diagnoses including Severe obesity, Osteoarthritis unspecified hand and Disorder of muscle. A review of R62's MDS (minimum data set) with an ARD (assessment reference date of 10/20/23…

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, interviews, and record reviews the facility failed to administer oxygen as ordered by the physician for one (R44) of one resident reviewed for respiratory care. Findings include: Review of the medical record revealed R44 was admitted to the facility on [DATE] with diagnoses that included: acute and chronic combined systolic and diastolic congestive heart failure, pulmonary edema, acute respiratory failure with hypoxia, pneumonia, and sleep apnea. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition and required staff assistance for all Activities of Daily Living (ADLs). On 12/12/23 at 9:31 AM, R44 was observed lying on their back in bed. Oxygen was observed being administered via nasal cannula at 3.5 L (liters). The resident was snoring and did not wake up to verbal stimuli. Review of the physician orders documented the following order: 02 (oxygen) @ (at) 2 liters per minute via NC (nasal…

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 medically related social services to ensure accurate guardianship/legal representation for two (R7 and R99) of two residents reviewed, resulting in a residents with cognitive impairment not having a guardian/legal representative in place to assist in medical decisions. Findings include: On 12/12/23 at 11:03AM, R7 was observed in their room sitting in bed. An interview was attempted, R7 was asked how everything was going and R7 replied, I don't understand, I don't understand. Record review revealed that R7 was admitted to the facility on [DATE] with a diagnosis of dementia, insomnia and delirium and had a brief interview for mental status(BIMs) score of 00, indicating a severely impaired cognition. On 12/12/23 at 11:23 AM, R99 was observed in their room sitting in bed, an interview was attempted, R99 was waving hands and shaking them, however R99 did not understand due to a language barrier so the interview was ended. Record review…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate less than 5% when two medication errors were observed from a total 25 opportunities, resulting in a medication error rate of 8%. This deficient practice affected two (R19 and R319) of three residents observed during medication administration. Findings include: On 12/12/23 at 9:11AM, Nurse B prepared medications according to the Medication Administration Record(MAR) for R19 and took medications to the room. R19 asked Nurse B what pills were in the cup and Nurse B proceeded to state the medications, Folic Acid, Senna, Vitamin D, and Atenolol. R19 stated that she did not want the blood pressure medication (Atenolol) because her heart rate was only 56 when they took the vital signs that morning and did not want to take it because it (heartrate) needed to be 60 or above. Nurse B told R16 that the heart rate was 65 and that it was okay to take, R19 told Nurse B that she was not taking it because of the heart rate and that she did not want to take any of the medication but the stool…

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 #MI00135446 Based on observation, interview and record review the facility failed to ensure Physician Ordered Occupational Therapy services were provided for one resident (R62) of two residents reviewed for Specialized Rehabilitation Services. Findings include: On 2/12/23 at approximately 10:46 a.m., R62 was observed in room, laying in their bed. R62 was queried if they had any concerns regarding their care and they indicated they should be getting therapy but instead they are sitting in bed and did not know why they were not receiving any therapy. R62 reported they needed to get stronger and get their hands stronger to move their wheelchair and get out of the facility. On 12/12/23 the medical record for R62 was reviewed and revealed the following: R62 was initially admitted the facility on 5/14/22 and had diagnoses including Severe obesity, Osteoarthritis unspecified hand and Disorder of muscle. A review of R62's MDS (minimum data set) with an ARD (assessment reference date of 10/20/23 revealed 62's BIMS score (brief interview for mental status) 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 This citation pertains to intake: MI00139857. Based on observation, interviews, and record reviews the facility failed to ensure adequate and resident specific fall interventions were implemented in an attempt to prevent further falls for two (R's 802 & 804) of two residents reviewed for accidents. Findings include: R802 Review of the medical record revealed R802 was admitted to the facility on [DATE] with diagnoses that included: wedge compression fracture of T9-T10 vertebra, intervertebral disc degeneration lumbar region, scoliosis, delirium, unspecified psychosis, hallucinations, and falls. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11 (which indicated moderately impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of the preadmission hospital documents provided to the facility upon R802's admission contained a Physician report dated 7/23/23 at 10:23 AM, that documented in part . Chief…

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: MI00139857. Based on interviews and record reviews the facility failed to timely complete a STAT (immediate) X-ray as ordered by the physician for one (R802) of three residents reviewed for a change of condition. Findings include: Review of the medical record revealed R802 was admitted to the facility on [DATE] with diagnoses that included: wedge compression fracture of T9-T10 vertebra, intervertebral disc degeneration lumbar region, scoliosis, delirium, unspecified psychosis, hallucinations, and falls. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11 (which indicated moderately impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of the physician's orders documented the following order . stat xray of low back and pelvis . one time only for pain for 4 days . dated 9/2/23 at 5:15 PM. Review of the medical record revealed no documentation of the STAT lower back 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.