Medilodge of West Bloomfield

Based on observation, interview and record review, the facility failed to ensure an emergency pull cord to was available within the immediate shower area (accessible if lying on the floor) for two shower stalls, affecting all residents that utilize the C/D shower room. Findings include: On 2/24/26 at 1:30 PM, a confidential resident council interview was conducted with eight residents. When asked about whether there were any concerns regarding the facility's physical environment, several residents reported concerns. Responses included: I get my own showers and Nursing staff tell me they have to stay in, but some don't stay in. I'm solo when they step out of the shower room. The pull cord is across the room, what happens if I fall in the shower? There is no pull cord in the shower.On 2/25/2026 at 10:51 AM, the Director of Nursing (DON) was asked to observe the C/D unit shower room. Upon entering the shower room, there were two shower stalls and each of them did not have an emergency pull-cord in the vicinity. The closest emergency pull-cord was on the wall outside of the shower…

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 2561059.Based on interview and record review, the facility failed to honor a full code advance directive for one (R146) of one reviewed, who wanted to receive all possible medical interventions in the event of a cardiac or respiratory arrest. R146 was found unresponsive, was not provided cardiopulmonary resuscitation (CPR) or other life saving measures as elected in their advance directives. Findings include:A review of a Facility Reported Incident (FRI) intake 2561059 reported the facility failed to ensure resident (R146) was free from neglect.Clinical record review revealed R146 was admitted on [DATE] and had diagnoses that included Parkinsons Disease (progressive neurological disorder) with dyskinesia (complication of Parkinson's Disease leading to involuntary movements of face, arms, legs, and torso) and encephalopathy (brain disease, damage, or malfunction). A Brief Interview of Mental Status (BIMS) reviewed from the Minimum Data Set (MDS) dated [DATE] scored 0/15 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 interview and record review the facility failed to ensure the appropriate Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) were provided and completed for three (R10, R127 and R164) of three residents reviewed for beneficiary notification, resulting in the residents and/or representatives to be uninformed of the potential private pay charges for continued services at the facility, and the inability to file an appeal. Findings include:On 2/23/26 at 1:20 PM, during an interview with R10's family, they expressed concerns with the facility's documentation for Medicare A coverage.On 2/25/26 at 2:30 PM, the Administrator was requested via email to complete and provide the applicable documentation in accordance with the instructions provided on the SNF (Skilled Nursing Facility) Beneficiary Worksheet for each of the following three residents R10, R127 and R164. These residents were identified on the documentation provided by the facility (Residents for the past six months that had Medicare A benefits 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 2621417. Based on interview and record review, the facility failed to ensure a safe discharge for one resident (R144) of two residents reviewed for discharge planning. Findings include: On 2/23/2026 a complaint submitted to the State Agency was reviewed which alleged the facility delayed in submitting the notification to the Michigan Department of Health and Human services that R144 had discharged from the facility and as a result, they could not access community level Medicaid services. On 2/24/26 the medical record for R144 was reviewed and revealed the following: R144 was initially admitted to the facility on [DATE] and discharged back to the community on 8/1/25. A review of R144's payor source at the time of their discharge was Medicaid-MI On 2/25/26 at approximately 10:55 a.m., during a conversation with the facility's Regional Business Office Manager I (RBOM I), RBOM I was queried regarding the process for switching a resident's Medicaid health insurance over from Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to submit a notification of transfer to the state ombudsman's office for one resident (R141) of one resident reviewed for hospitalization.Findings include:On 2/24/26 the medical record for R141 was reviewed and revealed the following: R141 was initially admitted to the facility on [DATE], transferred to the hospital on [DATE] and had diagnoses including Congestive heart failure and Chronic obstructive pulmonary disease A review of R141's progress notes pertaining to their hospitalization revealed the following:11/27/2025-12:26 Progress Note-General: Pt (patient) observed to be extremely lethargic and confused, writer assessed pt upon assessment BP (blood pressure) 118/62, 78 HR (heart rate) RR (respiratory rate)14 Blood sugar 183 and 89% o2 on oxygen via nasal cannula. NP (Nurse Practitioner) contacted and gave order to transfer pt to [local hospital] 911 . On 2/24/26 at approximately 8:26 a.m., a request for documentation that notifications of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level II evaluation (community mental health assessment) was completed and implemented within the resident's plan of care for one (R3) of one resident reviewed for PASARR. Findings include:Review of the clinical record revealed R3 was admitted into the facility on 7/16/25 (from another nursing home) with diagnoses that included: adjustment disorder with mixed disturbance of emotions and conduct, borderline personality disorder, bipolar disorder in partial remission most recent episode mixed, other specified depressive episodes, bipolar disorder, current episode mixed, severe, with psychotic features, and mood disorder.According to the Minimum Data Set (MDS) assessment dated [DATE], R3 had intact cognition and exhibited verbal behavioral symptoms directed towards others which occurred one to three days.According to the MDS assessment dated [DATE], R3 was marked as No for Is the 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 ensure the facility nurses consistently followed the standards of practice for the administration and documentation of a controlled medication observed for the medication administration (R65) and failed to ensure that physicians orders were transcribed and carried out as ordered for one (R162) resident of three residents reviewed for closed records. Findings include:On [DATE] at 8:16 AM, LPN A was observed preparing the morning medications for R65. Included in the morning medications prepared was Ativan 0.5 mg (milligrams). LPN A was observed to have obtained one tablet of Ativan from the controlled medication locked drawer and added to the rest of R65 morning medications. LPN A failed to verify R65's current Ativan count and failed to document the dose they removed on the controlled count sheet. LPN A was observed to have prepared and administered three additional residents' morning medications, without signing out the Ativan dose…

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 the coordination of a Cardiology appointment and failed to communicate with the legal guardian for one (R9) of one resident reviewed for the coordination of medical appointments. Findings include:On 2/23/26 at 12:54 PM, a telephone interview was conducted with the guardian for R9. The guardian reported they drove to R9's cardiologist appointment on 2/19/26 for a pacemaker follow up. The facility staff did not ensure that R9 attended their appointment. The guardian expressed their frustration that the facility staff did not notify them before they traveled to another city to meet R9 for their appointment.A review of the medical record revealed R9 was admitted to the facility on [DATE], with diagnoses that included a presence of a pacemaker and dependence on renal dialysis.On 2/23/26 at 10:11 AM, R9 was observed in a geri chair. A brief interview was conducted with the resident.A review of the medical record revealed no documentation…

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 appropriate catheter care was provided for one resident (R6) of one resident reviewed for indwelling catheters. Findings include:On 2/23/26 at approximately 10:44 a.m., R6 was observed in their room, sitting up in their bed. R6 was observed to have an indwelling catheter with their catheter bag touching the floor and the tubing extended/taut. R6 was queried if they had any pain from the catheter tube pulling and they reported they did. Further observation of R6's catheter tubing revealed no method of securing the tubing to prevent pulling on the genitals. On 2/24/25 at approximately 10:26 a.m., R6 was observed in their room with Nurse E. R6's catheter tubing was observed to contain cloudy urine. R6's drainage bag was observed to be crumpled up in the privacy bag with urine unable to flow freely into the bag. Nurse E was queried to show R6's catheter securement device and they indicated that R6 did not have one, and they would 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes 2696875 and 2718805.Based on interview, and record review, the facility failed ensure provision of medically-related social services regarding psychosocial well-being post abuse allegations, resident-to-resident incidents, and/or changes in mood/behavioral concerns for two (R35 and R49) of two residents reviewed for behavioral/emotional needs. Findings include:Review of complaints reported to the State Agency (SA) included concerns that R49 had been physically assaulted by R35, and the allegations that the facility's social worker was not assisting with necessary discharge paperwork to transfer to another facility or making time to visit with the resident.On 2/24/26 at 9:07 AM, the facility was requested to provide documentation of the facility's investigation regarding a resident-to-resident incident between R35 and R49. R35:Review of the clinical record revealed R35 was admitted into the facility on 7/18/25 and readmitted on [DATE] with diagnoses that included: vascular…

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 #2621426Based on observation, interview and record review the facility failed to ensure accurate and timely medication administration was provided to a resident who required seizure medication for one (R43) out of seven residents reviewed for medication administration. Findings include:A complaint was filed with the State Agency (SA) that alleged on 9/15/25, Nurse N falsified they provided R43 with their needed seizure medication (Valproic Acid) resulting in the resident sustaining two seizures during the night. The complainant further alleged that Nurse N often provides medication late or not at all.On 2/23/26 at approximately 11:43 AM, R43 was observed lying in bed. The resident was receiving tube feeding and oxygen. R43 could not answer any question asked.A review of R43's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: other seizures, neuromuscular dysfunction of bladder and contractures of muscle, multiple…

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, observation and record review the facility failed to ensure residents received a clear understanding of the facility's binding arbitration agreement for three (R60, R103 and R152) out of 72 residents reviewed for Binding Arbitration. Findings include: A review of the facility Policy titled, Binding Arbitration Agreements (7/28/2020) documented, in part: .Policy: This facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration.Binding Arbitration is a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship.the decision is final, can be enforced by a court, and can only be appealed on very narrow grounds.When explaining the arbitration agreement, the facility shall:. Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her…

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 Incident #2588421.Based on observation, interview, and record review, the facility failed to assess resident's skin on a regular basis and thoroughly assess a new skin tear and bruise for one (R702) of two residents reviewed for skin management. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency on 8/2/25 revealed, On 8/2/2025, (Certified Nursing Assistant - CNA 'D') reported to her nurse that (R702) had a skin tear on her right arm. (CNA 'D') stated that (R702) hit her arm on her wheelchair arm rest, when (R702) was asked how it happened she pointed at (CNA 'D'). (R702) is non-verbal and did not provide further explanation .A head-to-toe assessment was conducted on (R702) with nothing remarkable to report .On 8/28/25 at 9:58 AM, R702 was observed in bed sleeping. R702 had a tracheostomy (a surgical hole in the windpipe to assist with breathing) and was receiving nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube surgically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI00153326, MI00153330, MI00153348. Based on interview and record review, the facility failed to ensure an allegation of physical abuse was reported to the State Agency for one resident (R803) of two residents reviewed for abuse. Findings include: A review of multiple complaints received by the State Agency alleged R803 was assaulted by a staff member. Review of the clinical record revealed R803 was initially admitted into the facility on 1/9/25, readmitted on [DATE], and discharged to the hospital on 6/6/25. As of this review, R803 did not return to the facility. Diagnoses included: fracture of unspecified part of right clavicle (5/28/25), generalized anxiety disorder, dysthymic disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. According to the Minimum Data Set (MDS) assessment dated [DATE], R803 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated severe cognitive…

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: MI00152471. Based on interview and record review the facility failed to consistently assess, monitor, and review the nutritional needs and ensure adequate interventions were consistently implemented and/or modified to prevent further weight loss for one (R305) of three residents reviewed for nutrition, resulting in a severe weight loss of -15.05 lbs (pounds) within four weeks of admission. Findings include: A review of a complaint submitted to the State Agency (SA) documented the following in part, . On 03/19/2025, (R305's name) was discharged from (hospital name) to (facility name) On 04/20/2025 . admitted to (hospital name) . (R305's name) has lost roughly around 20 pounds since he was admitted to (facility name) A review of the hospital documents provided to the facility upon R305's admission documented the following: A Nutrition consult dated 3/17/25 at 3:45 PM, . Weight: 68 kg (kilogram) (149 lb (pounds) 14.6 oz (ounces) . 03/14/25 . Problem: Malnutrition acute disease or…

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 #MI00152154. Based on observation, interview, and record review the facility failed to thoroughly investigate an allegation of sexual abuse for one resident (R304) of three residents reviewed for abuse, resulting in the potential for unidentified instances of abuse. Findings include: A complaint received by the State Agency alleged R304 had been sexually abused. A review of R304's clinical record revealed they admitted to the facility on [DATE], went to the emergency room on 4/12/25, and returned to the the facility on 4/13/25. A review of R304's progress notes revealed a note entered into the record by Nurse 'D' on 4/11/25 at 8:04 AM that read, .Patient woke up this morning at 6:30am <sic> confused and thinks there was a man in her room . A review of a facility provided investigation file for R304 was conducted on 4/30/25 at 9:30 AM. The file included a typed summary that indicated the facility had been made aware by a city police officer that while in the hospital on 4/12/25,…

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): MI00151843. Based on interview and record review, the facility failed to assess a resident timely after a fall, document the fall in a timely manner, and investigate to determine the root cause of the fall for one (R303) of two residents reviewed for falls. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that R303 fell in the shower while assisted by a Certified Nursing Assistant (CNA) who transferred the resident by herself. R303's knee was swollen as a result of the fall. According to the complainant, as noted in the intake, the facility staff said R303 slipped down but didn't fall. On 4/30/25 at 10:03 AM, it was explained by staff that R303 was on leave of absence from the facility for the day. Therefore, R303 was not available for observation or interview. A second attempt to observe or interview R303 was made at approximately 1:30 PM. R303 had not yet returned to the facility. A review of R303's 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 This citation pertains to intake: MI00152471. Based on interview and record reviews, the facility failed to obtain STAT (immediate) labs ordered by the physician for a resident identified with a change of condition for one (R305) of one resident reviewed for lab services. Findings include: A review of the medical record revealed R305 was admitted to the facility on [DATE], with diagnoses that included: encounter for orthopedic aftercare following surgical amputation, severe protein-calorie malnutrition, peripheral vascular disease and acute kidney failure. Further review of the medical record revealed the following: On 4/18/25 at 12:55 PM, a Dietary note documented in part . Per nursing communication to RD (Registered Dietitian) and SLP (Speech Language Pathologist) Therapy patient asked for water yesterday however started coughing may need eval (evaluation) for thicken liquids- SLP plan to f/u (follow up). Patient does not each much, wt (weight) loss . On 4/18/25 at 1:08 PM, a Nursing note documented in part .…

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 Number(s): MI00148496 Based on interviews and record reviews the facility failed to maintain on effective infection control prevention and control program for 82 of 82 residents who resided in the facility. Findings include: A review of a complaint submitted to the State Agency revealed it was alleged the facility did not follow proper infection control procedures to prevent the spread of MRSA (Methicillin-resistant Staphylococcus aureus). On 1/28/25 at 12:46 PM, an interview was conducted with R802 via the telephone. R802 reported he was notified by his dermatologist on 11/25/25 that the culture taken from a cyst on his head was positive for MRSA and that he was told it was contagious. R802 reported the facility was notified and they did not take the proper steps to clean R802's room and wear the appropriate protective equipment. R802 reported, one nurse explained to him that MRSA was contagious, but never came back after that. R802 reported staff were not wearing gowns when providing care and he was transported to Physical therapy and other doctor…

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

This citation pertains to intake #'s MI00149476 and MI00149540. Based on interview and record review the facility failed to keep service reports and ensure regular inspections of the domestic hot water boilers to maintain proper functioning of the hot water supply were completed in a timely manner potentially affecting all 82 residents who reside in the facility. Findings include: On 1/28/25 multiple concerns submitted to the Stage Agency alleged the facility did not have any hot water for consecutive days in a row. On 1/28/25 at approximately 10:24 a.m., during a conversation with Maintenance Director C (MD C), MD C was queried if the facility had recently been without hot water and the reported that the facility had no hot water from 1/11/25 until 1/16/25 due to both hot water boilers failing. MD C was queried how often the boilers were inspected for their CSD-1 inspections (CSD-1 refers to the boiler code that addresses periodic testing and maintenance of boiler Controls and Safety Devices)and they indicated that it was on an annual basis to ensure the boilers are functioning…

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): MI00148496. Based on interview and record review, the facility failed to ensure the physician evaluated the total program of care to include a newly developed skin impairment for one (R802) of one residents reviewed for physician visits. Findings include: A review of a complaint submitted to the State Agency revealed allegations that on 10/31/24, R802 consulted with the physician at the facility about oiling bumps that formed on his scalp. R802 was told it was common for diabetics, was given a medication, and that helped a little, but then the bumps continued to spread. R802 contacted his dermatologist and went to an appointment. On 11/25/24, the dermatologist called R802 and informed him that he had MRSA (Methicillin-resistant Staphylococcus aureus) and it was contagious. On 1/28/25 at 12:46 PM, an interview was conducted with R802 via the telephone. R802 reported he consulted with Attending Physician 'D' about a pus filled blister located on his scalp. R802 reported…

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# MI00149540. Based on observation, interview and record review, the facility failed to ensure activities of daily living (ADL's) including regular bathing and transfers were provided for one resident (R803) of one resident reviewed for activities of daily living (ADL's). Findings include: On 1/28/25, a concern submitted to the State Agency was reviewed and alleged R803 was not being provided scheduled showers. On 1/28/25 at approximately 10:57 a.m., R803 was observed in their room, sitting up on the edge of their bed. R803 was observed with their pants half way down with both of their feet hanging off the bed and R803 leaning on their left side. R803 reported they had been waiting for someone to help get them out of the bed and into their chair for approximately two hours. R803 indicated that the CNA (Certified Nursing Assistant) had been aware of their need but had forgotten about them due to the CNA having to assist another resident with eating earlier that morning and 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 Number(s): MI00148496. Based on interview and record review, the facility failed to identify, monitor, and assess a skin impairment and provide follow up after an outside appointment for one (R802) of one resident reviewed for skin impairments. Findings include: A review of a complaint submitted to the State Agency revealed allegations that on 10/31/24, R802 consulted with the physician at the facility about oiling bumps that formed on his scalp. R802 was told it was common for diabetics, was given a medication, and that helped a little, but then the bumps continued to spread. R802 contacted his dermatologist and went to an appointment. On 11/25/24, the dermatologist called R802 and informed him that he had MRSA (Methicillin-resistant Staphylococcus aureus) and it was contagious. On 1/28/25 at 12:46 PM, an interview was conducted with R802 via the telephone. R802 reported he consulted with Attending Physician 'D' about a pus filled blister located on his scalp. R802 reported…

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 personal clothing items that were sent to laundry were returned to the residents in a timely matter. This deficient practice has the potential to affect all residents sending clothing items to laundry, including residents who attended a resident council meeting who asked to remain anonymous. Findings include: On 11/19/24 at 1:30 PM a Resident Council meeting was conducted with cognitively intact residents who asked to remain anonymous. The residents were asked questions as to care provided in the facility and any grievances that had been reported to the facility. Several of the residents reported that they were missing clothing items. One resident stated that they had two green shirts and some pants that they never got back from laundry. They further reported that they had reported their concerns and none of the clothing was either returned, nor did they receive money to purchase replacement clothing. A second resident noted that were missing pants and shirts. A third resident reported that they could…

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

Based on observation and interview, the facility failed to ensure safe and secure medications from one of two medication carts and one of three refrigerators observed for medication storage and labeling. Findings include: On 11/19/24 at 9:10 AM, medication administration observation was conducted with Licensed Practical Nurse (LPN) A. Medications were prepared from the cart identified as Cart C Hall and an observation of the medication storage revealed the following loose unidentifiable medications: Drawer two, one round white pill no identifier, two round white pills stamped 337, one half peach colored pill, one round pink pill stamped R50, one quarter white pill. Drawer three, one round pink pill stamped IG/207 and one-half white round pill. LPN A acknowledged the loose medications were not properly stored and should not be stored loose with no patient identifiers. The Medication Room identified as Traverse was reviewed for medication and storage and identified two stacked refrigerators. The top refrigerator storing insulin was observed with no thermometer and no temperature logs.…

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

Based on observation and interview, the facility failed to maintain clean storage of linens and resident clothing in the laundry room resulting in contamination and build up of dust and dryer lint. Findings include: On 11/19/24 at 12:15 PM, a tour of the facility's laundry room was conducted with Housekeeping Manager B and Assistant Housekeeping Manager C. An observation of two linen carts storing clean folded linens, comforters, and clothing was observed with large amounts of thick white fuzzy textured debris. The green protective sheet panel of the right cart was lifted on top containing a cardboard box and wheelchair adaptive equipment covered with thick amounts of the white fuzzy debris. The linen cart to the left was observed with folded cardboard boxes used as a top shelf covered with dusty material, and a half-consumed water bottle. Managers B and C acknowledged both carts contained clean laundry and the thick white debris was from the dryer lint and confirmed the conditions were contaminated of dust and dirt and were unhygienic. Clean laundry storage policy was requested…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake# MI00142611. Based on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by facility staff for one resident (R901) of two residents reviewed for abuse. Findings include: On 5/13/24 a FRI (facility reported incident) was reviewed which alleged Certified Nursing Assistant C (CNA C) verbally abused R901. On 5/13/24 the medical record for R901 was reviewed and revealed the following: R901 was Initially admitted to the facility on [DATE] and had diagnoses of Chronic Obstructive Pulmonary Disease and Adjustment Disorder. A review of R901's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/3/24 revealed R901 was independent with most of their activities of daily living. R901's BIMS score (brief interview for mental status) was 14 indicating intact cognition. On 5/13/24 a review of the facility investigation pertaining to the allegation was reviewed and revealed the following: On 1/27/2024, [R901] alleged that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #s: MI00135137, MI00136540, MI00137861 and MI00137525. Based on observation, interview and record review, the facility failed to ensure nine residents (R12, R16, R17, R20, R40, R43, R67, R72, and R91) of ten residents reviewed dignity, and multiple residents that attended the confidential resident council interview were treated in a dignified manner, resulting in the expressions of frustration, loss of autonomy, and the potential for decreased feelings of self-worth. Findings include: Review of complaints reported to the State Agency included allegations that staff were not treating the residents in a dignified manner. On 10/17/23 at 10:24 AM, during an interview at bedside with R17, Housekeeper 'H' was observed to enter the room, then go in and out of the bathroom, back to their housekeeping cart in the hallway and then re-enter the room. Housekeeper 'H' was not observed at any point to knock, announce who they were, or wait for R17 to give them the okay to enter the room. R17…

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 Number: MI00137861 Based on observation, interview and record review the facility failed to ensure the cleanliness of the shared shower room located on the C/D unit for one (R40), anonymous residents attending Resident Council and potentially effect additional residents who used the shared shower located on the unit. Findings include: On 10/17/23 at approximately 11:20 AM, R40 was observed in their room. The resident was alert and able to answer all questions asked. The resident noted several concerns and reported that the shared shower room is always dirty and has what appears like black mold on the walls and floor of the shared shower room utilized by residents on the C/D unit. The resident reported that they made several complaints about the dirty shower. Following the interview with R40, an observation of the shower shared by residents on the C/D hall was conducted. The shower room had dirty black mold like tiles on both the floor and wall. The shower area appeared that it had not been cleaned for several days. On 10/17/23 at approximately 11:30…

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): MI00134510 & MI00135137. This citation contains two Deficient Practice Statements (DPS). DPS #1 Based on observations, interviews, and record reviews the facility failed to ensure medications were transcribed and ordered as directed by the physician (R93), failed to administer medications per the physician's order (R's 93 & 46) and ensure a gastroesophageal reflux disease (GERD) medication was administered prior to dinner as requested (R4) for three of three residents reviewed for accurate and timely administration of medications. Findings include: R93 Review of a complaint submitted to the State Agency (SA) documented concerns of the resident to not have their medications received by the facility, which included the concern of their pain medications. Review of the medical record revealed R93 was admitted to the facility on [DATE] and was found unresponsive without a pulse one day later on 3/13/23 and transferred to the hospital. R93 was admitted with diagnoses that included:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure consistent communication and coordination of care with the dialysis center for one (R85) of two residents reviewed for dialysis. Findings include: On 10/17/23 at 10:28 AM, R85 was observed seated in a wheelchair. R85's left upper arm was observed with a bulge with an area that was bleeding slightly. A bloody tissue was observed on the ground. R85 reported that the blood was from his dialysis access site. R85 reported he received dialysis offsite on Mondays, Wednesdays, and Fridays. On 10/18/23 at 8:24 AM, R85 was not in his room and was at dialysis. Review of R85's clinical record revealed R85 was admitted into the facility on 9/30/23 with diagnoses that included: end stage renal disease and type 2 diabetes mellitus. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R85 had moderately impaired cognition. Review of R85's care plans and physician's orders revealed R85 went to dialysis on Monday, Wednesday, 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 #MI00135137 Based on observation, interview, and record review the facility failed to ensure resident's food preferences were honored for two residents (R#'s 62 and 489) as well as multiple attendees at the group meeting, resulting in verbalized complaints about the facility's food. Findings include: On 10/17/23 12:25 PM R62's breakfast tray was observed untouched, still in their room. They said they did not like wheat bread and they were served wheat bread for breakfast. A review of R62's breakfast ticket indicated they had a listed dislike of wheat bread. It was observed on the breakfast tray R62 had been served wheat toast. On 10/18/23 at 9:33 AM, R62 was asleep, but their breakfast tray was observed in their room. Their meal ticket indicated they were supposed to receive egg and cheese breakfast casserole, a muffin, two bowls of cereal, and a banana. R62's meal tray revealed they had been served two hard boiled eggs, toast that appeared nearly untoasted, and two bowls 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 ensure two (R17 and R71) of two residents reviewed for medications were assessed for the safe self-administration of medication, resulting in the potential for mismanagement of the prescribed medication. Findings include: According to the facility's policy titled, Self-Administration of Medications dated 7/11/2018: .If the resident is a candidate for self-administration of medications, this will be indicated in the chart .Nursing will be responsible for recording self-administered doses in the resident's medication administration record (MAR) .Appropriate notation of these determinations will be placed in the resident's care plan. R17 On 10/17/23 at 9:57 AM, R17 was observed laying in bed, asleep with a nebulizer treatment actively in use. On 10/17/23 at 10:02 AM, R17's Nurse (Nurse 'W') was observed at a medication cart a few rooms away from R17's room. When asked about R17's nebulizer that was observed actively in use and why they were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to accommodate a preference for the Physical Therapy scheduled sessions for one resident (R489) of one resident reviewed for choices. Findings include: On 10/17/23 at 09:20 AM, R489 was observed in bed lying on their right side with head underneath the covers. A nurse entered the room to let R489 know that their medications would be prepared and brought to the room. R489 slowly turned over on their back. On 10/17/23 at 09:47, R489 was interviewed and it revealed that on dialysis days, R489 is too weak to receive Physical Therapy (PT). R489 stated that I have told them before that I am too tired and weak to receive PT but they do not listen and make me do it anyway. R489 stated that all I want to do is lay down when I return to the facility, and I do not mind doing PT on the days that I am not dialyzed but they still do it when I get back, I guess it's the process. On 10/18/23 at 07:40 AM Rehab Director was interviewed and asked how often do…

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: MI00135231. Based on observation, interview and record review the facility failed to ensure a comprehensive plan of care was updated and revised to reflect resident centered and individualized areas of care for two residents (R11 and R392) of two residents reviewed for comprehensive care plans. Findings include: R392 On 10/17/23 at approximately 2:08 p.m., R392 was observed in their room, laying in their bed. R392 was observed to have oxygen infusing via nasal cannula at four liters per minute (LPM). On 10/17/23 at approximately 4:13 p.m., R392 was observed in their room, laying in bed. R392 was observed to still have oxygen infusing via nasal cannula at four LPM. On 10/18/23 at approximately 8:19 a.m., R392 was observed in their room, laying in their bed. R392 was again observed to have oxygen infusing via nasal cannula at 4 LPM. On 10/18/23 at approximately 1:17 p.m., R392 was observed in their room, laying on their bed. R392 was still observed to have oxygen infusing…

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 was administered appropriately for one resident (R388) of one resident reviewed for Nursing standards of practice. Findings include: On 10/17/23 at approximately 10:02 a.m., R388 was observed in their room, up in their wheelchair. No Nursing staff was observed in the room. R388 was observed to have blue pill contained in a small plastic medication cup on top of their computer. R388 was queried how they were administered the pill and if the Nurse gave it to them and R388 reported that the Nurse gave it to them in the cup but they were still sleeping so they left it there. R388 was queried if they knew what the blue pill was and they reported it was their zoloft (anti-depressant). On 10/17/23 the medical record was reviewed. R388 was initially admitted to the facility on [DATE] and had diagnoses including Depression and Anxiety disorder. A Physician's order dated 9/29/23 revealed the following: Sertraline HCl (Zoloft) Oral…

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): MI00135715. Based on observation, interview, and record review, the facility failed to ensure restorative services to prevent functional decline for one resident (R24) of five residents reviewed for restorative services resulting in activity of daily living functional declines. Findings include: On 10/17/23 at 10:13 AM R24 was observed in their bed with a wrist-hand orthotic on their right hand. It was also observed R24 had soft heel boots on their feet. At that time, they were asked if staff were consistently applying their splints or performing any range of motion (ROM) exercises and they said they were not. On 10/18/23 at approximately 9:40 AM, R24 was observed in bed. They were asked if they had their specialized PRAFO boots on and said they did not and staff never put them on. R24 said they thought they were in their closet. With R24's permission, an observation of their closet revealed a PRAFO boot on top of R24's belongings, the second boot was not 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 This citation pertains to intake #MI00135231. Based on interview and record review, the facility failed to ensure a clinical indication for the use of an indwelling urinary catheter and an assessment and trial discontinuation for a urinary catheter in the absence of a clinical indication for one resident (R94) of one resident reviewed for urinary catheters. Findings include: On 10/19/23 at 8:32 AM, a review of R94's clinical record revealed they admitted to the facility on [DATE] and discharged to the emergency room on 2/2/23. R94's diagnoses included: stroke, hemiplegia, hemiplegia, protein calorie malnutrition, presence of a feeding tube, and inflammatory reaction due to indwelling urethral catheter. It was noted R94's diagnoses did not include a diagnosis or clinical indication (urinary retention, neurogenic bladder, wounds, etc.) for the use of an indwelling urinary catheter. R94's admission Minimum Data Set assessment dated [DATE] revealed R94 had severe cognitive impairment, required extensive to total…

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 # MI00136540. Based on observation, interview and record review, the facility failed to order routine colostomy care for one (R11) of one resident reviewed for colostomy care, resulting in the potential for inadequate assessment and treatment of unrecognized skin and/or stoma problems. Findings include: On 10/17/23 at 11:48 AM, R11's door was closed and there was a strong fecal odor in the hallway near their door. Upon entry into the room, the resident was observed laying in bed, slightly on their right side, facing the window. The resident was asked about general care and reported they had a colostomy and that was the reason for the strong odor. Review of the clinical record revealed R11 was admitted on [DATE], and readmitted on [DATE] with diagnoses that included: unspecified intestinal obstruction and colostomy status. According to the Minimum Data Set (MDS) assessment dated [DATE], R11 had severe cognitive impairment, and had an ostomy. Review of the physician orders revealed…

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): MI00135715. Based on observation, interview and record review the facility failed to ensure one resident (R392) had Physician orders for oxygen therapy of three residents reviewed for respiratory care. Findings include: On 10/17/23 at approximately 2:08 p.m., R392 was observed in their room, up in their bed. R392 was observed on oxygen therapy via nasal cannula and was being administered oxygen at four liters per minute (LPM). On 10/17/23 at approximately 4:13 p.m., R392 was observed in their room, laying in their bed. R392 was observed to still have oxygen infusing via nasal cannula at four LPM. On 10/18/23 at approximately 8:19 a.m., R392 was observed in their room, laying in their bed. R392 was observed to have have oxygen infusing via nasal cannula at four LPM. On 10/18/23 at approximately 1:17 p.m., R392 was observed in their room, laying on their bed. R392 was still observed to have oxygen infusing via nasal cannula at four LPM. On 10/17/23 the medical record for…

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

This citation pertains to intake #MI00138044 and MI00136540. Based on interview and record review the facility failed to ensure as needed pain medication was administered for one resident (R95) of three residents reviewed for pain. Findings include: On 10/19/23 at 1:33 PM, a review of R95's clinical record was conducted and a progress note dated 6/6/22 at 5:19 PM read, .resident arrived back to facility via stretcher .Resident moaning in pain when touched or moved. Reside has bruising and swelling to left side of face, large hematoma to lle (left lower extremity) multiple bruises over body . A review of R95's electronic Medication Administration Record (eMAR) was conducted and revealed R95 had a documented pain score of 4/10 for the evening shift. Further review of the eMAR was conducted and revealed the first documented administration of pain medication was a scheduled dose for 12:00 PM on 6/7/23. It was further noted R95 had an order for dilaudid (narcotic pain medication) 2 milligrams to be given every 3 hours, as needed. At 12:00 PM no pain med medication was administered around…

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 timely coordination of behavioral health services for one (R11) of one resident reviewed for mood and behavior. Findings include: Review of the clinical record revealed R11 was admitted on [DATE], readmitted on [DATE] with diagnoses that included: unspecified psychosis not due to a substance or known physiological condition, vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, bipolar disorder, manic episode in full remission, and major depressive disorder recurrent. According to the Minimum Data Set (MDS) assessment dated [DATE], R11 had severe cognitive impairment, had no mood concerns, had no hallucinations, delusions, or behavior concerns, received antipsychotic medication on a routine basis for seven days during this assessment period of seven days, and had no GDR attempted, and had no physician documented GDR as clinically contraindicated. Review of the physician orders…

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 (R11) who was prescribed antipsychotic medication had adequate indication for continued use, had adequate monitoring and identification of resident-specific targeted behaviors, and had timely gradual dose reductions (GDR) attempted in absence of supporting documentation. Findings include: Review of the clinical record revealed R11 was admitted on [DATE], readmitted on [DATE] with diagnoses that included: unspecified psychosis not due to a substance or known physiological condition, vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, bipolar disorder, manic episode in full remission, and major depressive disorder recurrent. According to the Minimum Data Set (MDS) assessment dated [DATE], R11 had severe cognitive impairment, had no mood concerns, had no hallucinations, delusions, or behavior concerns, received antipsychotic medication on a routine basis for seven…

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 insulin pen was labeled with the resident's name and prescribing information and ensure it was removed from the medication cart when expired in one of two medication carts reviewed. Findings include: On [DATE] at 01:13 PM an observation of the medication cart on the Mackinaw Unit revealed that there was a aspar flex insulin pen with an open date [DATE]. On [DATE] the Director of Nursing(DON) was interviewed on the labeling of medication and storage, the DON revealed that all medications should be labeled and discarded appropriately accorded to expiration date. No additional information was provided by the exit of the survey.

Based on interview and record review the facility failed to implement an effective antibiotic stewardship program that included consistent implementation of protocols for appropriate antibiotic use for three (R's 438, 33 and 42), this deficient practice had the ability to affect multiple residents who were prescribed antibiotics during their inpatient care at the facility. Findings include: According to the Center for Disease Control's (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes, dated 2015: .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year .studies have shown that 40-75% of antibiotics…

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.