Notting Hill of West Bloomfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure acceptable standards of nursing care and services were provided for one (R14) out of six residents reviewed for medication administration. Findings include:A review of R14's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: bipolar disorder, schizophrenia and anxiety disorder. A review of the residents Minimum Data Set (MDS) revealed R14 had a Brief Interview for Mental Status (BIMS) score of 13/15 (intact cognition).Continued review of R14's clinical record, documented, in part, the following:2/2/26: Administration Note: .appears she is spitting out the medication in her room, under the bed. (Authored by Registered Nurse (RN) HH)3/22/26: Administration Note : .Patient appears to have been hoarding all of her medications and throwing them away under the bed. It appears to be several days of medication found. (Authored By RN HH)Care Plan: Focus: (R14) is at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake 2793611Based on interview and record review, the facility failed to ensure pressure ulcer treatments were ordered, completed as ordered, wound care was provided timely, and accurate skin assessments were completed for two (R2 and R115) of three residents reviewed for pressure ulcers. Findings include:R2 Review of R2's MDS assessment, dated 3/08/26, revealed they were admitted to the facility on [DATE], with diagnoses including spinal stenosis (narrowing of spine), polyneuropathy (nerve impingement), kidney disease, and urinary retention. The skin assessment showed R2 was admitted with one stage 3 pressure ulcer (the wound dept extends beyond the skin layers) and a surgical wound. On 3/23/26 at 2:16 p.m., R2 confirmed their right foot pressure injury was on their heel, and said the wound developed at home and at the hospital, when they pushed into their mattress too hard in bed repeatedly due to back pain. R2 said their wound care at this facility was supposed to be completed…

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 irregularities identified by the consultant pharmacist and signed by the physician were completed for two (R9 and R19) of five residents reviewed for monthly medication regimen reviews [MMR's]. Findings include: R19 Review of the clinical record revealed R19 was admitted into the facility on 3/19/21 and readmitted [DATE] with diagnoses that included: Parkinson's Disease, dementia and hallucinations. According to the Minimum Data Set [MDS] assessment dated [DATE], R19 had severely impaired cognition. Review of monthly pharmacist medication reviews revealed there were irregularities with R19's medication on 8/15/25. No documentation of what the irregularities were, or what the physician's response to the irregularity was found in R19's clinical record. An email was sent to the facility requesting the pharmacist recommendation and the physician response for R19 on 8/15/25 on 3/25/26 at 8:50 AM. No documentation was provided prior to the end of the…

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

Based on observations, interview and record review the facility failed to ensure that the medication error rate was less than five percent with a percentage of 6.45. Findings include: On 3/23/26 at 9:18 AM, a medication administration pass was completed with Registered Nurse (RNHH). RNHH was observed pulling medications from the pack and administered Lasix 20mg(milligrams), multivitamin, MiraLAX 17 g(grams) Duloxetine 60 mg, allopurinol 100 mg, carvedilol 3.125, vitamin B12 and lisinopril 5 mg.On 3/23/26 at 12:38 PM, a review of the medical administration record was made and the following errors were discovered. Duloxetine 60 mg was ordered as DULoxetine HCl Capsule Delayed Release Particles 60 MG Give 1 capsule by mouth at bedtime for depression. It was ordered to be given at bedtime and was giving during the morning medication pass. There was also an order for Famotidine Oral Tablet 20 MG Give 1 tablet by mouth one time a day for GERD (Gastro Esophageal Reflux Disease) IN THE MORNING and it was not observed being given but was signed off on the medication administration record as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for two (R9 and R19) of five residents reviewed for monthly regimen reviews [MRR's]. Findings include: R9 A review of R9's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: traumatic ischemia, schizoaffective disorder and Alzheimer's. According to the MDS assessment the resident had a Brief Interview for Mental Status (BIMS) score of 3/15 (severely impaired cognition). Review of the monthly medication reviews revealed there were irregularities with R9's medication as follows: 9/16/25, 11/14/25, 12/9/25, 1/16/26, 2/11/26. No documentation of the physician response to the irregularities was in R9's clinical record. On 3/25/26 at 11:07 AM, the Director of Nursing [DON] was interviewed and asked about R9's MRR dated 9/16/25, 11/14/25, 12/9/25, 1/16/26, 2/11/26. The DON explained she could find no documentation in the chart, so she had asked…

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 #2574455Based on interview and record review the facility failed to thoroughly investigate an injury of unknown origin for one resident (R701), of two residents reviewed for abuse, resulting in the potential for undetected incidences of abuse. Findings include: A complaint received by the State Agency alleged R701 was intentionally handled roughly causing a skin tear to their forearm.On 11/25/25 at 9:40 AM, an interview was conducted with the complainant, and they alleged a facility staff member intentionally caused a skin tear to R701's during a transfer from the toilet to their wheelchair. They reported R701 told the staff member they were hurting them, and rather than stop grabbing them by their forearm the staff member grabbed it tighter causing a skin tear.On 11/25/25 at 9:53 AM, a review of R701's clinical record revealed they admitted to the facility on [DATE] and discharged to the emergency room on [DATE]. R701's diagnoses included: left pubis fracture, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake 2660427.Based on interview and record review, the facility failed to provide care for a cholecystostomy tube (biliary drainage tube inserted into the gall bladder to relieve symptoms of gall bladder disease) consistent with professional standards and in accordance with Physician orders for one (R704) of one resident reviewed with a cholecystostomy (biliary) tube resulting in a delay of surgical intervention to exchange R704's biliary catheter.Findings include:A complaint was filed with the State Agency on 10/31/25 alleging the facility did not provide care for a cholecystostomy biliary drain consistent with professional standards and in accordance with Physician orders. On 11/25/25 at 9:26 AM, a telephone interview with R704's family (complainant) confirmed on October 11, 2025, while visiting with R704 they had observed drainage from the area of the biliary drain which grossly soiled R704's linens and clothing. The family had to get a nurse at which time they observed the nurse…

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

This citation pertains to Intake Number: 2563408.Based on observation, interview, and record review, the facility failed to ensure food in the kitchen was labeled and dated when opened or prepared. This had the potential to affect all residents who eat food from the kitchen. Findings include: On 8/6/25 at 9:20 AM, an observation of the refrigerators and freezer in the kitchen was conducted with Dietary Aide 'F'. The following observations were made:Two opened containers of sour cream were stored in the walk-in refrigerator and were not dated. DA 'F' reported they should have been dated when opened.In one of the reach-in refrigerators, the following was observed: A tray of prepared fruit cups was not labeled with a prepared on or use by date. One container of ranch salad dressing was opened and undated. One contained of Italian salad dressing was opened and undated. DA 'F' stated, We use the dressing quickly.In a second reach-in refrigerator, the following was observed: A tray of prepared fruit (sliced pears) was not labeled or dated. A tray that contained slices of sweet potato pie…

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 1245809Based on interview and record review, the facility failed to prevent excessive tension and tugging of an indwelling urinary catheter for one resident (R702) of two residents reviewed for catheter care, resulting in a penile full thickness urethral tear. Findings include:Clinical record review revealed R704 was admitted [DATE] post hospitalization for lower spinal and sacral area wound infections. Due to wound healing to the sacrum and history of urinary retention, R702 maintained a temporary Foley Catheter (Indwelling catheter inserted into the urethra to drain urine) and required further medical, wound care and rehabilitation treatment. The BIMS (Brief Interview for Mental Status) score assessed on 6/12/25 totaled 15/15 indicating R704 was cognitively intact.Clinical record review of Wound Care Progress note dated 6/9/25 by Wound Care Physician C documented a newly identified wound as .Wound #7 Penis is a full Thickness Medical Device Related Injury.On 8/5/25 at 9:55 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00151259 Based on observation, interview and record review the facility failed to ensure regularly scheduled/routine bathing was offered for one resident (R802) of three residents reviewed for activities of daily living. Findings include: On 5/14/25 a complaint submitted to the State Agency was reviewed that alleged R802 was not being provided regular scheduled bathing. On 5/14/25 at approximately 9:10 a.m., R802 was observed in their room, laying in their bed. R802 was queried if the facility had been offering and providing regularly scheduled bathing and they reported that staff were missing their showers and that R802 prefers showers in the afternoon/evenings. R802 reported if they did not want a shower at that time, nobody comes back to offer it again later and the staff say they refuse. R802 was queried how often the staff are offering showers and they reported that they were lucky if they got bathed once a week and that they needed more than that because they sweat a 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 #MI00150658 Based on interview and record review the facility failed to ensure pain medications were refilled timely, pulled from the back-up medication supply for administration and administer pain medications per physician orders for one resident (R803) of two residents reviewed for pain management, resulting in uncontrolled pain and a transfer to the emergency room for pain management. Findings include: A complaint received by the State Agency alleged the facility failed to administer pain medications per physician's orders. On 5/14/25 at 9:25 AM, a review of R803's closed clinical record revealed they admitted to the facility on [DATE] and had multiple emergency room discharges and re-admissions to the facility. R803's diagnoses included: morbid obesity, urinary tract infection, diabetes, high blood pressure, peripheral vascular disease, and depression. A review of R803's progress notes was conducted and revealed the following: A progress note dated 1/25/25 at 8:25 PM entered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00151259 Based on observation, interview and record review the facility failed to ensure resident food preferences were honored for one resident (R802) of three residents reviewed for food preferences/palatability. Findings include: On 5/14/25 a complaint submitted to the State Agency was reviewed that alleged R802 was not being provided good tasting food according to their preferences. On 5/14/25 at approximately 9:10 a.m., R802 was observed in their room, laying in their bed. R802 was queried if the facility had been providing food according to their liking and they indicated they had not. R802's breakfast meal tray was observed to contain scrambled eggs and a sausage patty. R802 reported the facility kept getting their meal ticket wrong and that they were supposed to be served double portions and have cheese on their eggs. R802 indicated the kitchen could not get their meal right and they won't eat it and the food is always cold. At that time, R802's food was not projecting…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 1/14/25 between 9:00 AM-9:30 AM, during an initial tour of the kitchen with Dietary Manager (DM) Q, the following items were observed: In the walk-in cooler, there was an undated container of salad, an opened undated bag of diced chicken, and an opened, undated bag of polish sausage. DM Q confirmed the items should have been dated. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original…

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 adequate privacy for Resident Council group meetings and addressing grievances for four of 14 Confidential (C) residents (C-4, C-7, C-8, C-10) reviewed for organized monthly Resident Council meetings. Findings include: On 1/15/25 at approximately 10:50 a.m., Activity Director (AD) R reported the Resident Council President, C-4, was unable to be in attendance, despite being invited the day before. On 1/15/25 at 11:04 a.m., the group meeting to review resident council per regulatory guidance was held in the Private Dining room, an enclosed room off the main dining room. It was observed there initially were no signs announcing the meeting; signs were placed on the door just prior to the meeting starting . The State Ombudsman (resident advocate), Ombudsman U, was present for the meeting along with the Surveyor. Residents reported they wanted the Ombudsman present and declined for any other staff to be present. There were 13 residents…

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 provide a sanitary homelike environment amongst residential common areas including,the central shower room, first floor dinner, room [ROOM NUMBER] and room [ROOM NUMBER]) resulting in an unkempt environment resulting in potential for resident dissatisfaction with their living conditions and failure to maintain a clean healthcare environment. Findings include: On 1/24/25 at 10:08 AM, An observation of the second-floor resident rooms revealed carpeted floors unkempt, appeared not vacuumed regularly and were observed with paper straw wrappers, and other paper like debris. Passing by residential rooms in the 200 hallway was observed with all rooms having tiled flooring was not mopped and sticky ring marks were noted. room [ROOM NUMBER] floor was observed with a moderate pile of cakelike substance surrounded by a dried sticky ring. The white door facing the residents and entrance to their bathroom area was observed with five moderate sized rings of pink…

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/completed assessments and investigations into multiple falls, and identify and implement appropriate fall interventions for one (R85) of three residents reviewed for accidents. Findings include: On 1/14/25 at 1:25 PM, R85 was observed laying in bed, positioned halfway down the bed with their right leg positioned in the air and resting on a large pillar in the middle of the room, next to their bed. R85 was observed to have a perimeter mattress in place (edges of mattress raised) and was lightly hitting themselves and saying No, no, no. On 1/14/25 at 1:30 PM, a Nurse was observed asking the Nurse Aide to reposition the resident in bed. On 1/15/25 at 7:51 AM, R85 was observed laying in bed, positioned on their back. The perimeter mattress was observed to have additional pillows to the side centers of the mattress on both sides and the bed was positioned lower, but not all the way to the floor. The wheelchair next to the bed was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to consistently ensure sufficient nursing staff was provided for residents who resided in the facility, resulting in verbalized complaints of delayed care and services, lack of supervision of residents with wandering behaviors, and the likelihood for further delayed care and unmet care needs. This deficient practice has the ability to affect all 101 residents in the facility, including resident# (R86). Findings include: According to the facility's policy titled, Nursing Staffing dated 11/4/2024: .Nursing service is provided by number and type of personnel to ensure that each resident .Receives rehabilitative nursing care as needed; Receives proper care to maintain their highest level of functioning (prevent decline in function or poor clinical outcomes); Is kept clean, comfortable, and well-groomed; Is protected from accidents, injury, and infection .Nursing assistants are expected to carry out their daily assignments in a professional…

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 medication storage and labeling for medications and biologicals in one of six medication carts and one of one treatment cart. This deficient practice has the potential to affect multiple residents throughout the facility, including R70. Findings include: On 1/15/25 at 8:54 AM, Observation of the first-floor central shower room revealed one pink colored oblong sized pill lying on the floor bordering the back corner next to the tub. Licensed Practical Nurse (LPN) C was asked to retrieve and while picking up with their bare hand, said oh that's an omeprazole When inquired how medication is found in the central shower area, LPN C replied that it must have fallen off the medication cart and rolled into the common shower area. On 1/15/25 at 10:15 AM, One small round white pill was lying in common hallway in front of room [ROOM NUMBER]. LPN F commented that should not be there and was observed picking up the pill off the floor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure effective infection control practices (hand hygiene) during medication pass and implementation of Enhanced Barrier Precautions (EBP) for one (R60) of one resident reviewed for a urinary catheter, resulting in the potential for cross-contamination and the development and spread of infection and disease. Findings include: R60 On 1/14/25 at 10:15 AM and 1/15/25 at 7:58 AM, R60 was observed in bed with a urinary catheter drainage bag observed secured to the side of the bed. At each of these observations, there was no signage posted to indicate the resident was on any precautions such as Enhanced Barrier Precautions (EBP) and there was no Personal Protective Equipment (PPE) available for use. On 1/14/25 at 12:57 PM, the Certified Nurse Aide (CNA 'O') who was assigned to R60 was observed holding a bag of linens just inside the resident's room. When asked about whether they were aware of R60 being on any infection control precautions such…

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 develop a comprehensive care plan to address a resident's specific nutritional needs for one (R297) of four residents reviewed for nutritional care planning. Findings include: Review of the closed clinical record revealed R297 was admitted into the facility on [DATE] with diagnoses that included: other complications of gastric band procedure, sepsis, unspecified severe protein-calorie malnutrition, morbid (severe) obesity due to excess calories, metabolic encephalopathy, acute respiratory failure with hypoxia, altered mental status, and encounter for surgical aftercare following surgery on the digestive system. The resident was transferred to a local hospital on [DATE] at 12:35 PM and has not returned to the facility. According to the Minimum Data Set (MDS) assessment dated [DATE], R297 had no communication concerns, had intact cognition, weight was 359 pounds, with no weight loss or weight gain, had no parenteral/intravenous feeding on admission, 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 nursing services met professional standards for medication administration and documentation for one resident (R55) out of one reviewed for self administration. Findings Include: Clinical record review revealed R55 was admitted to the facility on [DATE] with a medical history of hepatitis (inflammation of the liver), hypertension, and diabetes. Psychiatric history included major depressive disorder, bipolar disorder, and anxiety. A Brief Interview of Mental Status (BIMS) score assessed on 11/14/24 scored 14/15 indicating R55 was cognitively intact. On 1/14/25 at 10:48 AM, During initial interview, an observation revealed nine scabbed, red colored blister/lesions on forehead, bilateral cheeks, nose and chin. R55 voiced concerns since they had developed the sores, Nursing leaves some kind of lotion at the bedside and has no idea what the lotion is. R55 was observed grabbing two medicine cups filled with a white colored lotion from…

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 communication devices and services were in place for one (R902) of three residents reviewed for communication, resulting in the potential of unmet care needs. Findings include: A revisit survey was conducted onsite to verify if the facility corrected an identified noncompliance regarding communication services for residents whose primary language was not English. A review of the medical record for R902 revealed their admission to the facility on 1/29/25, with diagnoses that included: dementia and anxiety disorder. A review of a care plan titled . impaired communication noted R902's primary language to be Arabic but noted the resident to speak and understand English and had severely impaired cognition. Documented on the care plan was two interventions- Anticipate and meet needs as needed and Observed for non-verbal indicators of attempts to express self such as tears, furrowing of the brow, pursing of the lips, yelling, grabbing, reaching, gestures etc . On 3/18/25 at approximately 12:50 PM, an…

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

Based on observation, interview, and record review the facility failed to provide timely toileting/brief care for three residents (R78, R31, and R55) of three reviewed for incontinence care, resulting in the resident being left wet for extended periods. Findings include: On 1/15/25 at 2:36 PM, R78 was observed in their room asking an unknown staff member to change them. At that time, R78 was told that they would find someone to help them and exited the room. At 2:45 a nurse entered the room and turned the call light off and exited the room without helping the resident. At 3:10 PM, a certified nurse assistant (CNA) went into the room and assisted R78. On 1/16/25 at 10:30 AM, an observation of the nurse's station revealed a view of the call light board to see how long the call lights had been on. R31's light had been on since 9:51 AM, R78's call light had been on since 10:03 AM. At 10:32 AM, R31 was observed in their room and asked what they needed. R31 asked to be changed and stated that they had been waiting for some time now. At 10:33 AM, R78 was observed in their room and asked if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that a physician was notified of a change in condition for one resident (R78) of one resident reviewed for change in condition. Findings include: On 1/14/25 at 10:12 AM, an interview was conducted about the care in the facility with R78 and their family member. R78 stated, It's been fine but, they take a long time to change me. R78 further went on to explain that he felt that 40 minutes to an hour or 2 is too long to be sitting with mess on your bottom. R78 also explained they needed some type of antibiotic for their skin and that it had been itching and burning for a while and told the nurses. Family member II explained that R78 had been calling them for the past month asking if they could take them to the doctor so they can get antibiotics because the spot on their back was hurting and they were afraid it may be an abscess forming. Family member II tried to explain to R78 that they couldn't do that because they had doctors in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide restorative therapy services for one (R25) of one resident reviewed for restorative services and range of motion. Findings include: On 1/14/25 at 3:29 p.m., R25 was observed in their hospital bed, with their knees bent partially, and their heels pressing on the bed mattress. Their knees appeared to be lacking in full extension, by about 20 to 30 degrees. On 1/14/25 at 3:31 p.m., R25 was asked if they received restorative therapy services due to their bilateral leg range of motion deficits. R25 reported they were receiving restorative therapy prior to their hospitalization and were unsure why restorative therapy was not doing range of motion, since their legs felt tighter. R25 reported they wanted restorative therapy services to resume and clarified they were not receiving therapy services (physical or occupational therapy) recently. On 1/14/25 at 3:45 p.m., the Restorative Aide, Certified Nurse Aide (CNA) X, was asked if R25 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 # MI0048767. Based on interview and record review, the facility failed to complete a comprehensive nutritional assessment and ongoing evaluation per physician order for one (R297) of four residents reviewed for nutrition. Findings include: Review of a complaint filed with the State Agency included allegations that R297 had not received adequate nutritional assessment and monitoring in accordance with hospital recommendations following a gastric sleeve revision surgery with complications. Review of the closed clinical record revealed R297 was admitted into the facility on [DATE] with diagnoses that included: other complications of gastric band procedure, sepsis, unspecified severe protein-calorie malnutrition, morbid (severe) obesity due to excess calories, metabolic encephalopathy, acute respiratory failure with hypoxia, altered mental status, and encounter for surgical aftercare following surgery on the digestive system. The resident was transferred to a local hospital on [DATE]…

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 appropriate indication for use, ensure non-pharmacologic interventions were attempted and identify behaviors exhibited prior to the administration of as needed (PRN) psychotropic medication (anxiolytic) for one (R85) of six residents reviewed for unnecessary medications. Findings include: Review of the clinical record revealed R85 was admitted into the facility on 8/26/24 with diagnoses that included: hemiplegia and hemiparesis, generalized anxiety disorder (12/4/24), dysthymic disorder (12/4/24), vascular dementia moderate with mood disturbance, adjustment disorder with mixed anxiety and depressed mood. According to the minimum data set (MDS) assessment dated [DATE], R85 had severe cognitive impairment, had no psychosis, no behaviors, and did not receive any antianxiety medication. Further review of the clinical record revealed R85 was started on Alprazolam (Xanax) oral tablet 0.5 MG (Milligrams) by mouth every 12 hours as needed for agitation…

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 and/or coordinate timely radiology services for an X-Ray for one (R63) of one resident reviewed for radiology/other diagnostic services, resulting in the potential for delayed identification of any abnormalities which may require additional medical/treatment intervention. Findings include: Review of the resident's incident/accident reports provided by the facility for the past three months included a fall incident from 1/11/25 which documented R63 was .lying on the side of the bed on left side . Review of the physician orders following this fall incident included an order for the facility to obtain an X-Ray of R63's Left Shoulder. As of this review on 1/15/25, there was no radiology report available in the electronic medical record. Additional review of the radiology log at the nursing station revealed the most recent entry was on 1/11/25 for another resident and R63's request had not been completed despite the order from 1/13/25.…

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 Based on interview and record review, the facility failed to ensure pursuing and administration of the pneumococcal and influenza vaccine for one resident (R3) of five reviewed for immunizations. Findings include: Clinical record review revealed R3 was admitted to the facility on [DATE] with a medical history of influenza, pneumonia, heart failure, osteoarthritis, and gastrointestinal hemorrhage. R3's primary language is Arabic/Chaldean and translation was provided by family, specifically their daughter. A Brief Interview of Mental Status (BIMS) assessed on 11/14/24 scored 15/15 indicating R3 was cognitively intact. On 1/16/25, a clinical record revealed R3 consented on 11/16/24 (via their daughter who is their translator) to receive the influenza and pneumonia vaccinations. Review of the Electronic Medical Record (EMR) revealed no documentation that R3 received the elected vaccinations. On 1/16/25 at 9:49 AM, an interview was conducted with the facility Infection Control Preventionist (ICP) A. During 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.

This citation pertains to Intake Number(s): MI00147948. Based on observation and interview, the facility failed to maintain a sanitary and comfortable environment in the hallway near the main dining room. Findings include: On 11/18/24 at 8:16 AM, a strong, putrid, sour odor was experienced in the hallway that extended from the main dining room to the hallway that led to the lobby. At that time, Registered Dietician (RD) 'E' was asked what the odor was from and reported she thought it was due to a problem with the dish machine. The door to the dish room was located on the hallway where the odor was observed. On 11/18/24 at 8:40 AM, an interview was conducted with the Infection Control Nurse/Staff Development Nurse, Staff 'D' who acknowledged there was a pungent odor in the hallway that ran along side the dining room. On 11/18/24 at 10:00 AM, an interview was conducted with Housekeeping Supervisor (HK) 'F'. When queried about the odor, HK 'F' reported it was due to an issue with the dish machine that needed repairs. On 11/18/24 at 12:00 PM, an observation was made of the dish 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 This citation pertains to Intake MI00146159 Based on observation, interview and record review the facility failed to protect the residents' right to be free from depravation of goods and services by a nurse for three (R701, R704 and R705) of three residents reviewed for neglect. Findings include: Review of a facility document titled, Charge Nurse Job Description undated read in part, .The Charge Nurse plans, coordinated, provides and manages nursing care, nursing services and health education to nursing home residents . 2. Provides safe and accurate Medication Related interventions to residents. a. Administers and documents medications and treatments according to each resident's medication schedule using current standards of medication pass technique . R701 A complaint was filed with the State Agency (SA) on 8/6/24 that alleged in part, on 7/31/24, R701's Family Member visited R701 from 7:32 PM until approximately 12:30 AM 8/1/24 and Registered Nurse (RN) B never came to R701's room to administer 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.

This citation pertains to Intake # MI00144835. Based on interview and record the facility failed to ensure that one Nurse (Nurse A) had an active license to practice as a Licensed Practical Nurse (LPN). Failure to ensure Nursing Staff had a valid, active/current license had the potential to affect multiple residents at the facility. Findings include: A complaint was filed with the State Agency (SA) that alleged Nurse A was working at the facility with a suspended license. The complainant alleged when they viewed the State Licensing Verification website, it was noted Nurse A's license was suspended in February 2024. On 6/5/24 at approximately 8:00 AM, a review of the State Licensing Verification website was conducted. Nurse A 's information was entered into the Profession Licensing search for LPNs. The License Detail section indicated Nurse As license had been suspended on 2/3/24. Additional documentation included Disciplinary Actions that resulted in suspension to practice as an LPN with an effective date of 2/3/24. On 6/5/24 at approximately 9:30 AM, a review of the facility's…

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

Based on interview and record review the facility failed to establish a comprehensive infection control program that identified resident infections, calculated monthly infection rates, tracked and trended infections, utilized laboratory and pharmaceutical data, and ensured departmental surveillance and staff education on infection control. This deficient practice had the ability to affect all 91 residents who resided in the facility. Findings include: On 12/12/23 at 1:58 PM, a review of the facility provided infection control program was conducted. Registered Nurse (RN) J, who served as the Infection Preventionist (IP), explained she was hired in September 2023, and the facility had not had an IP when she was hired. The binder provided was reviewed and no resident specific data was documented for March 2023, April 2023, August 2023, November 2023 and December 2023. May 2023, June 2023 and July 2023 only contained line listings and a surveillance map. For September 2023, there was a printout listing all the residents on antibiotics and a document logging employee illnesses. October…

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 consistently have an employed Infection Preventionist to properly assess, develop, implement, monitor and manage the Infection Control Program. This deficiency had the ability to affect all 91 residents that resided at the facility. Findings include: On 12/12/23 at 1:58 PM, Registered Nurse (RN) J, who served as Infection Preventionist (IP), was interviewed and asked how long she had been at the facility. RN J explained she had started in early September 2023 to be the IP. RN J was asked if she had replaced someone already serving as IP. RN J explained there had not been an IP at the facility when she was hired. Review of RN J's certificate for Nursing Home Infection Preventionist Training Course revealed it was dated 12/8/23. On 12/14/23 at 11:30 AM, Administrator A was interviewed and asked when the facility's last IP had left. Administrator A explained he believed it was in March 2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the nursing standards of practice for two Residents (R70 and R19) by not accurately transcribing the physician orders and not priming an insulin pen prior to administration resulting in a Resident receiving incorrect medication dose and the potential for receiving incorrect insulin doses. Findings include: R70 A record review of the facesheet revealed R70 was recently readmitted to the facility on [DATE] for skilled nursing and rehabilitation after a hospitalization. R70's admitting diagnoses included fractured right humerus, hypertension (high blood pressure), urinary retention, dementia, and metabolic encephalopathy (condition that affects how the brain functions). R70 had a Brief Interview for Mental Status (BIMS) score of 00/15 indicative of severe cognitive impairment based on the Minimum Data Set (MDS) assessment dated [DATE]. R70's preferred language was Chaldean. An initial observation was completed on 12/12/23, at…

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 implementation of a pharmacy recommendation after the physician's agreement for one (R55) of five residents reviewed for Medication Regimen Review (MRR). Findings include: Review of the clinical record revealed R55 was admitted into the facility on 5/5/21 and readmitted [DATE] with diagnoses that included: stroke, diabetes and schizoaffective disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R55 had moderately impaired cognition and was dependent on staff for activities of daily living. Review of a Consultation Report by a Consultant Pharmacist dated 6/22/23 revealed a recommendation that read, Please consider increasing Novolog to 21 units with meals (to be held if patient does not eat). The physician response was marked with I accept the recommendation(s) above, please implement as written and signed by Dr. W on 7/28/23. Former Director of Nursing (DON) C had signed the form on 7/26/23, two days before Dr. W had signed…

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 continuously implement an antibiotic stewardship program that included consistent implementation of protocols for appropriate antibiotic use for multiple resident at the facility, including R9, of 19 sampled residents. Findings include: On 12/12/23 at 1:58 PM, a review of the facility provided infection control program was conducted and revealed the following: January 2023, line listings and a surveillance map. February 2023, line listings and a surveillance map. March 2023, an Interdisciplinary Team surveillance paper. April 2023, nothing. May 2023, line listings and a surveillance map. June 2023, line listings and a surveillance map. July 2023, line listings and a surveillance map. August 2023, nothing. September 2023, a printout of all residents on antibiotics. There were no signs and symptoms, no laboratory or radiology reports, or documentation on if the antibiotic therapy meet McGeer's criteria or not. There was a log of employee illnesses. October 2023, a printout of all residents on antibiotics and a surveillance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a dining experience with dignity that promoted independence with eating for one of one Resident (R90) reviewed for dignity with potential for frustration, decreased nutrition intake, and weight loss. Findings include: A record review of the facesheet of R90 revealed they were a long-term resident of the facility. R90 was recently re-admitted to the facility on [DATE] after a recent hospitalization. R90's diagnoses included right Femur fracture due to a fall at the facility on 5/9/23, dementia, stroke, and hemiplegia. R90 had history of multiple falls since admission to the facility. R90 had a Brief Interview for Mental Status (BIMS) score of 5/15, indicative of severe cognitive impairment, based on the Minimum Data Set (MDS) assessment dated [DATE]. An initial observation was completed on 12/12/23, at approximately 11:30 AM. R90 was observed in their bed. R90 had a wheelchair parked on the left side of the bed, near the wardrobe.…

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): MI00139772 and MI00141293. Based on interview and record review, the facility failed to ensure that a resident was free from neglect by not providing timely assistance from the commode chair after toileting for one (R107) of one resident reviewed for neglect, resulting in frustration and emotional distress. Findings include: A facility provided document titled Abuse Prohibition Policy with an effective date of 10/14/22 read in part, Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property . A complaint received by the State Agency read in part, Around 9 PM (R107 - name omitted) was placed on the toilet and was left for over an hour. (R107 - name omitted) called for help and although staff would stick their head in, no one would help her off the toilet EMS (Emergency Medical Services) arrived at the facility and got (R107- name omitted) off the toilet. (Name omitted) called the rehab facility informing staff (R107 name…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide timely fingernail care for one (R9) of two resident's reviewed for Activities of Daily Living (ADLs). Findings include: On 12/12/23 at approximately 10:09 AM, R9 was observed lying in bed. The resident was contracted and yelling out in pain. Both hands were observed to have excessive long nails, approximately one third inch past the finger bed. The resident was asked if they liked their nails long and replied that they did not. On 12/13/23 at approximately 12:00 PM, R9 was again observed in bed. Their nails on both hands were still long. A review of R9's clinical record documented that the resident was admitted to the facility on [DATE] with diagnoses that included, in part: Alzheimer's Disease, dysphagia and repeated falls. A review of R9's Minimum Data Set (MDS) dated [DATE] revealed the resident has a Brief Interview for Mental Status (BIMS) score of 6/15 (severely impaired cognition). Continued review of R9'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 has two Deficient Practice Statements (DPS): DPS #1 Based on observation, interview, and record review the facility failed to follow up timely with the physician for one of one Resident (R35) reviewed for physician orders, resulting in the potential for delay in treatment and further decline in health. Findings include: R35 R35 was originally admitted to the facility on [DATE]. R35's admitting diagnoses included hypertension (high blood pressure), heart failure, and urinary tract infection. R35 had a Brief Interview for Mental Status (BIMS) score of 14/15, based on the Minimum Data Set assessment dated [DATE], indicative of intact cognition. An initial observation was completed on 12/12/23, at approximately 11:45 AM. R35 was observed in their bed watching TV covered with blankets. During this observation an interview was completed. During the interview R35 reported that they were doing okay and that they were planning to stay long term at the facility, and they were completing paperwork. R35…

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): MI00141293. Based on observation, interview and record review, the facility failed to implement interventions, treatments, and assessments for two (R42 & R104) of three residents reviewed for pressure ulcers. Findings include: R42 On 12/12/23 at 9:37 AM, R42 was observed lying in bed with an air mattress. R42 was lying on their back. The air mattress controller hooked on the end of the bed was not on, and R42's bottom appeared to be resting directly on the frame of the bed with the mattress enveloping R42 on either side. Upon inspection of the controller, labeled as an alternating pressure low air loss with patient sensing technology, the power cord was not plugged into the controller and was hanging down towards the floor. R42 was asked about the mattress, but did not reply to questions asked. Review of the clinical record revealed R42 was admitted into the facility on 1/12/22 and readmitted [DATE] with diagnoses that included: Alzheimer's disease, Parkinson's disease…

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 appropriate catheter care and identify signs of a urinary tract infection (UTI) for one (R63) of one resident reviewed for UTIs. Findings include: On 12/12/23 at 5:10 PM, R63 was observed lying in bed. A urinary catheter drainage bag was observed hanging from the side of the bed and contained viscous, opaque, green colored urine. R63 did not answer any questions when addressed and made groaning noises. A foul, sweet smelling odor was present in R63's room. On 12/13/23 at 7:48 AM, R63 was observed lying in bed. A foul, sweet smelling odor was present in R63's room. R63's urinary catheter drainage bag was observed to contain a small amount of viscous, opaque, green colored urine. There was a document present in R63's room that noted they were going out of the facility for a procedure that day. On 12/13/23 at 7:53 AM, an interview was conducted with Licensed Practice Nurse (LPN) 'H', R63's assigned nurse. When queried about the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an attending physician was supervising medical care, participating in resident assessments and available for consultation for two (R55, R46) of three residents reviewed for physician services. Findings include: R55 On 12/12/23 at 1:05 PM, R55 was observed sitting on the bed. Another person was sitting in a chair in R55's room. R55 spoke with broken English, but could make themselves understood. The other person in the room explained they were R55's Durable Power of Attorney (DPOA). R55's DPOA was asked about care in the facility. R55's DPOA explained R55's doctor, Dr. N had never once called them to discuss R55's medications or plan of care. They were concerned that R55 had dementia and a language barrier and could not communicate everything that was going on with the doctor. The only way they knew R55 had been seen by Dr. N was when they received a summary of charges from R55's insurance company and there was a charge for a physician visit.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide timely laboratory services as ordered by the physician to one (R100) of one resident reviewed for laboratory services. A record review of the Electronic Medical Record (EMR) revealed R100 was admitted to the facility on [DATE], for short-term skilled nursing and rehabilitation after recent hospitalization. R100's admitting diagnoses included sepsis, heart failure, and diabetes. R100 had a Brief Interview for Mental Status (BIMS) score of 15/15, based on the Minimum Data Set (MDS) assessment dated [DATE], indicative of intact cognition. An initial observation was completed on 12/12/23, at approximately 9:55 AM. R100 was observed in their bed. During this observation an interview was conducted. During the interview R100 reported that they have been feeling tired for about ten days. R100 reported that they were receiving antibiotic medication once a day for the infection and had been waiting for their laboratory results. 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 ensure radiology/x-ray services were obtained and addressed timely for two (R46 and R9) out of two residents reviewed for radiology services. Findings include: R46 On 12/12/23 at approximately 9:53 AM, R46 was observed in their room. The resident was alert and not able to answer questions pertaining to care provided by the facility. A review of R46's clinical record revealed the resident was initially admitted to the facility on [DATE] and readmitted to on 9/28/23 with diagnoses that included: diabetes type II and dementia. The resident's Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4/15 (severely cognitively impaired). Continued review of R46's clinical record documented, in part, the following: Nurses Notes (9/25/23): MD (Medical Doctor) notified that resident O2 (oxygen) is 86%. Albuterol ordered and 2 liters of 02. Stat Chest x-ray ordered. Order Details (9/25/23): Order date…

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 #MI00137881 Based on observation, interview, and record review the facility failed to document care concerns and follow the facility's policy for concerns for one (R902) of one resident reviewed for grievances. Findings include: On 9/6/23 a concern submitted to the state agency was reviewed which alleged the facility administration was not following up on resident concerns. On 9/6/23 The medical record for R902 was reviewed and revealed the following: R902 was initially admitted to the facility on [DATE] and had diagnoses including Progressive neuropathy, Low back pain and Pain in left knee. A review of R902's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/3/23 revealed R902 needed staff assistance with toileting and bathing. R902's BIMS score (brief interview for mental status) was 15 indicating intact cognition. On 9/6/23 at approximately 12:03 p.m., R902 was observed in their room, up in their wheelchair. R902 was queried if they had any concerns about…

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 MI00138181 and MI00138398 Based on observation, interview and record review, the facility failed to ensure medications were available for administration for two residents (R902 and R903) of two residents reviewed for Nursing standards of practice. Findings include: Resident #902 On 9/6/23 a concern submitted to the State Agency alleged R902 was not receiving their medications as ordered. On 9/6/23 at approximately 12:03 p.m., R902 was observed in their room, up in their wheelchair. R902 was queried if they had any concerns about their care and they indicated that they have had episodes of where they were unable to get their pain medication because the facility had run out of it and the Nursing staff did not ensure it was in the facility. On 9/6/23 The medical record for R902 was reviewed and revealed the following: R902 was initially admitted to the facility on [DATE] and had diagnoses including Progressive neuropathy, Low back pain and Pain in left knee. A review of R902's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00137881 and MI00134566. Based on observation, interview and record review, the facility failed to ensure regular scheduled bathing was provided for one resident (R902) of two residents reviewed for activities of daily living. Findings include: On 9/6/23 a concern submitted to the State Agency was reviewed which alleged R902 was not receiving regular bathing. On 9/6/23 at approximately 12:03 p.m., R902 was observed in their room, up in their wheelchair. R902 was queried if they had any concerns about their care and they reported that the facility had been missing showers during the summer months. R902 reported that they are often left wet in their brief and needed to be showered regularly to prevent the urine from breaking down their skin. On 9/6/23 The medical record for R902 was reviewed and revealed the following: R902 was initially admitted to the facility on [DATE] and had diagnoses including Progressive neuropathy, Low back pain and Pain in left knee. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI00134566 Based on observation, interview and record review the facility failed to ensure treatments for a wound were completed timely per Physicians orders and were appropriately assessed for one resident (R901) of one residents reviewed for wound care. Findings include: On 9/6/23 a concern submitted to the State Agency for review alleged R901 did not receive appropriate wound care treatment. On 9/6/23 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Heart Failure. A review of R901's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/7/22 revealed R901 needed extensive assistance from facility staff with their activities of daily living. R901's BIMS score (brief interview for mental status) was seven indicating severely impaired cognition. A review of R901's careplan revealed the following: [R901] has Actual impairment to skin integrity r/t…

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.