Four Seasons Nursing Center of Westland

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake 2569649.Based on observation, interview, and record review, the facility failed to protect one resident's right (R703) out of one reviewed to be free from mental abuse and verbal abuse by staff.An allegation of staff to resident abuse involving Staff F and R703 was submitted to the state agency around 7/9/25.On 7/30/25 at 9:45 AM, R703 was observed sitting up in their wheelchair in their room. When the resident was asked about the incident involving Certified Nursing Assistant (CNA) F on 7/9/25, they said the nursing assistant came in that morning to empty my catheter bag. I told them to be sure it was closed because it has been leaking. The nursing assistant got smart with me and said she knew how to do her job. So, I called her a B and spelled it out to her. We argued. The nursing assistant then proceeded to pull my covers off me and throw them on the floor and threw water at me. I was trying to use my call light to call for help, but she pulled it away from me and put it…

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

This citation pertains to Intake 1246198Based on observation, interview, and record review, the facility failed to apply compression stockings for one resident (R700) out of two reviewed for following physician orders. Findings include:A review of Intake called into the State Agency noted R700's legs are swollen and painful.On 7/30/2025 at 9:48 AM, R700 was observed lying in bed. R700 was observed to have heel boots on and nothing else. R700 reported they are supposed to have compression stockings on to help with the swelling in their legs, but the facility staff have only been put them on once or twiceA review of the medical record revealed R700 was admitted into the facility on 3/20/2024 with the following medical diagnoses, Muscle Weakness and Disorder of Muscle. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 12/15 indicating an impaired cognition. R700 also required staff assistance with bed mobility and transfers.A review of active physician orders revealed the following, please apply (name of compression…

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 2564064Based on interview and record review, the facility failed to prevent the development of an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) for one resident (R702) out of one reviewed for pressure ulcers. Findings include:A review of Intake called into the State Agency noted R702 admitted into the facility with their skin intact and developed an unstageable pressure ulcer on their coccyx/buttocks while in the facility due to not being turned and repositioned, as well as delayed incontinence care.A review of the medical record revealed R702 was admitted into the facility on 5/7/2025 with the following medical diagnoses, Muscle Weakness and Lymphedema. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating an intact cognition. R702 also required staff assistance with bed mobility and transfers.Further review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI0015340. Based on interview and record review, the facility failed to ensure appropriate documentation of administration and accountability of controlled substances for one (R903) of four residents reviewed for medication administration. Findings include: Review of a complaint filed with the State Agency included allegations that R903 was admitted for a five-day hospice respite stay and did not receive their medications either at all, or as prescribed, including controlled substances (liquid morphine-for pain and lorazepam-antianxiety). Review of the clinical record revealed R903 was admitted into the facility on 5/27/25 and discharged on 6/1/25. Diagnoses included: encounter for palliative care, multiple sclerosis, pseudobulbar affect, attention-deficit hyperactivity disorder, other seizures, stiff-man syndrome, and diplopia. According to the Minimum Data Set (MDS) assessments, there was only an entry assessment documented and a discharge return not anticipated assessment with…

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

Based on observation, interview and record review, the facility failed to ensure proper storage and discarding of medications in one of eight medication carts affecting three residents (R906, R907 and R908) of three residents reviewed for medication storage. Findings include: On 6/11/25 at 10:28 AM, upon walking onto the Spring Unit, an unlocked medication cart was observed with no licensed staff present. Additionally, the monitor on the top of the cart was left open with personal information in view to anyone that walked by for R907. The medication cart had an insulin pen (Lantus Solostar for R907) stored directly on top of the cart. Upon opening the unlocked top drawer of the medication cart, there were several clear medicine cups with pills in each cup. One of the cups contained five pills (later identified by Registered Nurse, RN 'E', as medication for R906); one cup had a white pill and another cup contained a white pill. At 10:30 AM, RN 'E' was observed exiting a seperate resident's room. When asked about the unlocked cart, open monitor and insulin stored on top of the cart,…

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 MI00153683 Based on observation, interview, and record review, the facility failed to provide nail care to one (R703) of five residents observed for nail care. Findings include: R703 was admitted on [DATE] with the following relevant diagnoses: Sequelae of Cerebral Infarction (Stroke); Functional Quadriplegia, Anxiety. R703 required substantial staff assistance for all activities of daily living (ADL's) and mobility. On 5/29/2025 at 1:35 PM, an observation of R703's fingernails revealed the nails were very long, about ¾ of an inch beyond the end of the finger and contained debris, some was yellow and some darker in color. On inquiry, R703 revealed they wanted them trimmed and had some anxiety about having them cut, afraid the skin may get nipped. During an interview with Registered Nurse (RN) Dat 2:45 PM, they confirmed the resident's should get regular nail care. An interview with Assistant Director of Nurse (ADON) revealed regular nail care should be carried out as part 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 MI00153683 Based on observation, interview and record review facility failed to answer call light in a timely manner for one (R703) of five residents reviewed for timely call lights. Findings include: R703 was admitted on [DATE] with the following relevant diagnoses: Sequelae of Cerebral Infarction (Stroke); Functional Quadriplegia, Anxiety. R703 required substantial assistance for all activities of daily living (ADLs) and mobility. On 5/29/2025 at 1:35 PM, R703 was observed lying in bed. On inquiry R703 reported after activating the call light, it often takes a very long time saying, if I put it on to much they (facility staff) don't like it. On 5/29/25 at 1:51 PM, Registered Nurse (RN) D came in the room making rounds. R703 indicated they needed a brief change and their feet hurt due to being against the footboard. RN D replied they would notify R703's Certified Nurse Assistant (CNA) they needed assistance. ON 5/29/25 at 2:06 PM, CNA B entered the room, turned the call light…

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 pureed food items were of the proper consistency. This deficient practice had the potential to affect all 9 residents receiving a pureed diet texture. Findings include: 02/10/25 at 12:15 PM, the lunch tray-line service was observed in the main kitchen. A pan of pureed carrots was observed on the steam table. The mixture was observed with visible small chunks of orange carrot bits, mixed in with a pale orange viscous substance. On 02/10/25 at 12:25 PM, a puree test tray was obtained. A taste test of the pureed carrots revealed small chunks of carrots, that required chewing before swallowing. On 02/10/25 at 12:30 PM, Dietician M and Chef L were shown the pureed carrots and asked if the texture looked acceptable for a pureed diet. Both stated the pureed vegetable was not the proper consistency, and that the vegetable would be pulled from the steam table and re-made. According to an IDDSI (International Dysphagia Diet Standardization Initiative) chart posted in the facility kitchen, for a pureed diet, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide timely repositioning for four dependent residents (R34, R44, R97, R118) of five reviewed for positioning. Findings include: Resident #34 On 02/10/25 at 9:38 AM, 12:29 PM, 1:54 PM, and 2:35 PM, R34 was observed to be on their backside in a specialty bed with the head of the bed elevated around 30-45 degrees and a foam wedge was on the mattress at the foot of bed. On 02/11/25 at 8:10 AM, 8:35 AM, 9:30 AM, and 11:41 AM, R34 was observed to be on their backside in bed and a foam wedge was on the mattress at the foot of bed. The head of the bed was up around twenty or thirty degrees. On 02/11/25 at 12:09 AM, 12:39 PM, and 12:43 PM, R34 was observed to be in bed dressed in a hospital style gown, turned toward the door. A foam wedge was visible behind the torso on the left side. At 12:51 PM, 2:02 PM, and 2:59 PM, the head of the bed was around 45 degrees and the wedge was behind the torso at the left side. R34 leaned over to the right edge…

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 administer the correct tube feeding formula for one resident (R119) of four reviewed for tube feeding. Findings include: On 2/10/25 at 9:46 AM, R119 was observed lying in bed. A bottle of Jevity 1.5 tube feeding dated 2/9/25 was observed to be hanging on a pole in their room. On 2/11/25 at 9:19 AM, two bottles of Jevity 1.5 tube feeding, one of which was dated 2/10/25 and the other dated 2/9/25 was observed in the trash can next to R119's bed. A review of R119's record revealed they were admitted to the facility on [DATE] with the following diagnosis: Benign Neoplasm of Meninges (brain tumor) and Dysphagia, oropharyngeal (inability to swallow). Further record review revealed a Brief Interview for Mental Status score of 11 indicating moderate cognitive impairment. A review of R119's physician orders revealed the following: active order dated 1/29/25 Enteral feed two times a day Nutren 2.0 @88ml/hr (milliliters per hour) x 12 hours…

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 the medication error rate was less than five percent resulting in two medications errors in 32 opportunities for a 6.25% medication error rate. Findings include: On 02/11/25 at 9:03 AM, a medication pass observation was conducted with Registered Nurse (RN) F for R108. The Lanthanum Carbonate, 1000 mg (milligram) supplement was not available to be given. RN F attempted to pull two calcium carbonate 500 mg tablets and was then asked to review the order. The Lanthanum carbonate was not given. A review of the January 2025 and February 2025 Medication administration record and electronic medical record medication progress notes documented the medication was not given and or not available. The February 2025 MAR documented the medication had been given 19 times. A pharmacy receipt request for the Lanthanum Carbonate was requested and a response via email dated 03/12/25 at 2:14 PM by the Director of Nursing revealed, Discussed again with dialysis regarding this medication - Order was active, but labs drawn on…

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

Based on observation, interview, and record review, the facility failed to ensure medications were dated when opened in two of five medications carts and two of two medication rooms reviewed. Findings include: On 02/12/25 at 8:43 AM, the Spring unit front cart was reviewed with Regeistered Nurse (RN) H revealed an Arnuity inhaler was not labeled with a resident identifier and not dated when opened on the inhaler nor the box. On 02/12/25 at 9:01 AM, the Spring unit back cart was reviewed with Licensed Practical Nurse (LPN) J a lispro insulin was not dated when opened and was without a resident identifier. On 02/12/25 at 11:12 AM, the Winter medication storage room was reviewed with LPN K, one tuberculin derivative vial was not dated when opened on the vial nor the box. On 02/12/25 at 11:51 AM, the Summer medication storage room was reviewed with LPN J, one tuberculin derivative vial was not dated when opened on the vial. On 02/12/25 at 11:14 AM, the Director of Nursing (DON) reported the tuberculin vials should be dated when opened. A review of the manufacturer's insert for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices by removing used urinals from overbed tables for three residents (R26, R122, 135) out of three residents reviewed for infection control practices. Findings Include: R26 On 02/10/25 at 9:15 AM, R26 was observed laying in bed watching television and a urinal half filled with yellowish urine sitting on over bed table. The resident was preparing for breakfast. A review of R26's medical record revealed R26 was admitted on [DATE] with diagnoses of atheroscloratic heart disease, muscle weakness, and atrial fibrillation. A review of R26's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental status (BIMS) assessment of 15/15 indicating resident is cognitively intact. R22 On 02/10/25 at 9:20 AM, R122 was observed laying in bed watching television with a urinal noted quarter filled with yellowish urine sitting on the over bed table. R122 had recently had breakfast and tray was being…

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 call lights were in reach for two (R42, R24) of two dependent residents. Findings include: R42 On 02/12/25 at 9:13 AM, R42 was observed to be in a recliner at the nurse's station outside the door to the dining room. At 10:19 AM, R42 was observed to have been returned to bed and changed into a hospital style gown. The call light was tucked under the left edge of pillow for their head. R42 was asked if they could reach the call light. R42 attempted to reach the light with their right hand but was not able to reach the call light. R42 was not able to move their left arm to reach the light. R42 reported it had been affected by a stroke. A review of the record for R42 revealed R42 was admitted into the facility on [DATE]. Diagnoses included Stroke and Heart Disease. The care plan initiated 06/18/20 documented an alteration in mobility related to limited range of motion to the left shoulder. The care plan did not provide an intervention…

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: MI00147682. Based on observation, interview, and record review, the facility failed to ensure a comprehensive nursing assessment was completed and timely acute care emergent hospital transfer for one Resident (R702) of three residents reviewed for care, when R702 sustained a fall with head trauma and bleeding while taking anticoagulant medication. Findings include: Review of R702's Accident and Incident report, dated 8/19/24 at 3:00 (a.m.), revealed Licensed Practical Nurse (LPN) H was notified by staff that R702 was observed sitting on floor in their room and hit the back of their head on the wall near their bed, sustaining a head laceration. R702 stated they were trying to get up and clean and slipped and fell. The report showed LPN H assessed R 702 for pain and injuries, found R702 had 8/10 pain, and applied a cold compress to back of their head to stop the bleeding. On 11/13/24 at approximately 12:00 p.m., R702 was observed with LPN B in their room. R702's room was clean,…

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 Intakes MI00147560 and MI00147466. Based on observation, interview, and record review, the facility failed to prevent resident to resident abuse, between two residents (R700 and R701) out of three reviewed for abuse. Findings Include: A review of an Incident and Accident (I/A) report for R700 dated 10/10/2024 at 5:19 AM revealed the following, Nursing Description: CNA (Certified Nursing Assistant) reported that resident was wet, and the resident stated that R701 poured water on [them]. Writer asked R701 did [they] pour water on R701, [they] stated, I've been asking (R700) for months to shut the f* up. Resident Description: Resident stated, R701 poured water on me repeatedly and stated,what are you going to do about this. A review of the medical record revealed R700 admitted into the facility on 8/16/2024 with the following diagnoses, Functional Quadriplegia, Depression, and Anxiety. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R700 also required staff assistance…

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 MI00147570. Based on observation, interview and record review, the facility failed to implement a nutritional care plan intervention for one resident (R702) out of one reviewed for nutrition. Findings Include: On 10/23/2024 at 12:48 PM, R702 was observed eating lunch in their room. R702 stated they were making a mess and said they had a method for how to eat their food, which included trying to scoop the food together and take a bite. R702 was observed to have food on their (bib like) towel and the bedside table. Observation of the diet ticket on R702's meal tray stated they were supposed to have a divided plate. R702's food was observed to be on a regular plate. On 10/23/2024 at 12:50 PM, Certified Nursing Assistant (CNA) E was observed removing R702's meal tray. CNA E was asked to observe the meal ticket, as well as the plate R702 was eating off. CNA E stated R702 should have a divided plate, and they were unsure why they did not have one. A review of the medical record revealed R702 admitted into the facility on 7/23/2024 with the following…

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 MI00147570. Based on observation, interview, and record review, the facility failed to provide and/or document colostomy care for one resident (R702) out of one reviewed for ostomy care. Findings Include: A review of Intake MI00147570 noted the following, Complainant states that there has been skin breakdown around R702's ostomy because they sit in their own waste for extended periods of time. A review of the medical record revealed that R702 admitted into the facility on 7/23/2024 with the following diagnoses, Dysphagia and Multiple Sclerosis. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. On 10/23/2024 at 9:33 AM, an interview was conducted with R702. R702 stated the facility staff do not empty their colostomy as often as they should. R702 stated because the colostomy is not emptied as it should be then it fills and burst and has to be changed frequently. A review of the Treatment Administration Record (TAR) for the month of September revealed the following,…

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 M100144631. Based on observation, interview, and record review, the facility failed to implement measures to reduce the risk of a fall with injury for one (R701) of five residents reviewed for falls. Findings include: Review of the facility record for R701 revealed an admission date of 05/03/24 and indicated the resident was admitted for short-term rehab following a trigger finger repair surgery. The record indicated the resident was expected to be discharged to an assisted living facility. On 05/29/24 at 9:48 AM, R701 was interviewed in their room and reported they did recall their recent fall. The resident was observed to have a dressing on the right forearm and bruising under their eyes and on their forehead. R701 reported they were transferring from the wheelchair to the bed and they were being assisted by Certified Nursing Assistant (CNA) A. The resident indicated CNA A was holding their pants and when they stood and began to pivot to the bed they fell forward and landed on the floor. When asked if the CNA was wearing a gait belt R701 stated No,…

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 MI00142546 Based on observation, interview, and record review, the facility failed to pass and /or date water for five of five residents (R804, R805, R806, R807, and R808) reviewed for hydration. Findings Include: R804 On 3/13/2024 at 11:16 AM, R804 was observed laying in bed. Their water cup was beside them on the nightstand. The water was observed to be dated 3/8/2024. On 3/13/2024 at 11:25 AM, an interview was conducted with Registered Nurse (RN) B. RN B was shown the water cup. RN B stated that the water should be passed at the beginning of the shift and as needed. RN B removed the water from the room. R805 On 3/13/2024 at 12:00 PM, R805's water cup was observed dated 3/9/2024. The water cup was observed sitting in a corner. R806 On 3/13/2024 at 12:01 PM, R806's water cup was not dated. The water cup was half full without any ice. R807 On 3/13/2024 at 12:01 PM, R806's water cup was not dated. The water cup was full. R808 On 3/13/2024 at 12:01 PM, R806's water cup was not dated. The water cup was full. On 3/13/2024 at 1:14 PM, an interview 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 MI00143053. Based on interview and record review, the facility failed to implement a baseline care plan related to falls and an indwelling catheter upon admission for one resident (R803) of one reviewed for baseline care plans. Findings include: On 3/13/2024 at 9:13 AM, an interview was conducted with Family Member (FM) E. FM E stated that R803 had a fall in the facility that resulted in a broken hip and their foley catheter becoming dislodged. FM E stated that R803 was not admitted into the facility correctly and was not being properly monitored. A review of the medical record revealed that R803 admitted into the facility on 2/10/2024 with the following diagnoses, Difficulty in Walking and Neuromuscular Dysfunction of Bladder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 12/15 indicating an impaired cognition. A review of the nursing assessment dated [DATE] revealed that R803 admitted with an indwelling catheter and was also 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.

This citation has two deficient practices. Deficient practice statement #1. Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 144 residents who receive meal services (7 nothing by mouth residents, or NPO) out of the facility's total census of 151 residents. Findings include: 1. On 12/5/23 between 9:45 AM, and 10:47 AM, the following non-food contact surfaces in the kitchen were observed soiled and with visible debris on their surfaces: On the doors of the cook's reach in refrigerator. On the flooring in the dry storage room. On the walls and flooring behind the juice machine. On the floor of the walk-in cooler and its shelving. On the lower interior portion of refrigerator #1. On the flooring throughout the kitchen. On 12/5/23 at 10:50 AM, upon interview with Dietary Manager, staff A, on if the facility keeps daily cleaning logs for tasks to be completed to which they replied, Yes. We have sign off sheets…

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 midigate the spread of COVID-19 per facility policy, and the Centers for Disease Control (CDC) guidance resulting in the potential of transmission of infectious disease, and the development of new or recurring infections potentially affecting all 151 residents residing in the facility. Findings include: R92 On 12/4/23 at 10:21 AM, during an initial tour of the facility a transmission based precautions (TBP) sign was observed on the door of R92's room. The sign indicated that any person entering the room should don (put on) proper personal protection equipment (PPE) which included gown, gloves, N95 mask (Filtering mask), and face shield. Observation and inspection of the infection control cart located next to R92's room revealed an absence of sanitary bleach wipes, N95 masks, and gloves. On 12/4/23 at 10:24 AM, R92 was interviewed in their room and asked why they were on TBP. R92 responded, I tested positive for COVID-19 on Sunday…

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 dignity during care for one (R27) of eight residents reviewed for resident rights and dignity. Findings include: Review of the facility record for R27 revealed an admission date of 02/04/19 with diagnoses that included Dementia, Psychotic Disorder with Delusions and Anxiety Disorder. The Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident required primarily total assistance with activities of daily living and demonstrated severe cognitive impairment. On 12/05/23 at 3:39 PM, R27 was observed laying in bed. There was no pillow case on the pillow or laying nearby and therefore the resident's head/face was resting on the plastic pillow covering. The surveyor attempted to interview the resident regarding the sling and they were responsive but not able to communicate functionally during this interaction. On 12/06/23 at 9:13 AM, R27 was observed from the hallway receiving completion of peri-care and having their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to revise and implement an intervention on the care plan for one resident (R137) from a sample of 10 residents reviewed for care plans following a fall. Findings include: A review of R137's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Cerebral Infarction, Dysphagia, Encounter for attention to tracheostomy, Diabetes and Anxiety. Further review revealed a quarterly Minimum Data Set assessment dated [DATE] indicating that the resident was cognitively intact and required total dependence for all Activities of Daily Living. A review of R137's Incident and Accident reports revealed that on 11/20/23, the resident sustained a fall. A review of R137's progress notes revealed the following progress note: 11/30/202310:05 (10:05am) Case Mgnt (management) Note Text: Reviewed by IDT (interdisciplinary team) r/t (related to) recent unintentional change in elevation. The root cause was identified 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 This citation pertains to Intakes MI00136173, MI00138504, and MI00138662. Based on observation, interview, and record review the facility failed to provide activities of daily living care (ADLs) for two dependent residents (R9 and R77) of nine residents reviewed for ADL care, resulting in feelings of frustration. Findings include: R9 On 12/4/23 at 10:52 AM, during an initial tour of the facility R9 was interviewed and asked about the care they received at the facility. R9 indicated that they did not receive enough showers. R9 stated, I don't receive showers on my scheduled shower days. On 12/5/23 at 12:02 PM, a thirty day review of R9's shower documentation in their electronic medical record (EMR) revealed that R9's scheduled shower days were Fridays and Tuesdays, and that R9's documented showers during the thirty day review period revealed that R9 had been offered showers on 11/7/23, 11/24/23, and 11/29/23 indicated, Activity did not occur. No other shower documentation was indicated for R9. On 12/5/23 at 12:47…

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: Deficient Practice Statement #1. Based on observation, interview, and record review, the facility failed to follow speech recommendations for one residemt (R77) out of two reviewed for speech. Findings include: On 12/6/2023 on 9:20 AM, R77 was observed in their room. R77 was observed laying in bed with the bed of their raised up. R77 was noted to have a breakfast tray in front of them and with a coffe cup, a straw was noted to be in the cup. A sign was observed on the wall that noted R77 was not supposed to have straws. A review of the medical record revealed that R77 admitted into the facility on 9/7/2022 with the following diagnoses, Dementia, Aphasia, and Cerebral Infarction. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 1/15 indicating an impaired cognition. R77 also required extensive one to two person assist with transfers and bed mobility. On 12/5/2023 at 9:30 AM, a review of R77's diet order 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 Based on observation, interview, and record review, the facility failed to apply knee braces for one resident (R133) out of two reviewed for range of motion. Findings include: A review of the medical record revealed that R133 admitted into the facility on [DATE] with the following diagnoses, Legal Blindness and Muscle Weakness. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 5/15 indicating an moderatly impaired cognition. R133 was also dependent on staff for bed mobility and transfers. A review of the physician orders revealed the following, Frequency: Every Shift. Schedule Type: Everyday. Facility Time Code: 12 Hour Evry Shift. For (Indications for Use): Bilateral Knee Splints to prevent contractures. On 12/4/2023 at 12:25 PM, R133 was observd in bed. No knee braces were seen in place. On 12/5/2023 at 9:00 AM, R133 was observed in bed. No Knee braces were observed in place. On 12/5/2023 at 12:23 PM, R133 was observed in a geriatric chair. No Knee braces 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 maintain medications in a safe manner for one sampled resident (R254) of one reviewed for medication storage. Findings include: On 12/4/23 at 9:04 AM, R254 was observed sitting up in bed eating breakfast. A medication cup full of medications were observed sitting on their overbed table. R254 was asked about the medications, and stated that they would take the medications after they finished their breakfast. R254 was asked how many medications they had to take, and was observed to count the medications indicating that there were eight medications, including a large potassium pill that needed to be melted. On 12/4/23 at 9:55 AM, R254 was observed to still have the medication cup sitting on their overbed table with one pill remaining in the cup. A review of R254's medical record revealed that the resident was admitted into the facility on [DATE] with diagnoses that included Acute Kidney Failure, Muscle Weakness, and Hyperlipidemia. Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes MI00138504 and MI00138662 Based on observation, interview, and record review, the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for two residents (R9 and R116) of four residents reviewed for food palatability, resulting in dissatisfaction during meals. Findings include: On 12/4/23 at 10:47 AM, during an initial tour of the facility R9 was interviewed about the palatability of the food at the facility and indicated that their food was, Frequently cold. On 12/4/23 at 1:24 PM, R116 was interviewed about the palatability of the food at the facility and indicated that the food didn't taste good and was cold. An observation of R116's lunch meal revealed that R116 had eaten their hamburger patty, their hamburger bun and french fries were uneaten on their plate. R116 was asked about the uneaten food on their plate and stated, The french fries are cold and hard as a rock. On 12/5/23 at 12:32 PM, a random food tray selected off 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.

This citation pertains in part to Intake: MI00137574. Based on interview and record review the facility failed to ensure timely x-ray services after a fall with injury for one sampled resident (R901) of two residents reviewed for falls, resulting in a delay in treatment. Findings include: A review of R901's medical record revealed that they were admitted into the facility on 5/2/23 with diagnoses that included Acute Kidney Failure, Muscle Weakness, and a Urinary Tract Infection. Further review of R901's medical record revealed an admission Minimum Data Set assessment dated for 5/8/23 revealing that the resident was significantly cognitively impaired, and required extensive assistance for transfers, bed mobility, and toilet use. Further review of R901's medical record revealed the following progress notes: 5/27/2023 15:06 (3:06pm) Nursing - Progress Note: Resident attempting to ambulate self to bathroom. [R901] fell on rt (right) hip and knee. [R901] is c/o (complaining of) pain at knee cap area. No bruising observed, no abnormal anatomy. Ice applied and resident given Tylenol 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 Number: MI00137967. Based on observation, interview, and record review, the facility failed to ensure two (R801 and R802) of two residents reviewed for abuse who were known to be attracted to one another but were not cognitively able to consent to sexual activity, did not engage in sexual activity. Findings include: Review of a facility policy titled, Abuse, updated on [DATE], revealed, in part, the following: Residents have the right to be free from abuse .Prevention consists of facility systems designed to detect, identify, correct, and prevent the occurrence of abuse .The facility's procedures include: Establishing a safe environment that support, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as how to identify the when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number: MI00137967 Based on interview and record review, the facility failed to report an allegation of sexual activity between two (R801 and R802) of two residents reviewed for abuse who were not cognitively able to consent to sexual activity, to the State Agency. Findings include: Review of a facility policy titled, Abuse, updated on 5/24/23, revealed, in part, the following: .Sexual Abuse .Non-consensual sexual contact of any type with a resident including but not limited to unwanted touch especially breasts or perineal area .The facility will ensure that all allegations involving abuse .are reported immediately to the Administrator and: Reported to the State Survey Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse . Review of a complaint submitted to the State Agency revealed an allegation that R801 was found outside on the patio with R802 engaging in sexual activity. The complaint further alleged that R801 was not…

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: MI00137967 Based on interview and record review, the facility failed to thoroughly and accurately investigate an allegation of sexual activity between two (R801 and R802) of two residents reviewed for abuse who were not cognitively able to consent to sexual activity, to the State Agency, resulting in the lack of development of new interventions to prevent future occurrences of sexual activity between the two residents. Findings include: Review of a facility policy titled, Abuse, updated on 5/24/23, revealed, in part, the following: .Sexual Abuse .Non-consensual sexual contact of any type with a resident including but not limited to unwanted touch especially breasts or perineal area .Key to investigating abuse allegations is an environment that facilitates that reporting of such allegations. Once reported, the center conducts a timely, thorough, and objective investigation of any allegation of abuse .The investigation process includes: .Determining the purpose 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.