Optalis Health & Rehabilitation of Whitehall

Based on observation, interview and record review, the facility failed to provide showers for 1 (R45) of 1 resident reviewed for showers.Findings include:Review of the Electronic Medical Records (EMR) revealed R45 had pertinent diagnoses of contractures, morbid obesity, and paraplegia. During an observation and an interview on 3/2/26 (Monday) at 9:48 AM, R45 was lying in bed and not able to provide cares for herself. R45 reported she required extensive assistance of 2 staff for many activities of daily living (ADL's) due to her contractures. R45 had concerns of not enough staff available to provide her showers twice a week. Her last shower was 2 1/2 weeks ago and had to really push to get that shower so she could get her hair washed. R45 reported she gets a shower maybe once a month. Review of the Care Plan for R45 revealed she is to get a shower on Mondays and Fridays and is totally dependent on 2 staff for showers. During an interview on 3/4/26 at approximately 2:00 PM, R45 reported she did not get her shower on Monday 3/2/26. In an interview on 3/4/26 at approximately 2:23 PM…

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 supervision to prevent falls and injuries for 1 Resident (R52) contributing to increase and likelihood of further injuries and potential for harm.Findings include:Resident #52 (R52)Review of a Face Sheet revealed R52 originally admitted to the facility on [DATE] with pertinent diagnoses which included Wernicke's encephalopathy (acute neurological emergency caused by severe vitamin B1 deficiency), dementia, delusional disorders, and hallucinations. Review of a Psychiatry Note dated 4/13/26 reflected, BIMS (Brief Interview of Mental Status, a mental status assessment) score declined significantly from 15 on 2/16/2026 to 3 on 4/14/2026 which indicated resident is severely cognitively impaired.Observation of the locked 100 Hallway on 4/13/26 at approximately 5:43AM, revealed that the hallway was absent of staff, it was quiet and the lights were low with one bright light noted at the far end of the hallway.Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # 2695940 and 2690356Based on interview and record review, the facility failed to ensure that weights were obtained, and medications were administered in accordance with physician orders for 5 out of 7 residents (Resident #4, #8, #9, #10, and #11), reviewed for the provision of nursing services.Findings:Resident #4 (R4) Review of an admission Record revealed R4 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: adrenocortical insufficiency (adrenal glands don't produce enough cortisol and aldosterone.)Review of R4's Order Summary dated 12/2/25 revealed a steroid taper dose:predniSONE Oral Tablet 10 MG (Prednisone) Give 2 tablet by mouth two times a day for inflammation for 2 Days thenpredniSONE Oral Tablet 10 MG (Prednisone)Give 1 tablet by mouth two times a day for inflammation for 3 Days thenpredniSONE Oral Tablet 10 MG (Prednisone) Give 1 mg by mouth one time a day for inflammation for 3 Days.Review of R4's December…

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 review the facility failed to resolve grievances in a timely manner for 2 residents (R1 and R5) of 3 residents reviewed for grievances.Finding includedReview of the facility policy for Concern (Grievances) Process. Dated 5/31/24 revealed Concerns, grievances, recommendations stemming from resident or family group council concerning issues of resident care in the facility will be documented. Actions on such issues will be responded to at or before the next resident or family meeting. Concerns/Grievances may be voiced in the following ways: -verbal complaint to staff member including the Grievance Officer. - The staff member will transcribe the concern onto the concern form or assist the complainant with completing the concern form. The staff member receiving the concern form will review the specifics of the grievance on the concern form. - take immediate actions needed to prevent potential violation of the resident's rights. - Forward concern to the Grievance Officer…

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, interviews and record review the facility failed to safely transfer with an electronic lift 2 of 2 residents (R5 and R6) reviewed for lift transfers. Findings include:During an interview with R5 on 9/10/25 at 12:05 PM, R5 reported that he did not like the new electronic lift to get out of bed. R5 was not sure why he could not still use the other facility lift. R5 said the lift did not fit him right and when they got him out of bed on 9/8/25 he hit his head on the bar. Review of R5's Kardex (care guide) dated 9/10/25 revealed, Toileting - use toileting sling and hoyer, 2 assist. Transfer: [brand name of electronic lift] with 2 staff assistance for transfers. UP 2 TIMES A DAY IN WC (wheelchair) AS TOLERATED, CERVICAL PRECAUTIONS-NO BENDING, PUSHING/PULLING, NO OVERHEAD LIFTING, NO BENDING NECK DOWN.Review of R5's progress note dated 9/5/25 at 14:34 (2:34 PM) revealed, Quarterly Therapy screen completed: R5 has had a decline in function, but at this time is not getting up in wheelchair daily due to left hip pain. Provider aware of decline in ability to complete PT…

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 2590962.Based on observations, interviews and record review the facility failed to provide proper infection control for 1 Resident (R1) of 3 residents sampled for infection control. Findings include:R1Review of R1's admission assessment dated [DATE] revealed she was a [AGE] year-old female with a last admission date of 3/22/25 and had diagnoses that included: Urinary Tract Infection onset 8/8/25, diabetes mellitus type 2, rheumatoid arthritis, lack of coordination, contractures, paraplegia (spinal cord injury affecting the lower body muscles and nerves) and retention of urine. She was her own responsible party. Review of R1's care plan dated 1/3/25 revealed, Resident has limited/impaired physical mobility r/t (related to) limited mobility d/t (due to) weakness r/t paraplegic (spinal cord damage). Interventions included: Bed mobility: Participates by: total assist with 2 staff. Eating: 1:1 feed at meals. Toileting - bed pan 2 assist.Review of R1's care plan dated 8/19/25 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 ensure sufficient staff to meet the needs of seven Residents on the 100 hall (R202, R207, R210, R212, R215, R216 and R207) and five residents on the 200 hall (R204, R206, R208, R211, and R214). Findings Include: Review of the staff schedules provided by the facility for 8/12/25 through 8/14/25 reflected that one Certified Nurse aide (CNA) was scheduled for the 100 hall and one CNA was scheduled for the 200 hall for each day, afternoon, and night shifts.A review of documentation provided by the facility reflected fourteen residents resided on the 100 hall and eight residents on the 200 hall.R202 - 100 HallR202 was admitted to the facility 7/10/2025 with diagnoses that include Muscular Dystrophy and Chronic Obstructive Pulmonary Disease. Review of the Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) reflected R202 scored 15 out 15 which indicated the Resident was cognitively intact.Review of the care plan for R202 reflected…

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 #MI00152587 Based on interview and record review the facility failed to follow professional standards for three of three residents (Resident #100, Resident #109, and Resident #113) reviewed for medication administration. Findings: Resident #100 (R100) Review of an admission Record revealed R100 was a [AGE] year old male, originally admitted to the facility on [DATE], with pertinent diagnoses of diabetes mellitus. During an interview on 06/16/25 at 9:00 AM, R100 stated that a week or so ago he was given an incorrect dose of insulin and had to go to the emergency room for monitoring. It was scary. Review of an incident report for R100, dated 06/07/25, reflected the following: (a) nurse read wrong record and gave resident (R100) too much insulin, and (b) (R100) was sent to the emergency room for monitoring due to potential risk for hypoglycemia ( low blood sugar). Resident #109 (R109) Review of an admission Record revealed R109 was a [AGE] year-old male, admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation is related to intakes MI00152587, MI00152791, and MI00152955. Based on observation, interview, and record review, the facility failed to provide meal assistance to one of four residents (Resident #116) reviewed for accommodation of needs. Findings: Resident #116 (R116) Review of an admission Record revealed R116 was an [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of fractured right shoulder that required surgical repair, dementia, and lack of coordination. R116 sustained the broken shoulder in early May 2025 while out on leave with a family member. During an observation on 06/16/25 at 8:48 AM, R116 laid in bed, had a sling on her right arm and the breakfast tray sat untouched on the over bed table, lids were still on the plate, cups, and bowl, and the over bed table sat out of reach and out of sight of R116. Review of the task monitoring documentation system revealed that staff documented on R116's breakfast intake on 06/16/25 as resident not available.…

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 1.) provide care following professional standards of practice and facility policy to prevent the development of a pressure injury, 2.) promptly notify the provider of a new pressure injury, 3.) promptly notify the DPOA (Durable Power of Attorney) of a new pressure injury and subsequent treatment changes, and 4.) ensure ordered treatments were completed for 1 of 4 residents (Resident #106) reviewed for pressure injury prevention/management. Findings: Resident #106 (R106) Review of an admission Record revealed R106 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: multiple sclerosis. Review of R106's Care Plan revealed: The resident has Stage 2 pressure ulcer (Partial-thickness skin loss with exposed dermis) to right buttock r/t (related to) Immobility and at risk for recurring skin impairment to sacrum. Date Initiated: 05/08/2025 .Avoid positioning the resident on right side. Date Initiated:…

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 # MI00149091 and MI00150877 Based on observation, interview and record review, the facility failed to follow physician ordered wound care and provide care to prevent the development of skin breakdown/pressure injuries for 6 residents (Resident #302, #303, #311, #316, #317, and #318) out of 9 reviewed for alterations in skin integrity. Findings: Resident #302 (R302) Review of an admission Record revealed R302 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R302's After Visit Summary from an inpatient hospital stay from 1/1/25-1/10/25 revealed, .Apply Zinc oxide to buttock 3 x (times) daily and as needed due to irritation in buttock region. Review of R302's Order Summary dated 1/10/25 revealed, Apply zinc oxide to buttocks 3x daily and as needed for excoriation every day and night shift for skin integrity. Review of R302's January Treatment Administration Record revealed the application of zinc oxide to buttocks was ordered to be completed at 7:00 AM and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI00150877 Based on interview and record review, the facility failed to 1.) ensure residents received care and services following provider orders, 2.) identify and notify the physician a change in condition, and 3.) ensure complete and accurate medical records, for 1 resident (Resident #302) out of 3 residents reviewed for quality of care. Findings: Resident #302 (R302) Review of an admission Record revealed R302 was a [AGE] year-old female, admitted to the facility from 1/10/25-1/16/25. Pertinent diagnoses included: congestive heart failure, irritable bowel syndrome, dysphagia (difficulty swallowing), and non-celiac gluten sensitivity. During an interview on 03/18/25 at 2:10 PM, Family Member (FM) H reported R302's discharge orders from the hospital and the orders from the facility provider were not followed by the facility which resulted in R302's receiving poor care. FM H reported that R302's bottom becoming raw from excessive diarrhea from being given food that had gluten…

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 effectively clean and maintain food service equipment, and date mark potentially hazardous food item potentially affecting 68 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: During the initial tour of the kitchen on 12/08/24 between 8:18 AM to 9:05 AM the following issues were observed and identified to [NAME] V: Observation of the Walk In Cooler (WIC) revealed mold, mildew, grime, and debris on the shelving. located inside the and on the fan compressor grate. An undated container storing hot dogs were being stored on the shelving. Observation of the cook line area revealed the can open blade and holster have food residue and debris on them. Further, observation of the cook line revealed the lid on the commercial blender had a yellow/white build-up of scale/lime with a touch of black speckles that resembled mold/mildew. An observation of the Walk In Freezer (WIF) revealed ice build-up on the shelving, and on the opened/sealed boxes of food…

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

Based on interview and record review, the facility failed to implement a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors to prevent the spread of an illness/outbreak. Findings: On 12/8/24 at 9:20 AM, a copy of the last 3 months of infection surveillance/tracking (all illnesses) for staff and residents including line lists were requested. During the onsite survey Previous Director of Nursing/Infection Control Preventionist (PDON/ICP) S abruptly ended her employment with the facility on 12/8/24 and was unable to be interviewed regarding the Infection Control Program. During an interview on 12/10/24 at 10:28 AM, Regional Director of Clinical (RDC) X reported PDON/ICP S had been responsible for the Infection Control Program for approximately the last 6 weeks. Prior to that PDON/ICP T had been responsible for the program. RDC X reported PDON/ICP S and T were responsible for the implantation, oversight, and maintenance of the Infection Control Program. 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 Based on observation, interview, and record review, the facility failed to provide for the needs of four of four residents (Resident #45, Resident #67, Resident #62, and Resident #7) reviewed for accommodation of needs. Findings: Residents #45 (R45) Review of an admission Record revealed R45 was a [AGE] year old male, last admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's, lack of coordination, muscle wasting, and a below the knee amputation of the left leg. During an observation on 12/08/24 at 8:44 AM, R45's call light laid on the floor on the resident's left side of the bed, out of sight and out of reach. The same observations were made on 12/08/24 at 9:47 AM and 10:34 AM. During an observation on 12/08/24 at 11:47 AM, two staff entered R45's room and boosted him up in bed. During an observation on 12/08/24 at 11:55 AM, R45's call light hung down from the railing on the left side of the bed, just off the floor, out of sight and out of reach. During an observation on 12/08/24 at 3:19…

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 refers to MI00147849 and MI00148347. Based on interview and record review, the facility failed to protect the residents' right to be free from verbal and mental abuse by staff for 5 of 24 residents (R8, R12, R35, R53, and R68), resulting in residents being verbally abused. Findings include: A review of the facility's Abuse and Neglect Policy and Procedure, dated 3/24/23, revealed verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing . A review of the facility's Abuse and Neglect Policy and Procedure, dated 3/24/23, revealed mental abuse includes but is not limited to humiliation . Examples: statements such as . Take a shower, you stink . attempts to embarrass or tell on the resident . A review of the facility investigation report received by the State Survey Agency (SSA), dated 11/19/24, 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.

This citation refers to MI00147849 and MI00148347. Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and report within a timely manner to facility management and the State Survey Agency allegations of verbal and/or mental abuse by staff for three of 24 residents (R12, R35, and R53), resulting in a delay in investigating allegations of abuse and the potential for residents to not be protected from abusive individuals Findings include: A review of the facility's Abuse and Neglect Policy and Procedure, dated 3/24/23, revealed verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing . A review of the facility's Abuse and Neglect Policy and Procedure, dated 3/24/23, revealed mental abuse includes but is not limited to…

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 1.) administer controlled medications following professional standards of practice, 2.) ensure medications were administered following the physician ordered parameters, and 3.) accurately transcribe/order a newly admitted resident's antipsychotic medication, for six of 12 residents (Resident #5, #46, #7, #2, #24, and #68) reviewed for medication administration, resulting in missed doses of medication, medication administration errors, and the inaccurate documentation of the administration of controlled drugs. Findings: Resident #5 (R5) Review of an admission Record revealed R5 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pain. Review of R5's Order Summary revealed, HYDROcodone-Acetaminophen (Norco) Tablet 10-325 MG Give 1 tablet by mouth every 4 hours as needed for breakthrough pain management. Review of R5's Control Substance Record revealed that on 12/7/24 R5 received 4 doses of Norco. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide quality care to three of three residents reviewed (Resident #14, Resident #3, and Resident #19) resulting in untreated significant swelling in the feet for R14, an order to change tube feed guidelines for R3 to be missed, and a delay in treating a urinary tract infection for R19. Findings: Resident #41 (R41) Review of an admission Record revealed R41 was a [AGE] year old male, originally admitted to the facility on [DATE], with pertinent diagnoses of seizure disorder, lymphedema, chronic kidney disease During an observation and interview on 12/09/24 at 4:30 PM, R41 laid in bed with eyes open and stated that his feet hurt. It feels like my feet are in gloves and the gloves keep getting smaller. R41 rated the pain in his left foot as really bad and reported intense pain if the foot was touched. R41 stated that he saw a lymphedema specialist in the past but has not seen the specialist since his admission to the facility. R41 had +4…

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 is related to intake # MI00148049 Based on interview and record review, the facility failed to prevent the misappropriation of controlled substances for three (Resident #35, Resident #5, and Resident #174) of three residents reviewed. Findings: Resident#35 (R35) Review of an admission Record revealed R35 was an [AGE] year old male, last admitted to the facility on [DATE] with pertinent diagnoses of diabetes mellitus, post traumatic stress disorder, chronic obstructive pulmonary disease, and left lower extremity below the knee amputation. Resident #5 (R5) Review of an admission Record revealed R5 was an [AGE] year old female, last admitted to the facility with pertinent diagnoses of dementia, anxiety disorder, claustrophobia, and chronic obstructive pulmonary disease. Resident #174 (R174) Review of an admission Record revealed R174 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of rheumatoid arthritis, chronic pain, and diabetes mellitus. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to utilize foot rests on a wheelchair for two of four residents (Resident #44 and Resident #62) reviewed for accidents and hazards. Findings: Resident #44(R44) Review of an admission Record revealed R44 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of left sided paralysis following a stroke and abnormal posture. R44 requires assistance from staff for bed mobility, transfers, and using the bathroom. During an observation on 12/08/24 at 11:45 AM, Certified Nurse Aide (CNA) AA propelled R44 down the 300 hall to the nurses station without the use of foot rests on the wheel chair. Resident #62(R62) Review of an admission Record revealed R62 was an [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses of dementia, rheumatoid arthritis, and difficulty speaking. R62 is dependent on staff to get dressed, for bathing, transfers, going to the bathroom and can independently…

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 that pharmacy recommendations are received by the facility and reviewed by the physician for 1 of 5 residents (R53) reviewed for monthly pharmacy medication regimen reviews, resulting in the facility and physician not being aware of a pharmacy recommendation for R53 and the potential for an adverse outcome from medications and/or lack of assessment and monitoring of medications. Findings include: A review of the facility's Medication Regimen Review (MRR) Policy and Procedure, dated 7/11/18, revealed, It is the policy of this facility that: . 2. The pharmacist must report any irregularities to the attending physician, facility medical director and the Director of Nursing Services . the report is provided by the Pharmacist or facility to the responsible physicians and the Director of Nursing Services within seven (7) working days of review . A review of R53's admission Record, dated 12/10/24, revealed they were a [AGE] year-old resident admitted…

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

Based on observation, interview, and record review, the facility failed to secure unattended medication carts for three of five carts reviewed and failed to label opened medications according to industry standards. Findings: During an observation on 12/09/24 at 7:19 AM, (a) the medication cart labeled 409-416 was unlocked and unattended by licensed nursing staff, (b) the medication cart contained 5 loose pills at the bottom of the second drawer, (c) a Lantus insulin kwik pen prescribed to the resident in bed 416-2 did not have a date written on it identifying when the medication was opened, (d) a bottle of Lantus insulin prescribed to the resident in bed 407-1 did not have a date written on it to indicate when the medication had been opened, and (e) contained the eye drops brimonidone 0.15% for the resident in bed 415-1 and did not have a date written on it to identify when it had been opened. During an observation on 12/9/24 at 7:31 AM, the medication cart labeled 309-316 contained eight loose pills at the bottom of the second drawer. During an interview at the same time, Licensed…

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 1.) implement an antibiotic stewardship program and 2.) ensure accurate monitoring and antibiotic use for two of 5 residents (Resident #45 and #5) reviewed for antibiotic use, resulting in inappropriate antibiotic utilization and the potential for antibiotic resistance. Findings: During the onsite survey Previous Director of Nursing/Infection Control Preventionist (PDON/ICP) S abruptly ended her employment with the facility on 12/8/24 and was unable to be interviewed regarding the Infection Control Program. During an interview on 12/10/24 at 10:28 AM, Regional Director of Clinical (RDC) X reported PDON/ICP S had been responsible for the Infection Control Program for approximately the last 6 weeks. Prior to that PDON/ICP T had been responsible for the program. RDC X reported PDON/ICP S and T were responsible for the Antibiotic Stewardship Program which included monitoring the use of antibiotics and ensuring clinical criteria was met, appropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the pneumococcal immunization per consent and the recommendation by the Centers for Disease Control and Prevention (CDC) for three (Resident #18, #4, and #56) out of 5 reviewed for immunizations, resulting in residents not receiving the pneumococcal immunization. Findings: Review of the CDC Pneumococcal Vaccine Timing for Adults dated October 2024 revealed, .the minimum interval for PPSV23 is >1 year since last PCV13 dose and >5 years since last PPSV23 dose. Shared clinical decision-making option for adults >[AGE] years old-Together, with the patient, vaccine providers may choose to administer PCV20 or PCV21 to adults >[AGE] years old who have already received PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old . Resident #18 (R18) Review of an admission Record revealed R18 was an [AGE] year-old female, admitted to the facility on [DATE]. R18's Electronic Medical Record revealed that she 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 #: MI00146305 and MI00146949 Based on interview and record review, the facility failed to 1.) assess and monitor pressure injuries/wounds, 2.) ensure pressure injury/wound assessments were complete, accurate, and documented in the resident record, 3.) notify the provider and the DPOA (Durable Power of Attorney) of new pressure injuries/wounds, and 4.) provide physician ordered treatments/assessments and ensure treatments were in place for pressure injuries/wounds for 4 of 4 residents (Resident #7, #8, #1, and #9) reviewed for quality of care. Findings: Resident #8 (R8) Review of an admission Record revealed R8 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Neurocognitive Disorder with Lewy Body Dementia. Review of a Minimum Data Set (MDS) assessment for R8, with a reference date of 7/2/24 revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a total possible score of 15, which indicated R8 was severely…

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: 1) develop and utilize an effective antibiotic stewardship program to ensure an accurate and effective program for tracking and monitoring antibiotic use potentially affecting all 79 residents who reside at the facility, 2) follow through with laboratory orders and implement antibiotic stewardship for 1 (Resident #8) of 2 residents reviewed for antibiotics/unnecessary medications. Findings include: Review of an Antibiotic Stewardship policy adopted 7/11/18 revealed: It is the policy of this facility that antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. This policy lacked the core elements for antibiotic stewardship as summarized by the Centers for Disease Control (CDC) (https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html#anchor_1616614363671). During an interview and record review on 2/28/24 at 2:19 PM, the Director of Nursing (DON) discussed her…

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

Based on observation, interview, and record review the facility failed to ensure acceptable standards of practice were observed during medication administration on the 400 Hall. Findings: On 2/27/24 at 7:32 AM an observation and interview were conducted with Registered Nurse (RN) D during medication administration on the 400 Hall. RN D was observed preparing medication for R27. RN D was observed removing oral medication from the packaging directly into her ungloved hand. RN D then dropped the medication from her hand into a medication cup. With the surveyor observing next to the medication cart five oral medications were prepared for R27 by RN D in this manner. RN D then locked the medication cart, cleared the Medication Administration Record (MAR) from the computer screen and proceeded to the room of R27. RN D was stopped before entering the room and asked about her handling of the medication for R27. RN D had no comment and offered no justification for this method of preparation and proceeded to administer the medication to R27. During an interview conducted 2/27/24 at 8:15 AM on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake M100140413 Based on observation, interview and record review, the facility failed to properly assess, document, monitor changes in condition, provide medication timely and accurately, and per standards of practice accurately document medication administration, and provide resident incontinence care for 5 residents (R39, R49, R11, R281, R8) of 5 residents reviewed for quality of care. Findings include Resident #39 (R39) Review of a Face Sheet revealed R39 admitted to the facility on [DATE] and resides on the 300 hall with pertinent diagnoses of chronic pain, spinal stenosis in the lumbar region, diabetes, and hypothyroidism (low thyroid function). During an observation on 2/26/24 during initial tour at approximately 10:00 AM, the 300-hall medication cart had the computer displaying nine residents in the red, indicating their medications were not yet given within the ordered time frames. During an observation and an interview on 2/26/24 at 3:02 PM, R39 was room [ROOM NUMBER] lying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow standards of practice for 1 of 1 resident ( R400) reviewed for tube feeding, resulting in the potential for contaminated equipment introducing pathogens into the resident, and the potential for choking or aspiration and the resident unable to call for help. Findings: Resident #400 (R400) Review of an admission Record revealed R400 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of multiple sclerosis and dependent on tube feedings for all nutrition and hydration. Review of Physician Orders for R400 revealed: NPO diet (nothing by mouth). Review of a Care Plan for R400 revealed the interventions: Be sure call light is within reach . encourage adequate nutrition. Offer small frequent feedings .Diet NPO (nothing by mouth which conflicts with previous intervention) . During an observation on 04/29/24 at 2:00 PM, R400 sat up in bed with a tube feed running. R400 had a thick white coating 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 interview and record review, the facility failed to assure that a Registered Nurse was on duty for eight consecutive hours a day, seven days a week. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) PBJ (Payroll Based Journal) Staffing Data Report for the 4th quarter of 2023 revealed the facility triggered for excessively low weekend staffing and the No RN (Registered Nurse) Hours was not triggered. Review of requested Daily Staffing Sheets revealed on 12/30/23 and 12/31/23 there were no RNs on duty. In an interview on 2/29/24 at 3:15 PM, Scheduler/Certified Nursing Assistant (CNA) L reported they do have some openings right now for nurses and aides and the facility is actively recruiting.

Based on observation and interview, the facility failed to secure controlled substances in one of two medication storage refrigerators. Findings: During an observation on 04/30/24 at 8:20 AM, the 300/400 hall medication storage refrigerator was unlocked. On the bottom shelf sat a clear plastic lock box that contained 1 bottle of liquid Lorazepam concentrate (a benzodiazipine used primarily to treat anxiety and a controlled substance) 2mg/ml (milligrams/milliliter). The top of the plastic lock box had been broken so that the bottle of Lorazepam could be reached without having to unlock the clear plastic lock box. This rendered the Lorazepam not double locked and easily accessible to anyone who gained access to the medication storage room. During an interview at the same time the Director of Nursing (DON) stated that the medication refrigerator was to be kept locked at all times. When asked about the broken clear plastic box that stored the bottle of liquid Lorazepam, the DON responded, I don't know. During an observation on 04/30/24 at 3:57 PM, the 300/400 hall medication storage…

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 R66 Review of the medical record reflected R66 was admitted to the facility 1/31/24 with diagnoses that included Left Below the Knee Amputation, Wound Infection, and Morbid Obesity. On 2/27/24 at 11:06 AM, R66 was observed laying in bed on sheets stained with what appeared to be drainage from a dressed wound on the right lower extremity. On the opposite side of the bed the sheet was also stained from drainage that appeared to be from the wound of the left leg stump. The sheet had holes in the upper half of the sheet toward the head of the bed. On 2/28/24 at 12:20 PM, R66 was observed lying in bed on the sheet with holes but the wound drainage stains previously noted covered a greater areas. It was observed that the dressing on the right lower extremity appeared fresh and was dated 2/28/24. Also observed was a wet, brown-tinged, dated dressing was on the floor next to the bed. Just across from this old dressing lay a pile of soiled white towels. No staff were observed in the area. At approximately 12:25 PM 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 Annual forms were fully completed for 1 resident (R44) out of 3 residents reviewed for Advance Directives and for their ability to participate in decision making. Findings: R44 Review of R44's admission Record dated 2/28/24 revealed the residents was re-admitted to the facility on was 5/27/23 and had diagnosis that included: Cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, contracture of left shoulder and Left hand, Anxiety, Bipolar and PTSD. Further review of the admission Record reflects the R44's sister is DPOA/HC Surrogate/Proxy, Emergency 1st Contact AR Representative 1. Review of Advance Directives in R44's Electronic Medical Record (EMR) Annual Review of Determination of Inability to participate in Complex Decision Making reflected R44 was evaluated/observed by an MD on 5/1/23 and was deemed is/is not (circle one) (not was circled) able to make medical treatment and/or financial decisions and is/is not (circle one) (not was circled)…

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 report timely an allegation of abuse for one Resident (Resident#180). Findings: Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #180 (R180) admitted to the facility 2/15/24 with diagnoses that include Parkinson's Disease and Depression. The MDS Section GG reflects that Mobility for toilet transfers that R180 is Dependent -Helper does ALL of the effort . review of the Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which indicated the Resident is cognitively intact. On 2/26/24 at 11:29 AM during an interview in her room, R180 reported that on her second night at the facility she had initiated a call light request for assistance to the bathroom. R180 reported at that time she required two staff for assistance but only one staff member had responded. R180 reported that she was assisted to the bathroom without incident. The Resident reported on return to the bed the staff member pretty much picked me up 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 maintain basic personal hygiene for one Resident (Resident #66). Findings: Review of the medical record reflected Resident #66 (R66) was admitted to the facility 1/31/24 with diagnoses that included Left Blow the Knee Amputation, Wound Infection, and Morbid Obesity. Section GG for Self-Care line E Shower/bathe self reflected R66 was Dependent. On 2/27/24 at 11:06 AM, R66 was observed in his bed wearing a soiled T-shirt with holes in the chest area of the shirt. R66 appeared to be unshaven, hair disheveled, and presented in a general unkempt state. It was observed that the bed sheet had holes in the upper half toward the head of the bed. Near the foot of the bed the sheet had stains from the drainage around the wound vac on the stump of the left amputated leg. A dressing was also in place on the right lower leg with spots of drainage in this area also. Review of the [NAME], a summary of care needs of a resident, reflected that R66 is to be…

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 implement positioning supportive care for 1 (Resident #48) of 3 residents reviewed for position and mobility. Findings include: Review of a Face Sheet revealed Resident #48 (R48) admitted to the facility on [DATE] with pertinent diagnoses of hemiplegia and hemiparesis (one sided weakness). Review of the Minimum Data Set (MDS) dated [DATE] revealed R48 has one sided weakness on the upper extremity and no impairment on lower extremity. During an observation on 2/26/24 at 10:52 AM, R48 is sitting up in her wheelchair talking on the phone with her left arm loosely laying across a stuffed animal that is in her lap and not supported. During an observation on 2/27/24 at 9:00 AM, Certified Nursing Assistant (CNA) had R48 sitting on the bed ready to be transferred via sit to stand while waiting for another CNA for assistance. R48 did not have her left upper or lower extremity supported for the transfer. In an interview on 2/27/24 at 9:33 AM, R48…

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 follow physician orders to provide the necessary respiratory care and services for 1 residents (R21) of 3 residents reviewed for utilizing the use of oxygen equipment. Findings: Review of the Policy/Procedure - Infection Prevention and Control Section Resident Care for Oxygen Use was revised on 9/24/18. Policy States It is the policy of this facility to promote resident safety in administering oxygen. Procedure reflects, The following procedures will be observed in oxygen administration. 1.The Oxygen tubing is to be replaced every (7) days. Oxygen or nasal prongs are to be replaced every (7) days. 2. The tubing should be kept off the floor. 3. The O2 equipment should be cleaned regularly. Resident #21 Review of R21's admission Record, reflects he was initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnea, Chronic kidney…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess, monitor, and provide pain management for 1 (Resident #39), resulting in not following physician orders and not accurately documenting in the medical record. Findings include: Review of a Face Sheet revealed Resident #39 (R39) admitted to the facility on [DATE] with pertinent diagnoses of displaced trimalleolar (ankle) fracture, chronic pain, low back pain, and spinal stenosis in the lumbar region. During an observation on 2/26/24 during initial tour at approximately 10:00 AM, the 300-hall medication cart had the computer displaying all residents in the red, indicating their medications were late and not yet given. During an observation and an interview on 2/26/24 at 3:02 PM, R39 was room [ROOM NUMBER] lying in bed and complained of pain right now in her sciatic nerve that is radiating down her right leg. She said she has a crushed vertebra. She complained she is not getting her pain medications on time and is just chasing the pain.…

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

Based on interview and record review, the facility failed to ensure Doctor Ordered medications were obtained from the Pharmacy and available to be administered to one Resident (Resident #27). Findings: On 2/27/24 at 7:32 AM, during the Medication Administration Task, an observation and interview were conducted on the 400 hall with Registered Nurse (RN) D. When medications were prepared for Resident #27 (R27), RN D reported the Latanoprost 0.005 ophthalmic eye drops were not available for R27. Review of the Electronic Medical Record (EMR) Physicians Orders for R27 reflected a current order for Latanoprost Ophthalmic Solution 0.005% Instill 1 drop in right eye one time a day for glaucoma. Review of the Medication Administration Record (MAR) for February 2024 for R27 reflected that on 2/27/24 the administration of the Latanoprost eye drops were initialed by RN D with the Chart Code of 9. The key to the MAR Chart Codes reflected 9 means See Nurses Notes. Review of the EMR Progress Notes (also accepted in the industry as Nurses Notes) for R27 did not reveal an entry on 2/27/24 by RN D…

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 safeguard the confidentiality of medical records for 2 of 79 facility residents (R36 and R69), resulting in the potential for unauthorized access to the medical records, and the potential for the loss of resident privacy and confidentiality of their personal health information. Findings include: During an observation on 02/28/24 from 8:35 AM to 8:40 AM, the computer screen, located on the 400 Hall Medication Cart was left unattended and open to R36's electronic medication administration record (e-MAR). R36's name, date of birth , room number, physician's name, allergies, special instructions for medication administration, code status, recent vital signs, and medication were visible to anyone walking by. No staff were within view of the medication cart during this time. Another resident (R18) was sitting in a wheelchair at an angle to the medication cart and the computer screen was potentially visible to him (the Surveyor could read the computer screen standing directly behind R18). During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat one Resident (R10) with dignity and respect. Findings include: Resident#10 (R10) On 8/16/23 at 8:34 AM, during the initial tour, an alarm was heard coming from the 200 Hall area. An alarm on the tube feed pump was going off. The bottle of tube feed was empty. Initial observation of R10 from the hallway, revealed he was wearing a brief. The resident's brief was partially covered by his sheet with the rest exposed to those in the hall. R10 was observed (from the hallway) for over 10 minutes prior to staff assistance. On 8/16/23 at approximately 8:48 AM, Licensed Practical Nurse (LPN) C entered resident's room and stated, (Name of R10's) tube feed started last night, he's empty and needs a new bottle. On 8/16/23 at 8:59 AM, LPN C stated (while providing care) the family does not like clothes on the resident from June on because he is so hot and contracted and clothing makes him uncomfortable. LPN C reflected she was going to care plan…

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 to ensure physician orders for immediate and necessary care and services on admission for one Resident (Resident#10), resulting in a delay of resident centered appropriate care. Findings include: Resident#10 (R10) On 8/16/23 at 8:34 AM, during the initial tour, an alarm was heard coming from the 200 Hall area. Further observation revealed the alarm on a tube feed pump for R10 was going off. The bottle of tube feed was empty. On 8/16/23 at approximately 8:48 AM, Licensed Practical Nurse (LPN) C entered resident's room and stated, (Name of R10's) tube feed started last night; he's empty and needs a new bottle. Review of the empty bottle of tube feeds label indicated the Name of the Brand and 1.0 Cal and the bottle had contained approximately 1000 ML of content. The writing on the label contained Residents Name and Room Number, 8/15/23 date, start time of 1 PM, with a rate of 80 ML/HR until 1920 ML infused. The bottle contained approximately 1000 ML.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess and monitor urinary catheters for one resident (Resident #10) resulting in cross contamination, with the potential of infection. Findings include. Resident #10 (R10): On 8/16/23, at 8:34 AM, R10 was observed lying in bed and the resident's purple dignity bag (goes around his urine collection bag) was found on the floor about 2 feet from the foot of the bed. The catheter collection bag and tubing were found on the floor beneath the bed. On 8/16/23 at approximately 11:00 AM, a record review of R10's admission Record revealed resident was admitted on [DATE]. The record failed to provide insight on the residents' diagnosis and advance directive information. Review of Resident #10's electronic medical record reflected; the admissions packet had not been completed. Further review of resident's electronic medical record reflected, no base line care plan, or [NAME] (a system of communication and organization used to document resident care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI000135323 Based on observation, interview, and record review, the facility failed to administer medication in accordance with Doctors Orders for one resident (Resident #13) resulting in repeated excessive dosing of a medication and the potential for all facility residents to not receive medication in accordance with the Doctor's Orders. Resident #13 (R13): Review of the Electronic Medical Record (EMR) Minimum Data Set (MDS) dated [DATE] reflected that R13 admitted to the facility 7/15/23 with Medically Complex Conditions that included Sepsis and Hemiplegia (weakness to one side of the body). Review of the Doctors Orders (DO) for R13 reflected an order for a Gabapentin 100 milligram (mg) capsule to be administered in the morning and for a Gabapentin 300 mg capsule to be administered at bedtime. Review of the 200-hall medication cart locked narcotic box did not reveal any Gabapentin 100 mg capsules but only Gabapentin 300 mg capsules for R13. Review of the 200-hall controlled…

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.