Regency at Whitmore Lake

Based on observation and interview the facility failed to follow infection control measures during medication administration for three residents (R97, R66, R65) resulting in potential of spreading germs to other residents.Resident 97, Resident 66, Resident 65 (R97, R66, R65) During an interview and observation on 05/15/2026 at 7:00 AM, Licensed Practical Nurse (LPN) O stated he had already given some patients their medication but had not signed them out. LPN O stated he works nights and was still trying to catch up on his medication administration. LPN O prepared medications to administer to R97, no hand hygiene was performed prior to setting up the medications, or after medications were prepared. LPN O picked up his medication cup from the medication cart and walked into R97's room. LPN O donned gloves and checked R97's blood sugar on left hand 1st finger wearing gloves, read 119. LPN O did not use hand hygiene before putting on gloves or after removing them.During an observation of 05/15/2026 at 7:15 AM, LPN O prepared medications for R66, no hand hygiene before or after prepping…

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 reviewed the facility failed to follow an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two Residents (#30, #39) out of four residents reviewed.Findings Included: Resident #30 (R30)Review of the medical record revealed R30 was admitted to the facility 06/07/2024 with diagnoses that included peripheral vascular disease (PVD), dementia with severe mood disturbance, abnormal posture, contracture of left hand, dysphagia (difficulty swallowing), malnutrition, traumatic brain injury, constipation, depression, anxiety, benign prostatic hyperplasia (enlarged prostate), and cognitive communication deficit. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/13/2026, revealed a Brief Interview of Mental Status (BIMS) that was not completed as R30 was identified as resident is rarely/never understood). Review of Section H- Bladder and Bowel, of the MDS with the same ARD, revealed R30 has an indwelling catheter.Review of facility document entitled Infection…

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 one out of three residents (Resident #12) received activities of daily living (ADL) care per the plan of care. Findings Included: Review of a Minimum Data Set (MDS) dated [DATE] on page #21 under section GG revealed, R12 was dependent on staff for Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed.The MDS defined dependent as, Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.On 12/23/2025 at 10:16 AM, Certified Nurse Aid (CNA) J was observed to perform catheter care for Resident #12 (R12) while R12 was in bed. R12 was observed to be laying on the left side of the bed, R12's left side and not in the middle of the bed, CNA J proceeded to tell R12 to roll over to his left side, in which R12 did. CNA J performed peri care and took out…

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 thoroughly investigate for two out of two residents (Resident #1, and Resident #3) allegations of abuse. Review of a facility reported incident (FRI) dated 07/07/25 at 5:45pm and reported to the state on 07/07/25 at 6:31 PM. 5 day follow up dated 07/10/25. R2 and CNA L were walking on hall 200 when R2 told R1 oh you look like you need a kiss, bent down and kissed R1 on the lips. R1 responded to R2 by telling R2 he was going to tell on her and called her a bitch. CNA L separated them and took R2 to another area. Social workers met with both residents. R2 did not recall the incident and remained ambulatory throughout the facility.R1 did recall the incident and was educated about the use of profanity and the need to call for staff for assistance.R1 was witnessed by LPN M yelling at R2, Get the fuck away from me. According to R1, R2 allegedly kissed him, and he shouted profane words towards her. LPN M immediately separated the residents.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update and revise resident care plan's, in three of three residents reviewed for care plans (Resident #2, Resident #1 and Resident #3), resulting in potential for not maintaining or obtaining their highest practicable physical and emotional wellbeing. Findings include:Review of a facility reported incident (FRI) dated 07/07/25 at 5:45pm and reported to the state on 07/07/25 at 6:31 PM. 5 day follow up dated 07/10/25. R2 and CNA L were walking on hall 200 when R2 told R1 oh you look like you need a kiss, bent down and kissed R1 on the lips. R1 responded to R2 by telling R2 he was going to tell on her and called her a bitch. CNA L separated them and took R2 to another area. Social workers met with both residents. R2 did not recall the incident and remained ambulatory throughout the facility.R1 did recall the incident and was educated about the use of profanity and the need to call for staff for assistance.R1 was witnessed by LPN M yelling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake(s) 1216042, 1216038, 1216041Based on observations, interviews, record reviews, and 1 (200) of 4 sampled residents, the facility failed to maintain ambient room temperatures within the acceptable regulatory parameters (71-81 degrees Fahrenheit) affecting 116 residents, resulting in the increased likelihood for resident dehydration and physical/emotional discomfort.Findings include:On 7/15/25 at 1:26 PM during an interview with LPN “D”, when asked if there had been any issues with the air conditioning, she reported “it is hell” (referring to the facility being excessively hot) and that they were trying to get portable air conditioning units for resident rooms [ROOM NUMBERS], as those rooms get direct sunlight and seem to be the warmest. LPN “D” reported that the unit she worked on was provided 6 fans for approximately 34 residents. LPN “D” further reported that when you enter the hallway of their unit from the main area you can feel a temperature increase. When asked if maintenance…

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 1216041Based on observations, interviews, record reviews, reviewed for food product palatability, the facility failed to provide palatable food products affecting 116 residents who consume food, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline.Findings include:On 07/15/25 at 09:43 A.M., An interview was conducted with Resident #200 regarding facility food products. Resident #200 stated: Food Sucks, “The waffles are hard.”, “The biscuits and gravy are stone cold.”, “The hushpuppies are hard as a rock.”, “The bread is dry and hard.”, The meat is dry., The menu is consistently the same., The vegetables are mushy., I go for days without eating facility food., The condensed soup is bad., The peanut butter is bad and doesn't spread., One day we had peanut butter and jelly and vegetable soup for dinner. On 07/15/25 at 09:45 A.M., An interview was conducted with Resident #200 regarding meal service times. Resident #200 stated:…

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 1216041Based on observations, interviews, record reviews, and 1 (200) of 4 sampled residents, the facility failed to provide timely meal service affecting up to 116 residents who consume food, resulting in the increased likelihood for delayed meal service, increased emotional/psychosocial distress, and decreased food acceptance/nutritional decline.Findings include:On 07/15/25 at 09:45 A.M., An interview was conducted with Resident #200 regarding facility meal service times. Resident #200 stated: Breakfast is served around 09:00 - 09:30 A.M., Lunch is served from 01:00 - 01:30 P.M. daily., and Dinner is served from 06:00 -06:30 P.M.On 07/15/25 at 01:57 P.M., Resident #200's lunch meal tray was observed stored within the insulated transport cart, located on the Unit 1 hallway corridor.On 07/15/25 at 02:04 P.M., Resident #200's lunch meal food tray was observed delivered by Certified Nursing Assistant (CNA) I. (CNA) I was also observed providing feeding assistance to Resident #200.(*) The State of Michigan Operations Manual Appendix PP states: F809…

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 includes intake MI000152150. Based on interview and record review the facility failed to revise a comprehensive care plan for one out of three residents (Resident #1). Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease. Review of R1's Brief Interview for Mental Status (BIMS) score revealed that on 12/7/2026 R1 scored a six, and on 2/7/2025, R1 scored a three, both score were indicative of a severe mental impairment. Review of a Physician's Statement of Competency dated 12/27/2024, revealed R1 was deemed to be incompetent and not able to make his own medical decisions. Review of R1's progress notes revealed that on 3/30/2025, R1 was found to be lying in a bed with another female resident. The note revealed staff had been following R1 the majority of the day trying to keep R1 and the female resident separate, but were eventually observed in another resident's bed with R1 having his hand down the female's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation includes intake MI000152150. Based on observation, interview, and record review the facility failed the provide one on one supervision for one out of two residents (Resident #1). Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease. Review of R1's Brief Interview for Mental Status (BIMS) score revealed that on 12/7/2026 R1 scored a six, and on 2/7/2025, R1 scored a three, both score were indicative of a severe mental impairment. Review of a Physician's Statement of Competency dated 12/27/2024, revealed R1 was deemed to be incompetent and not able to make his own medical decisions. Review of R1's progress notes revealed that on 3/30/2025, R1 was found to be lying in a bed with another female resident. The note revealed staff had been following R1 the majority of the day trying to keep R1 and the female resident separate, but were eventually observed in another resident's bed with R1 having his hand down 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 observations, interviews, record reviews, and 8 (R18, R27, R28, R30, R50, R75, R97, R117) of 30 sampled residents who consume food, the facility failed to provide palatable food products effecting 119 residents, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline. Findings include: On 03/24/25 at 12:09 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded: Chicken Cordon Blue - 140.5 Garlic Mashed Potatoes - 148.5 Seasoned Broccoli - 161.2 Dinner Roll - Room Temperature Apricot Halves - 44.6* Beverage (2% Milk) - 40.4 (*) The 2022 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1)…

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

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 119 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 03/24/25 at 09:27 A.M., An initial tour of the food service was conducted with Dietary Manager C. The following items were noted: 2 of 2 can opener assemblies and mounting brackets were observed soiled with accumulated and encrusted food residue. Dietary Manager C indicated she would have staff thoroughly clean and sanitize the can opener assemblies and mounting brackets as soon as possible. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The dry food product (Flour 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.

Based on interview and record review the facility failed to ensure a representative from the Governing Body had contributed to the facility assessment, and failed to ensure the facility assessment was re-assessed based on a change in resident acuity status potentially affecting all 119 residents who resided at the facility. Findings Included: Review of the facility assessment revealed that the last assessment was conducted on 7/16/2023, and was good through 7/15/2024, however the facility within the last 30 days had seven pressure ulcers with treatments, 42 residents who had falls; with two of the residents having a major injury from a fall, and 13 residents with catheters who required catheter care. The facility assessment was not re-assessed in order to determine if the facility was able to meet the care needs of the residents on a daily basis. Furthermore, the assessment was found to have the Administrator listed as the Governing body, and not the owner or CEO, or other individuals who are legally responsible to establish and implement policies regarding the management 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 observations, interviews, record reviews, and 1 (R50) of 30 sampled residents, the facility failed to effectively clean and maintain the physical plant effecting 119 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 03/24/25 at 04:13 P.M., An environmental tour of the facility outdoor smoking area was conducted by this surveyor. The following item was noted: The smoking area canopy roof was observed (worn, warped, missing), allowing seasonal weather events (snow, rain, etc.) to enter the open smoking space. The damaged canopy roof surface measured approximately 24-feet-long by 30-feet-wide. On 03/24/25 at 04:43 P.M., An interview was conducted with R50 regarding the condition of the facility smoking area canopy roof. R50 stated: The smoking area has been bad for quite a while. R50 also stated: I have been here for three years, and the roof has been bad the entire time. On 03/25/25 at 08:55 A.M., An environmental…

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 an allegation of staff to resident abuse to the State Agency for one (Resident #107) of two reviewed. Findings include: Review of the clinical record revealed Resident # 107 (R107) was admitted to the facility on [DATE] with diagnosis that included dementia. Review of the Minimum Data Set (MDS) dated [DATE] reflected R107 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status. Nursing progress notes dated 11/18/2024 revealed R107 reported a Certified Nursing Assistant physically and verbally abused him and that the Nursing Home Administrator (NHA) A and Social Worker (SW) L were notified. On 03/27/25 at 12:54 PM during an interview with SW L she reported she was aware of R107's allegation of abuse and stated she interviewed R107 and R107's spouse. R107 was unable to give a physical description but not the name of the alleged perpetrator/employee, R107 had some confusion and was potentially thinking 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.

Based on observation, interview, and record review the facility failed to ensure comprehensive care plans were developed and implemented to meet the needs for two (Residents 101, and 108) out of 30 residents. Findings included: Resident #101 (R101): Per the facility face sheet R101 had resided at the facility since 4/4/2023. Diagnoses included spinal cord injury, contractures of both hands and fingers, and muscle contractures. Review of a photo dated 12/17/24, of R101's buttocks area reveal moisture associated skin damage (MASD-damage of the skin cause by being constantly moist from things such as urine), and a stage III pressure ulcer (PU) (full thickness tissue loss, fat may be visible). The photo also had an assessment documented which revealed the PU was a stage III (3) in-house acquired PU. The PU was located on R101's right buttocks, and was documented as new on 12/17/2024. In an observation on 3/26/2025 at 3:02 PM, of R101's buttocks wounds it was observed R101 had MASD, and an open approximately 3 centimeter (cm) wound that was located in the same place as the stage 3 wound…

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 one out of 30 residents care plan interventions were appropriately revised. Findings Included: Per the facility face sheet Resident 101 (R101) had resided at the facility since 4/4/2023. Diagnoses included contractures of right, left hand, and muscles. Review of a care plan dated 1/20/2025, revealed, I (R101) have contractures to: Bilateral ankles Bilateral wrists/hands, Bilateral elbows. The interventions were, Provide the following assistive devices as tolerated, .Right and Left hand splints, Right and left elbow splints., dated 01/20/2025. On 3/25/2025 at 9:42 AM, R101 was visited but was asleep, however it was observed R101 had severe hand and finger contractions with the right fingers contracted into a z shape, and the left hand was observed to have all fingers contracted into the palm with the wrist severely bent backwards. A wash clothe was observed to be inside of R101's left hand. R101 was observed to be on his back. During an interview on 3/26/2025 at 3:02 PM, R101's hand splints 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 ensure podiatry care was provided for one (Resident #107) of one reviewed for foot care. Findings include: Review of the clinical record revealed Resident # 107 (R107) was admitted to the facility on [DATE] with diagnosis that included dementia. Review of the Minimum Data Set (MDS) dated [DATE] reflected R107 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status. On 03/24/25 at 11:04 AM R107 was observed resting in bed, family member P was at bedside and reported they visited on a daily basis. Family member P reported being frustrated that their multiple requests for podiatry care was ignored. Family member P reported that she had been cutting R107's toe nails and it was very difficult to do as the nails are so thick, family member P stated she was not able to do anything with one of the nails as it was curling under. Family member P stated she had asked nursing staff and Social Work staff and everybody…

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 for one out of two residents (Resident 101) hands splints were placed on, and a positioning wedge was put into place. Findings Included: Per the facility face sheet Resident 101 (R101) had resided at the facility since 4/4/2023. Diagnoses included contractures of right, left hand, and muscles. On 3/25/2025 at 9:42 AM, R101 was visited but was asleep, however it was observed R101 had severe hand and finger contractions with the right fingers contracted into a z shape, and the left hand was observed to have all fingers contracted into the palm with the wrist severely bent backwards. A wash clothe was observed to be inside of R101's left hand. R101 was observed to be on his back. Review of a care plan dated 1/20/2025, revealed, I (R101) have contractures to: Bilateral ankles Bilateral wrists/hands, Bilateral elbows. The interventions were, Provide the following assistive devices as tolerated, .Right and Left hand splints, Right 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 interview and record review, the facility failed to ensure the attending physician documented in the medical record that identified medication irregularities were reviewed, the action taken, and/or the rationale for no changes to the medications for one (Resident #72) of five reviewed. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected (R72 was admitted for long term care and resided in the facility's secured dementia unit. R72 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS). Review of the Monthly Medication Review (MMR) dated 5/31/2024 reflected R72 Receives Divalproex and has experienced recent mental status changes including agitation/anxiety. Recommendation: Please consider monitoring - serum ammonia concentration in response to documentation of altered mental status. - VPA level. (Valporic acid) Rationale for Recommendation: Valproic acid containing products have a BOXED WARNING which describes the potential 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 Based on observation, interview, and record review the facility failed to provide for resident's food choices for 2 residents (R117 and R 28) of 14 reviewed. Resident 28 (R28) On 03/24/25 at 4:30 PM R 28 was upright in bed and able to participate in an interview. R28 pointed out that chef salad is on the meal ticket to be served every day and yet I only get it about once a week. Sometimes it's a nice salad and other times it is just plain lettuce. R 28 said the chef salad is enjoyed when served with toppings. R 28 considers it healthy and said the doctor has encouraged R28 to eat healthy. On 03/26/25 at 9:05 AM during observation and interview R 28 said yesterday at lunch they sent barbecue chicken, and it states on my ticket I can't eat Barbecue sauce. It was covered in sauce. When asked about a salad R 28 said I did not get a salad. On 03/26/25 at 1:20 PM during observation and interview the meal tray and meal ticket was reviewed at the serving area (R 28s room) For lunch there was no salad on the tray. On the…

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

Based on interview and record review the facility failed to identify via the Quality Assurance Performance Improvement committee (QAPI) the need for an action plan for pressure ulcers. Findings Included: Per the facility policy and procedure titled Quality Assurance Performance Improvement Committee dated 7/1/2010 and last revised on 4/5/2024 revealed, The QAPI Committee meets quarterly or, more often as necessary to: .develop and implement a QAPI plan .,Develop and implement appropriate plans of action to correct quality deficiencies; and .determines what performance data will be monitored and the scheduled frequency for monitoring the data. The policy further revealed that the responsibility of the QAPI committee was to improve the quality of care in the facility by monitoring performance measures, develop and implement appropriate performance improvement plans to correct quality concerns, and evaluate the effectiveness of the performance improvement plans. It was identified during the onsite survey dated 3/31/2025 that two out of six residents reviewed for pressure ulcers (PU)…

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 MI00149592 Based on observation, interview and record review, the facility failed to prevent misappropriation for one (Resident #202) of three reviewed for misappropriation, resulting in feelings of loss of independence and potential mistrust. Findings include: Review of the admission Record revealed Resident #202 (R202) was admitted to the facility on [DATE] with diagnoses that included: fracture of neck, anxiety disorder, mood disorder due to known physiological condition, major depressive disorder, contracture of muscle, and cervical spinal cord injury, contracture of left and right hands. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/24 showed that R202 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. On 2/10/25 at 3:20PM, R202 was observed in his room, lying on his back in bed and was easily conversant. R202 explained that Activities Aide (AA) G had helped him with an online purchase and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of convenience in 1 of 1 resident (Resident #1) reviewed for restraints, resulting in the restriction of mobility and a potential for decline in physical functioning and psychosocial wellbeing. Findings Include: Review of the medical record revealed Resident #1 (R1) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness, dementia, and left femur fracture. The Minimum Data Set (MDS) dated [DATE] revealed R1 scored 1 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and required partial to moderate assist for rolling left to right in bed and substantial to moderate assist for transfers. On 10/9/24 at 9:35 AM, R1's door was shut. Upon entering the room, R1 was observed in bed, dressed in a gown. He was attempting to get out of bed independently. R1 was pleasant and conversant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain an x-ray in a timely manner for 1 (Resident #1) of 3 reviewed for delay of care, resulting in a resident not receiving timely treatment for a hip and femur fracture. Findings include: Review of the medical record revealed Resident #1 (R1) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness, dementia, and left femur fracture. The Minimum Data Set (MDS) dated [DATE] revealed R1 scored 1 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and required partial to moderate assist for rolling left to right in bed and substantial to moderate assist for transfers. On 10/9/24 at 9:35 AM, R1's door was shut. Upon entering the room, R1 was observed in bed, dressed in a gown. He was attempting to get out of bed independently. R1 was pleasant and conversant but with non-sensical answers to questions. The bed was positioned against the wall, with R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement interventions to prevent falls for one (Resident #1) of three reviewed for falls, resulting in a fall with major injury. Findings include: Review of the medical record revealed Resident #1 (R1) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness, dementia, and left femur fracture. The Minimum Data Set (MDS) dated [DATE] revealed R1 scored 1 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and required partial to moderate assist for rolling left to right in bed and substantial to moderate assist for transfers. On 10/9/24 at 9:35 AM, R1's door was shut. Upon entering the room, R1 was observed in bed, dressed in a gown. He was attempting to get out of bed independently. R1 was pleasant and conversant but with non-sensical answers to questions. The bed was positioned against the wall, with R1's legs hanging off the open side 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 Number(s): MI00144739. Based on observation, interview, and record review, the facility failed to implement effective interventions to prevent repeated falls for one (R802) of three residents reviewed for accidents and supervision. Findings include: A complaint was submitted to the State Agency that alleged there was a lack of supervision on Unit 3 and residents were at risk of falling. On 6/3/24 at 2:35 PM, an observation of Unit 3 was conducted. Unit 3 was a locked unit and residents with impaired cognition resided on that unit. Upon entrance to the unit, Certified Nursing Assistant (CNA) 'O' was observed in the hallway and Registered Nurse (RN) 'E' was seated behind the desk in the day room. No staff were interacting with the residents. R802 was observed seated at a table alone facing away from the television and sleeping in her wheelchair. Another resident was facing the doorway falling asleep at the table with her head pressed against the table. On 6/3/24 at 3:23 PM, R802…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00144739 Based on observation, interview, and record review, the facility failed to ensure care and supervision was provided based on professional standards of practice for one (R802) of eight residents reviewed . This had the potential to affect all 21 residents who resided on Unit 3 on 5/26/24. Findings include: A review of a complaint submitted to the State Agency revealed, Upon entering unit 3, there was no staff in sight. A chair with the company's computer was open but no one available. As we continued into the common area, there was a nurse aide playing trivia with the residents .After speaking to the one aide we went to a different unit looking for help and she found a second aide cleaning in the room and confirmed the main nurse was still on break and only the 2 aides were present in Unit 3 .While no staff on site there is resident with soiled pants, one resident behind the nurses station trying to use the phone and two others about to fall and trying 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 This citation pertains to Intake Number(s): MI00144739 and MI00133567. Based on interview and record review the facility failed to monitor blood pressures to ensure medications were administered according to physician ordered parameters for one (R802) of two residents reviewed for medications. Findings include: A review of two complaints submitted to the State Agency alleged residents' medications were not properly administered. A review of R802's clinical record revealed R802 was admitted into the facility on 6/16/23 and readmitted on [DATE] with diagnoses that included hypertension (HTN). A review of R802's Minimum Data Set (MDS) assessment dated [DATE] revealed R802 had severely impaired cognition. A review of R802's active Physician's Orders revealed an order dated 5/18/24 for amlodipine 5 milligrams (mg) two tablets one time a day (upon rising) with instructions to hold the medication if systolic blood pressure (top number) was less than 100 mmhg (millimeters of mercury). A review of R802's Medication…

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

Based on observations, interviews, and record reviews, the facility failed to: (1) clean and maintain food service equipment, and (2) date and label all food products effecting 112 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 02/27/24 at 10:05 A.M., A comprehensive tour of the food service was conducted with Dietary Manager M. The following items were noted: The mechanical dish machine pounds-per-square-inch (psi) gauge was observed to read 66 (psi) during the final rinse cycle. The 2017 FDA Model Food Code section 4-501.113 states: The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). The mechanical dish machine final rinse temperature…

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 levels of nursing staff to meet resident needs for three residents (Resident #79, #81, and #317) and in five of five residents reported in confidential resident council meeting, resulting in extended call light response times, cold food, delayed assistance with meal consumption, the potential for unmet care needs and all 112 facility residents to not attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #79 Review of an admission Record revealed Resident #79 (R79) admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pneumonitis due to inhalation of food and vomit, major depressive disorder, nausea, syncope and collapse, and difficulty in walking. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/5/24, reflected R79 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental…

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 MI00142988. Based on interview and record review, the facility failed to notify the responsible party following an incident in two of three residents reviewed for notification of change (Resident #77 & #20) resulting in a delay in care decisions. Findings include: Resident #77 R77's admission Minimum Data Set (MDS) assessment dated [DATE], revealed he admitted to the nursing home on 2/09/24, and had severely impaired cognition. Incident report dated 2/24/24 at 5:44 PM indicated R77 had an unwitnessed fall at the bedside, observed lying down on the floor with his sheet, no injuries, vital signs stable. The same report did not indicate R77's responsible party was notified of the incident. Director of Nursing (DON) B was interviewed on 3/05/24 at 9:31 AM and stated R77's fall was investigated by the interdisciplinary team (IDT) on 2/26/24. DON B stated she did not know how or when R77 obtained the injury on the right side of his head and the origin of the injury 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 Based on observation, interview and record review, the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for two residents of two residents reviewed for grievances (Resident #42 and #105), resulting in anger, frustration and unresolved grievances. Findings include: Resident #105 Review of the Resident 105 (R105's) electronic medical record (EMR) including the Minimum Data Set, dated [DATE] R#105 was admitted to the facility with diagnosis that includes dementia, anxiety and depression. Resident #105 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) . R105 had clear speech and was able to articulate all needs without difficulty. On 02/25/24 at 10:15 AM during a beside interview, Resident # 105 verbalized multiple complaints regarding the facility staff, resident rights, cleanliness of the building, food, dignity and activities. R105 pulled out a manilla folder which contained an abundance of filed grievances, again related…

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 report allegations of abuse that involved two residents (Resident # 20 and 105) of 3 reviewed, resulting in allegations of abuse that were not reported and the potential for further allegations of abuse to go unreported. Findings include: Resident #20 Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] reflected Resident # 20 (R20) was an [AGE] year old female with diagnoses of Alzheimer's disease, adjustment disorder and anxiety. R20 scored 00 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) MDS section E0200 question B Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) coded as1. occurred 1-3 days. C. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the protection of residents and thoroughly investigate allegations of abuse that involved 3 residents (Resident #20, #77 and #105) of 3 reviewed for abuse, resulting in the potential for further abuse to occur and allegations of abuse not being thoroughly investigated. Resident #20 (R20) Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] reflected Resident #20 (R20) was an [AGE] year old female with diagnoses of Alzheimer's disease, adjustment disorder and anxiety. R20 scored 00 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) MDS section E0200 question B Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) coded as1. occurred 1-3 days. C. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public,…

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 accurately complete a Minimum Data Set (MDS) assessment for one resident (#45) of 23 residents reviewed for accurate MDS assessments. Findings Included: Resident #45 (R45) Review of the medical record revealed R45 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancer) of the colon, depression, dementia, insomnia, gastro-esophageal reflux, chronic obstructive pulmonary disease (COPD), cerebral infarction (stroke), atrial fibrillation, hypertension, and anemia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2024 demonstrated a Brief Interview for Mental Status (BIMS) of 13 (intact cognition) out of 15. Section L-Oral/Dental Status , with the same ARD, demonstrated that mouth or facial pain, discomfort, or difficulty with chewing was checked no. During observation and interview on 02/25/2024 at 10:16 a.m., R45 was observed setting up in his electric wheelchair…

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 the resident care plan in one of 23 residents reviewed for care plans (Resident #75), resulting in unmet needs. Findings include: Resident #75 Review of an admission Record revealed Resident #75 (R75) admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included partial traumatic amputation of left food, osteomyelitis, and peripheral artery disease. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/13/24, reflected R75 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Care Plan reflected R75 required assistance of one person for ambulation and required the use of a walker. On 02/25/24 at 12:46 PM, R75 was observed resting in his bed. R75 had a hard boot on the left foot and lower leg and a wound vacuum. R75 stated that originally, he was here for short term purposes but had recently…

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.

During observation, interview, and record review, the facility failed to ensure residents receive showers according to their personal preferences for one residents (#42) of four residents reviewed for hygiene and grooming, resulting in missed showers and the potential for inadequate hygiene and feelings of embarrassment. Resident #42 (R42) Review of the medical record revealed R42 was admitted to the facility 02/05/2021 with diagnoses that included chronic obstructive pulmonary disease (COPD), depression, anxiety, difficulty walking, chronic kidney disease, history of falling, type 2 diabetes, hypertension, anemia, lymphedema (blockage of lymph nodes causes swelling), asthma, dermatitis (skin condition causing swelling or irritation of the skin), hyperlipidemia (high fat content in blood), bilateral osteoarthritis of knee, and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/06/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. Section GG of the MDS, with the same ARD, demonstrated…

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 placement of a wound vacuum, per physician order, for one resident (Resident #75) and failed to complete a physician ordered suprapubic catheter change for one resident (Resident #81) of 23 residents reviewed for quality of care, resulting in residents not receiving care and treatment in accordance with professional practice. Findings include: Resident #81 (R81) Review of the medical record revealed that Resident #81 (R81) was admitted to facility on 1/16/24 with diagnoses including other retention of urine, feeling of incomplete bladder emptying, obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, and infection and inflammatory reaction due to indwelling urethral catheter. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/24 revealed that R81 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively…

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 provide services to prevent further decrease in range of motion for one (Resident #317) of one reviewed for range of motion, resulting in a decrease in range of motion, contractures, and pain. Findings include: Review of an admission Record revealed Resident #317 (R317) admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fracture of neck, traumatic subarachnoid hemorrhage with loss of consciousness, need for assistance with personal care, disorder of the autonomic nervous system, and cellulitis of toe. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/9/23, reflected R317 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Care Plan reflected R317 was dependent on staff for all activities of daily living. In an observation and interview on 02/25/24 at 12:15 PM, R317 was observed in bed dressed in a gown.…

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 prevent weight loss in 1 of 4 sampled residents (#79) reviewed for weight loss, resulting in Resident #79's significant weight loss of 16 pounds in 52 days. Review of an admission Record revealed Resident #79 (R79) admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pneumonitis due to inhalation of food and vomit, major depressive disorder, nausea, syncope and collapse, and difficulty in walking. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/5/24, reflected R79 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Care Plan reflected R79 did not ambulate and required supervision/touching assistance of one person to eat. In an observation and interview on 02/25/24 at 9:39 AM, R79 was observed in bed with a breakfast tray on his bedside table. The tray included scrambled eggs and corn hash. The food was…

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

Based on interview and record review the facility failed to ensure that two Certified Nursing Aides (Q, BB) of three Certified Nursing Aides received annual performance evaluations to adequately meet the needs of the 112 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) Q had a hire date of 02/11/2021 and did not have an annual performance evaluation completed in 2024. Personnel records demonstrated that CNA BB had a hire date of 12/08/2010 and did not have an annual performance evaluation completed in 2023. In an interview on 03/05/2024 at 12:55 p.m. Human Resource Director DD explained that it is the facility policy and practice that all staff have an annual performance evaluation completed. She explained that the annual performance evaluations are to be completed no later than two weeks after their annual hire date. Human Resource Director DD could not locate the annual performance evaluations for CNA Q and CNA DD in their personnel files and explained that if they were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure psychotropic medications were administered for the treatment of a specific condition and monitored for side-effects in one of six reviewed for medications (Resident #77), resulting in a decline in mental and physical condition. Findings include: Resident #77 (R77) In review of R77's medical record, pre-admission documents dated 2/01/24, R77 was admitted from an adult foster care setting and diagnoses included: Gastroesophageal Reflux Disease (GERD, stomach acid irritates food pipe lining), Diabetes Mellitus, gait instability, urinary retention, and Dementia. There were no depression, anxiety or psychosis diagnoses listed in R77's history. The same pre-admission documents, under charting notes dated 11/04/23 through 1/21/24, indicated R77 had a history of being up most of the night, as needed medication not effective, refused a shower with a female caregiver, elopement seeking and wandered at night looking for snacks. Antipsychotic Risk Versus…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure proper storage of medications for two resident (R50 and R265), and 2 of 3 medication carts and 1 of 3 medication rooms reviewed, resulting in the increased likelihood for decreased medication efficacy and adverse side effects in a current facility census of 112 residents Findings include: During an observation on [DATE] at 10:05 AM, Registered Nurse(RN) SS unlocked the 300 hall medication cart. This Surveyor observed the following: -One bottle of open of [NAME]/Vit with Manufacture expiration date of 12/2023. RN SS reported should have been discarded after manufacture expiration date. -One unopened Basagar 100u/ml insulin for resident in zip bag delivered from the pharmacy [DATE] in the cart with and additional open insulin in use for same resident. RN SS reported unopened insulin should have been stored insulin the refrigerator until opened. RN SS verified unopened and reported was unsure how long it had been in medication cart and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the resident call system was functioning for one (R38) of 23 sampled residents, resulting in decreased emergent response time and potential resident adverse clinical outcomes. Findings Include: Resident #38(R38) Review of the Face Sheet and Minimum Data Set (MDS) with ARD date 12/25/23, reflected R38 was a [AGE] year old female admitted to the facility on [DATE] related to chronic obstructive pulmonary disease, stage 4 facility acquired pressure ulcer with chronic osteomyelitis, hypertension (high blood pressure), diabetes mellitus, cerebral vascular infarction with left non-dominant hemiparesis, anxiety, and depression. The MDS reflected R38 had a BIM (assessment tool) which reflected moderately impaired. The MDS assessment reflected R38 had no behaviors related to rejection of care. During an observation and interview on 2/25/24 at 11:03 AM, R38 was observed laying flat on back in bed with call light out of reach, draped over wall unit, about 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 112 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 02/27/24 at 02:00 P.M., An environmental tour of the 300 (Dementia Care) Unit was conducted by this surveyor. The following item was noted: Dining Room: The laminate flooring surface was observed raised and separated between the individual flooring segment planks. The damaged flooring surface area measured approximately 12-feet-wide by 12-feet-long. On 02/27/24 at 02:34 P.M., An environmental tour of the 200 Unit was conducted by this surveyor. The following item was noted: The lower wall surface was observed (etched, scored, particulate), adjacent to the Resident Lounge entrance. The drywall surface was also observed missing, exposing the inner wooden stud superstructure. The wall/floor coving carpet strip was further observed missing. On 02/27/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains in intake #MI00139231 Based on observation, interview, and record review, the facility failed to ensure a resident (R#2) was free from abuse by not implementing a care plan intervention for Resident (R#1) of two residents reviewed for abuse, from a total sample of 11 residents. This deficient practice resulted in an avoidable resident to resident altercation between Resident #1 and Resident #2. Findings Include: Resident #1 (R1) Review of the medical record reflected R1 was an initial admission to the facility on [DATE]. Diagnosis includes nontraumatic intracerebral hemorrhage, mood disorder and Dementia classified elsewhere, unspecific severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/25/2023, revealed R1 had a Brief Interview of Mental Status (BIMS) of 10 out of 15 (moderate impairment). MDS 3.0 Section D- Mood D0200, R1's Mood Interview (PHQ-9) was 12. MDS…

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 #MI00138784 Based on observation, interview, and record review, the facility failed to prevent, accurately assess pressure ulcers and promote healing in one of one resident reviewed for pressure ulcers (Resident #11), in a total sample of 11 total residents, resulting in delayed wound healing and development of a facility acquired pressure ulcer. Findings include: Resident #11 (R11) Review of the medical record reflected R11 was an admission to the facility on [DATE] and was discharged on 08/14/2023. Diagnosis includes fracture of the left femur, unsteady gait, muscle weakness, chronic kidney disease, difficulty in walking, bilateral osteoarthritis of both knees, respiratory failure and heart disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/06/2023, revealed R11 had a Brief Interview of Mental Status (BIMS) of 15 out of 15 (cognitively intact). Required extensive assistance with all activities of daily living. Balance was unsteady 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.