Regency at Whitmore Lake

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes: MI00136963, MI00137000, MI137972 Based on observation, interview, and record review the facility failed to provide activities of daily living, to include incontinent care, for 4 dependent residents (#1, #2, #5, #10) and bathing for one resident (#2) of six residents reviewed resulting in the potential of unmet needs. Findings included: Resident #1 (R1) Review of the medical record revealed R1 was admitted [DATE] to the facility with diagnoses that included difficulty in walking, congenital rectovaginal fistula, adjustment disorder, stage 3 kidney disease, hypertension, adult failure to thrive, chronic obstructive pulmonary disease (COPD), type 2 diabetes, hypertension, lymphedema (localized swelling caused by abnormal accumulation of lymph), chronic anemia (low red blood cells), major depression, cerebral vascular accident (stroke), diverticulitis (inflammation of the bowels causing bowel disturbances), glaucoma, and osteoarthritis. The most recent Minimum Data Set (MDS), with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00137972 Based on observation, interview, and record review the facility failed to prevent accidents (falls), by not following the plan of care, for one resident (#5) of three residents reviewed resulting in the potential for serious bodily harm and injury. Findings Included: Resident #5 (R5) Review of the medical record revealed R5 was admitted [DATE] to the facility with diagnoses that included congestive heart failure (CHF), contracture of left knee, hypertension, hyperlipidemia (high fat content in blood), anxiety, muscle weakness, difficulty in walking, adjustment disorder, mood disorder, type 2 diabetes, personality disorder, anencephaly (congenital condition in which large part of skull is absent), traumatic brain injury, hemiplegia (paralysis of one side of body) left side, cataracts, osteoarthritis, and rotator cuff tear. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2023, revealed R5 had a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains To Intakes: MI00128668, MI00128936 and MI00132164. Based on observation, interview, and record review the facility failed to ensure sufficient nursing staff for 5 out of 25 sampled residents (Resident 21, 69, 98, 100, 466), and 10 out of 10 resident council members, resulting in the potential for all 107 residents who resided at the facility to not attain or maintain their highest practicable physical, mental, and psychosocial well-being. Review of the facility's CMS-672 Resident Census and Conditions of Residents dated 11/2/22 revealed the facility's census was 107, of which 99 required assistance of one or two staff for bathing, 99 required assistance of one or two staff for dressing, 68 required assistance of one or two staff for transferring, 90 required assistance of one or two staff for toilet use, and 20 required assistance of one or two staff for eating. The CMS-672 also revealed 8 residents were dependent on staff for bathing, 5 were dependent on staff for dressing, 23 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.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 105 residents, resulting in the increased likelihood for plumbing leaks, cross-contamination, and bacterial harborage. Findings include: On 11/02/22 at 09:34 A.M., An initial tour of the food service was conducted with Dietary Manager NN and Registered Dietician (RD) FF. The following items were noted: The two US Range oven exterior surfaces were observed heavily soiled with accumulated and encrusted food residue. The gas stove/oven top backsplash was observed soiled with accumulated and encrusted food residue. The coffee machine exterior surfaces were observed soiled with accumulated food residue and splash. The sole facility Ice Machine interior plastic retention plate assembly was observed soiled with a black watery substance. Dietary Manager NN stated: I will have maintenance remove and clean the plastic plate as soon as possible. The mechanical dish machine ventilation hood return air exhaust grill was observed heavily soiled with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00129649, MI00130123 Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for three( R30, R46, and R72) of four residents reviewed for dignity and residents who attended the resident group interview, resulting in potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Resident #30 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R30 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included end stage renal disease with dependence on dialysis, heart failure, heart disease, diabetic, chronic obstructive pulmonary disease, hypertension (high blood pressure), anxiety and depression. The MDS reflected R30 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required one person physical assist with bed mobility, transfers, locomotion on unit,…

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: MI00126358 Based on observations, interviews, record reviews, 10 of 10 from the confidential group meeting, and 2 (#30, #72) of 25 sampled residents, the facility failed to effectively provide a continuous recirculated fresh air supply effecting 107 residents, resulting in the increased likelihood for stagnant environmental air supplies and resident respiratory distress. Findings include: On 11/04/22 at 08:30 A.M., An environmental tour of the facility physical plant was conducted to investigate allegations regarding all exterior windows being Nailed Shut. The following items were noted: Unit 1 Resident room exterior windows were observed secured with sheet metal screws (2 or 3) inserted from the outside of the building. The sheet metal screws were also observed inserted on each end of the sliding window panel assembly. Numerous sliding window panel assemblies were further observed with an additional sheet metal screw inserted midway near the top of the panel assembly. Unit 2…

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 adequately address concerns and grievances brought forth by the Resident Council, resulting in concerns not being addressed, unresolved and feelings of anger, frustration and being unheard. Findings Include: Review of the Resident Council meeting minutes dated 5/23/22 indicated under New Business a group concern regarding unit 4 not getting their coffee cart for lunch or dinner on a consistent basis. A concern form was indicated to have been complete. Facility Administrator A and Director of Nursing (DON) B indicated to be in attendance. Review of the Resident Council meeting minutes dated 6/27/22 indicated under Old Business concerns which included 1. Snacks being brought to the units all times of day 2. Unit 4 coffee not being given out at lunch and dinner 3. No ice in water, all shifts, all units varying when it happens and does not happen. Concern forms indicated to have been complete. Facility Administrator A and DON B indicated to be in attendance. Review of the Resident Council meeting minutes dated 7/25/22 indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes: MI00126358, MI00129910 Based on observations, interviews, and record reviews, the facility failed to effectively maintain ambient air temperatures effecting 107 residents, resulting in the increased likelihood for resident discomfort and dehydration. Findings include: On 11/04/22 at 03:16 P.M., Ambient room temperatures were monitored utilizing an Etekcity lasergrip model 1080 infrared thermometer. The following ambient room temperatures were recorded: Unit 4 Shower Room: 82.0 - 86.0 degrees Fahrenheit* Nursing Station: 80.6 - 81.8 degrees Fahrenheit* room [ROOM NUMBER]: 78.0 - 80.7 degrees Fahrenheit room [ROOM NUMBER]: 75.0 - 79.0 degrees Fahrenheit room [ROOM NUMBER]: 77.0 - 79.0 degrees Fahrenheit On 11/04/22 at 03:19 P.M., Registered Nurse MM stated: It's hot in here. On 11/09/22 at 02:10 P.M., Ambient room temperatures were monitored utilizing an Etekcity lasergrip model 1080 infrared thermometer. The following ambient room temperatures were recorded: Unit 1 Back Shower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00126385. Based on observation, interview and record review the facility failed to ensure that grievances were investigated, and resolved for three Residents(R46, R48 and R72) and failed to implement facility grievance policy, resulting in feelings of anger, frustration and feelings of not being heard. Findings include: According to the facility grievance policy titled, Care Program, dated 4/28/22, reflected, Purpose: To ensure that the facility actively resolves any concerns/grievances submitted orally or in writing .The concern/grievance can be documented using the Guest/Resident, Family, Employee, and Visitor Assistance Form .Staff receiving the concern/grievance should acknowledge receipt .concerns must be forwarded to the Administrator within 24 hours of receipt .All concerns shall be discussed with the Department Managers during the morning Interdisciplinary Team meeting following the day of receipt .will have 5-7 days following receipt of the concern to complete the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00129193. Based on observation, interview, and record review, the facility failed to report allegations of abuse for four (Resident #20, #54, #95, #100) of 24 reviewed, resulting in allegations of abuse that were not reported and the potential for further allegations of abuse to go unreported. Findings include: Review of the facility's Abuse policy dated 9/9/2022, revealed .staff members, volunteers, family members, and others shall immediately report incidents of abuse and suspected abuse, and should be assured that they will be protected against repercussions. Allegations by anyone who becomes aware of verbal, physical, mental, sexual or emotional abuse and mistreatment, neglect, exploitation, involuntary seclusion or misappropriation of property must immediately report it to his/her Administrator . Resident #100 Review of the facesheet, reflected that Resident #100 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia and anxiety disorder.…

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 Resident #21 (R21): R21 was an eighty-nine-year-old admitted to facility 2/18/20 with diagnoses including major depressive disorder, anxiety disorder, and unspecified dementia. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/22 revealed Brief Interview for Mental Status (BIMS) score of three (severely impaired cognition). Section G of MDS revealed that R21 required limited assist of one for bed mobility, transfers, and toileting. Section H of MDS reflected that R21 was frequently incontinent of bladder and always incontinent of bowel. Resident # 466 (R466): R466 was an eighty-two-year-old initially admitted to facility 3/23/22 and readmitted on [DATE] with diagnoses including Alzheimer's disease and major depressive disorder. Review of Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 9/24/22 revealed that resident was usually understood and understands with Brief Interview for Mental Status (BIMS) score of three (severely impaired cognition). Section D of 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 Based on observation, interview and record review, the facility failed to develop and implement comprehensive care plans for six (Resident #21, #52, #54, #97, #98, and #100) of 25 reviewed, resulting in the potential for unmet care needs and services. Findings include: Resident #54 (R54): Review of the medical record reflected R54 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included traumatic subdural hemorrhage without loss of consciousness, unspecified dementia, schizoaffective disorder, muscle weakness, difficulty walking, major depressive disorder and anxiety. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/25/22, reflected R54 had short-term and long-term memory problems. The same MDS reflected R54 performed activities of daily living with independence to extensive assistance of one to two or more people. An Incident Report reflected R54 was observed lying on the floor, on her left side, next to the bed on 3/26/22. The report 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 Resident #49(49) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R49 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), diabetes, dementia, schizophrenia and stage 4 pressure ulcer. The MDS reflected R49 had a BIM (assessment tool) score of 1 which indicated his ability to make daily decisions was severely impaired, and he required two person physical assist with bed mobility, transfers, and one person physical assist with locomotion on unit, eating, dressing, toileting, hygiene, and bathing. During an observation on 11/02/22 at 9:45 a.m. R49 was laying in bed with staff at bedside assisting with meal. During an observation and interview on 11/02/22 at 9:52 a.m., Certified Nurse Aide (CNA) N exited R49's room after assisting with meal. R49 appeared pleasantly confused and well groomed and able to answer simple questions. R49 had a wound vac in place with bed positioned at 90 degree and call light not in reach,…

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 pertain to intakes: MI00128668, MI00128936, MI00131788 Based on observation, interview, and record review the facility failed to coordinate hospice services for one resident (#3), failed to perform glucose monitoring as prescribed for one resident (#18), failed to recognize a change of condition for one resident (#22) and failed to perform dressing changes and monitor bowel movements for one resident (#464) of 25 reviewed for quality of care, from a total sample of 25 residents, resulting in residents not receiving care and treatment in accordance with professional practice. Finding included: Resident #3 (R3) Review of the medical record revealed R3 was admitted to the facility 12/06/1999 with diagnoses that included benign paroxysmal vertigo (episodes of dizziness), neuromuscular dysfunction of bladder (lack of bladder control), hyperlipidemia (high level of fats in blood), osteoporosis (weak and brittle bones), hypothyroidism (deficiency of thyroid hormones) , chronic ischemic heart disease,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes: MI00128809, MI00128936, MI00129910 Based on observations, interviews, record reviews, 10 of 10 from the confidential group meeting, and 2 (#8, #75) of 25 sampled residents, the facility failed to provide palatable food products effecting 105 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline. Findings include: On 11/02/22 at 12:12 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded: Baked Ziti - 189.9 degrees Fahrenheit Italian [NAME] Beans - 189.1 degrees Fahrenheit Garlic Bread - 143.9 degrees Fahrenheit Seasonal Fresh Fruit (Water [NAME]) - 47.8 degrees Fahrenheit* Beverage (Skim Milk) - 37.3 degrees Fahrenheit Note: (*) The 2017 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…

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 policy to offer 15-Valent Pneumococcal Conjugate Vaccine (PCV15) and 20-Valent Pneumococcal Conjugate Vaccine (PCV20), resulting in the potential for increased risk of acquiring, transmitting, or experiencing complications from pneumococcal disease for all residents in a current facility census of 107 residents. Findings include: Review of the Centers for Disease Control and Prevention (CDC) Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2022 dated 1/28/22 revealed On October 20, 2021, the Advisory Committee on Immunization Practices recommended 15-valent PCV (PCV15) or 20-valent PCV (PCV20) for PCV-naïve adults who are either aged [greater than or equal to] 65 years or aged 19-64 years with certain underlying conditions. When PCV15 is used, it should be followed by a dose of PPSV23, typically [greater than or equal to] 1 year later. The document 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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 97 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: The following was observed on 1/24/23 and 1/25/23. room [ROOM NUMBER]: The restroom commode base caulking was observed (cracked, stained, missing). There was flaked bits of chalking around the toilet on the floor. room [ROOM NUMBER]: Paint chips noted on floor from outside the door to the bathroom The door to the bathroom had flaking paint. room [ROOM NUMBER]: Corner going into room appeared to be missing a bumper piece that was previously glued on, with dried glue residue still on the wall and a different paint color than the wall color. room [ROOM NUMBER]: The entrance door frame was observed (etched, scored, particulate). Hole fist size near floor on wall adjacent to door. room [ROOM NUMBER]: The Bed 2 telephone jack was observed loose-to-mount. A hole…

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 exhaust ventilation was functioning in 17 resident bathrooms, serving 17 of a total 62 resident rooms. This deficient practice resulted in noxious odors permeating the resident environment rendering the living conditions unpleasant and uncomfortable. Findings include: During an observation and interview on 11/16/22 at 1:37 p.m., observed strong odor noted in room [ROOM NUMBER]. Resident in room reported foul odor was coming from the bathroom for weeks. Resident reported that staff had commented on odor but had not improved. room [ROOM NUMBER] bathroom was closed at the time. This surveyor opened the door, followed by a very foul smell. Ventilation in bathroom did not appear to be functioning. Resident reported uses bathroom to brush teeth and shave but smells like sewer. Verified even with bathroom door still smelled like sewer in the room. During an interview on 11/16/22 at 2:15 p.m., Director of Maintenance(DM) KK reported had been the DM 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 interview and record review, the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold for one (Resident #22) of three reviewed for hospitalization resulting in the potential of residents and/or representatives to be uninformed of the bed hold policy. Findings include: Resident # 22 (R22) was a sixty one year old initially admitted to facility on 10/10/19 with multiple rehospitalizations and facility readmissions including 10/10/22 facility readmission with diagnoses including acute and chronic respiratory failure with hypoxia, urinary tract infection, chronic obstructive pyelonephritis, gastro-esophageal reflux disease, acute on chronic diastolic congestive heart failure, obstructive sleep apnea, hypothyroidism, morbid obesity with alveolar hypoventilation, type 2 diabetes mellitus, schizophrenia, major depressive disorder, unspecified osteoarthritis, anemia, essential hypertension. Review of Minimum Data Set (MDS) with an Assessment Reference Date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI00128668, MI00128809, MI00128936, and MI00132134 Based on interview and record review the facility failed to provide showers for two (Resident #460 and #464) of four reviewed, resulting in missed showers and the potential for uncleanliness and feelings of neglect. Findings include: Resident #460 (R460) Review of the medical record revealed R460 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction, chronic obstructive pulmonary disease (COPD), bipolar disorder, adjustment disorder, anxiety disorder, dementia, major depressive disorder, borderline personality disorder, epilepsy, and diabetes. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/30/22 revealed R460 scored 9 out of 15 (moderate cognitive impairment on the Brief Interview for Mental Status (BIMS) and required total dependence of two staff for bathing. R460 was transferred to the hospital on 9/26/22 and did not return to the facility.…

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 meaningful activities were provided for one Resident (R49) out of one resident reviewed for activities. This deficient practice resulted in the potential for boredom and lack of stimulation. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R49 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), diabetes, dementia, schizophrenia and stage 4 pressure ulcer. The MDS reflected R49 had a BIM (assessment tool) score of 1 which indicated his ability to make daily decisions was severely impaired, and he required two person physical assist with bed mobility, transfers, and one person physical assist with locomotion on unit, eating, dressing, toileting, hygiene, and bathing. During an observation on 11/02/22 at 9:45 a.m. R49 was laying in bed with staff at bedside assisting with meal. During an observation and interview…

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 interventions and provide adequate supervision to prevent falls for two (Resident #54 and #98) of two reviewed for falls, resulting in Resident #54 falling and sustaining a major injury and the potential for continued falls and injury. Findings include: Resident #54 (R54): Review of the medical record reflected R54 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included traumatic subdural hemorrhage without loss of consciousness, unspecified dementia, schizoaffective disorder, muscle weakness, difficulty walking, major depressive disorder and anxiety. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/25/22, reflected R54 had short-term and long-term memory problems. The same MDS reflected R54 performed activities of daily living with independence to extensive assistance of one to two or more people. An Incident Report reflected R54 was observed lying on the floor, 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 intakes MI00131788, MI00131792, and MI00131765 Based on interview and record review, the facility failed to monitor the hydration status for one (Resident #460) of one reviewed, resulting in the potential for dehydration. Findings include: Review of the medical record revealed R460 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction, chronic obstructive pulmonary disease (COPD), bipolar disorder, adjustment disorder, anxiety disorder, dementia, major depressive disorder, borderline personality disorder, epilepsy, and diabetes. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/30/22 revealed R460 scored 9 out of 15 (moderate cognitive impairment on the Brief Interview for Mental Status (BIMS) and required total dependence of one person for eating. R460 was transferred to the hospital on 9/26/22 and did not return to the facility. Review of the [NAME] (Certified Nursing Assistant (CNA) care guide) 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 interview and record review, the facility failed to provide adequate medically related social services for 1 resident (R31) of 25 residents reviewed resulting in increased likelihood of advanced directive issues, lack of a legal representative, and resident overall psychosocial well-being. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected that Resident #31(R31) was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included vascular dementia, type two diabetes, insomnia, and chronic kidney disease. R31 was listed as a full code (by default) and the Face Sheet named the son as the responsible party. Review of the facility's Social Work Job Description document, defined medically-related social services as .services provided by the facility's staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs . which includes .assisting residents 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 act on the recommendations of pharmacy medication reviews, for one Resident (R36), from 6 reviewed for unnecessary medications. This deficient practice resulted in the potential for continued use of unnecessary medications leading potentially to adverse side affects. Findings include: According to the, 9.1 Medication Regimen Review Policy, dated 3/3/20, reflected, PROCEDURE .The Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the resident's health record .The pharmacist will address copies of residents MRRs to the Director of Nursing and/or the attending physician and to the Medical Director. Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRR's .Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician ordered parameters upon administering blood pressure medications for one resident (#21) and failed to justify the use on antibiotic medication for one resident (#36) of 7 residents reviewed for unnecessary medications, resulting in the potential for adverse drug consequences. Findings include: Resident #36(R36) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R36 was a [AGE] year old male admitted to the facility on [DATE] with most recent re-admission [DATE] related to , with diagnoses that included spastic quadriplegic cerebral palsy, diabetes, dysphasia, kidney stones, urinary tract infection(UTI) , anxiety and depression. The MDS reflected R36 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required one person physical assist with locomotion on unit, dressing, eating, hygiene, bathing and two person physical assist…

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 adequate monitoring of psychotropic medication for one (Resident #9) and justify the use of duplicate antidepressant therapy for one (Resident #21) of seven reviewed, resulting in the potential for adverse effects and unnecessary medications. Findings include: Resident #9 (R9) Review of the medical record revealed R9 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included alcohol dependence with alcohol induced persisting dementia, , heart failure, delusional disorders, mood disorder, unspecified psychosis, anxiety, and major depressive disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/22/22 revealed R9 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS), had a mood score of 0, no hallucinations, no delusions, and no behavioral symptoms. On 11/22/22 at 10:44 AM, R9 was observed lying in bed listening to music. R9's…

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

Based on observation, interview and record review, the facility failed to administer medications according to Physician's Orders and instructions for use for two (Resident #80 and #102) reviewed for medication administration, resulting in three medication errors out of 30 opportunities, which resulted in a 10% medication error rate. Findings include: Resident #80 (R80): During a medication administration observation that began on 11/18/22 at 09:30 AM, Licensed Practical Nurse (LPN) S administered medications to R80, which included but were not limited to Brimonidine-Timolol 0.2%-0.5% (medicated eye drops). One drop was administered to each eye. The inner canthus (inner corner) of R80's eyes were not held after the medication was administered. According to Brimonidine And Timolol (Ophthalmic Route), Proper Use instructions, .Tilt the head back and, pressing your finger gently on the skin just beneath the lower eyelid, pull the lower eyelid away from the eye to make a space. Drop the medicine into this space. Let go of the eyelid and gently close the eyes. Do not blink. Keep the eyes…

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

Based on observation and interview, the facility failed to 1) ensure appropriate labeling and storage of insulin in two of three medication carts and; 2) ensure appropriate wasting of controlled medications, resulting in the potential for outdated medications, decreased medication efficacy and drug diversion. Findings include: During an observation of the Unit three medication cart, with Licensed Practical Nurse (LPN) AA on 11/22/22 at 10:16 AM, the following were observed: -Resident #31's Levemir FlexTouch 100 units per milliliter (U/mL) insulin pen was not labeled with an open date or expiration date. -Resident #96's Basaglar KwikPen 100 U/mL insulin pen was not labeled with an open date or expiration date. -Resident #96's Victoza (diabetes medication) 18 milligrams per 3 milliliters (18mg/3mL) had an open date with a month that was unable to be read. LPN AA reported it looked like 10/11 or 11/11 to her, but she could not tell. -Resident #96's Insulin Aspart FlexPen 100 U/mL reflected a date of 11/7/22, written in marker. LPN AA believed that was the open date, but there was no…

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

This citation pertains to intake number MI00128936 Based on interview and record review the facility failed to provide rehabilitation services for one (resident #464) out of two residents reviewed for rehabilitation services, resulting in the potential of the resident not maintaining or achieving their highest practicable level of independence. Findings include: Resident #464 (R464) Review of the medical record revealed R464 was admitted to the facility 04/15/2022 with diagnoses that included hemiplegia (muscle weakness or partial paralysis on one side) and hemiparesis (another word for hemiplegia) of left dominate side, cerebral vascular infarction (stroke), anxiety, pancytopenia (deficiency of components of the blood-red cells, white cells, and platelets), protein-calorie malnutrition, vascular dementia, hyperlipidemia (high fat levels in blood), major depressive disorder, Alzheimer's disease, insomnia (difficulty sleeping), peripheral autonomic neuropathy (weakness, numbness, and pain from nerve damage), hypertension (high blood pressure), atherosclerotic heart disease, chronic…

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 operationalize an antibiotic stewardship program which consistently ensured appropriate clinical indication for us of antibiotic medications. This deficient practice affected residents at the facility (including R36) when residents who were deemed as not meeting criteria were prescribed on antibiotic therapy, resulting in the potential for increased antibiotic resistance. Findings include: Review of the Center for Disease Control's (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes dated 2015, documented in part, .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents…

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.