Applewood Nursing Center, Inc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain catheter bag privacy for one (R411) of three residents reviewed for catheter care. Findings include: On 9/18/24 at 10:00 AM and at 11:25 AM, R411's room door was open, and their catheter bag was observed hanging on the side of the bed facing the doorway clearly visible from the hallway and passersby. The catheter bag was clear and was not in a privacy bag. Yellow-colored urine was visible in the bag. On 9/18/24 at 12:05 PM, R411's catheter bag remained clearly visible from the hallway, uncovered and containing urine. R411's roommates family member entered the room to visit. R411 stated It bothers me that the foley bag isn't covered up. I'm not old enough for a foley and everyone (R411 pointed to her roommate's family member) can see it. I have an issue with it. Review of the Electronic Health Record (EHR) for R411 revealed an admission date of 4/15/24 with diagnoses that included obstructive and reflux uropathy and obesity. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop, implement, and revise care plans for one resident (R404) of four residents reviewed with a tube feeding, resulting in multiple hospital admissions for peg tube reinsertion. Findings include: On 9/18/24 at 9:00 A.M., review of the admission Record for R404 indicated the resident was admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following a cerebral infraction (stroke) affecting the left non dominant side, vascular dementia, dysphagia with J/G tube (Tube placed in the jejunum/stomach for feeding liquid nutrition), end stage renal disease requiring dialysis and Hypotension. Review of the Minimum Data Set (MDS), dated [DATE], R404 had a BIMs (Brief Interview for Mental Status of 14 (cognitively intact), required two person assist with ADL's (Activities of Daily Living) was NPO (nothing by mouth) and received a tube feeding for nutritional needs. On 9/18/24 at 9:15 A.M., complainant H reported to the State Agency…

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 MI00144652, MI00145045, and MI00145057 Based on interview and record review the facility failed to implement interventions to prevent the dislodgement and manipulation of a percutaneous enteral gastrostomy tube in a timely manner (PEG) for one (R404) of four residents reviewed for quality of care, resulting in ten (10) hospital transfers/admissions for treatment and care of a peg tube/J-tube. Findings include: On 9/18/24 at 9:00 A.M., review of the admission Record for R404 indicated the resident was admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following a cerebral infraction (stroke) affecting the left non dominant side, vascular dementia, dysphasia with J/G tube (Tube placed in the jejunum/stomach for feeding liquid nutrition), end stage renal disease requiring dialysis and Hypotension. Review of the Minimum Data Set (MDS), dated [DATE], R404 had a BIMS (Brief Interview for Mental Status of 14 (cognitively intact), required two person assist with…

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

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 129 residents who receive meal services (7 nothing by mouth residents, or NPO) out of the facility's total census of 136 residents. Findings include: On 4/30/24 at 8:16 AM, at 8:32 AM and at 9:05 AM, Dietary aide, staff C, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 4/30/24 at 8:44 AM, the surveyor requested the facility's hand hygiene policy from Dietary Manager, staff A, to review. At this time the surveyor asked staff A if they had conducted any trainings with staff on the proper procedure to wash their hands to which they stated, yes, upon hire and with the normal reminders every so often. On 4/30/24 at 9:12 AM, Dietary Manager, staff A, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 4/30/24 at 9:37 AM, and at 10:08 AM,…

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

This citation pertains to intake MI00135948. Based on observation, interview and record review the facility failed to post the appropriate directions for isolation care for one resident (R32) of nine residents reviewed for infection control. Findings include: On 4/30/24 at 10:52 AM during observation of R32's door and room it was noted there was a sign hung titled Enhanced Barrier Precautions and with directions for cleansing of hands and for PPE (Personal Protective Equipment) use for anyone providing high-contact resident care activities. On 4/30/24 at 10:54 AM during interview R32 mentioned being in isolation for C, Diff. (Clostridium Difficile is a contagious infection of the large intestine.) According to record review R32's admission date was 4/6/24 and according to a MDS (Minimum Data Set) dated 4/6/24 has a BIMS (Brief Interview for Mental Status) score of 14 indicating intact cognition. On 4/30/24 at 11:15 AM further record review revealed a current physician's order which stated, Contact Isolation. R32 had an order for Vancomycin (an antibiotic) for treatment 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.

Based on observation, interview, and record review the facility failed to ensure dignity for four residents (R15, R87, R88, and R90) out of 64 residents reviewed for resident rights on unit 200. Findings include: On 4/30/24 at 9:00 A.M. residents on the 200 unit were observed with assorted plastic ware and styrofoam containers. Resident's who ate their meals in their rooms were observed with domes that were not positioned correctly on the entrée items or their food was not covered or protected while being transported from the kitchenette to their rooms. A random observation was conducted during the breakfast and lunch service on the 200 unit. Residents were interviewed concerning the meal experience and the use of plastic ware, Styrofoam plates, and containers. R15 At approximately 9:30 A.M., R15 was observed with assorted plastic ware. The resident was queried about the food service. R15 held up the plastic spoon and responded they gave me this plastic ware; I don't know what I am supposed to use it for. Why can't we get regular silverware like the others? They deliver our food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure nail care and provide appropriate briefs for incontinence care for four residents (R7, R15, R25, and R128) of 10 reviewed for activities of daily living for dependent residents, resulting in unmet hygiene needs and residnets being left soiled for extended periods of time. Findings include: R128 On 4/30/24 at 8:14 a.m. R128 was observed in bed resting. R128 was also observed with scratches on the face (left cheek, forehead, and nose). The resident was asked about the scratches to the face. The resident confirmed the scratches were self-inflicted by accident. R128 was observed with long fingernails (estimated quarter inch long) that appeared to have what looked like dried substance (reddish brown in color) and debris underneath them. R128 stated, They don't cut them unless I ask. I need to get them cut. The resident also confirmed nails are supposed to get cleaned and cut during showers which are once a week per request. On 4/30/24 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.

This citation pertains to intake MI00142960. Based on observation, interview and record review the facility failed to ensure meals were served at a preferred and palatable temperature for four sampled residents (R15, R25, R88 and R90) from a total of 64 residents on the 200 unit, resulting in complaints of cold food and dissatisfaction with meals. Findings include: On 4/30/24 at 9:48 A.M. during a breakfast meal observation residents on the 200 unit were asked about the food. R15, R25, R88 and R90 voiced concerns that their meals were delivered to their rooms and the meals were always cold. During the meal observation entrees were observed delivered from the unit kitchen to residents' rooms without domes or coverings. On 4/30/24 at 9:50 A.M., R15 stated, My Food is always cold. It does not matter what food is served or the meal. The resident explained there was no place to have meals reheated or warmed and other residents had expressed to her the same concern about the food. On 4/30/24 at 9:55 A.M. R88 was asked how was the food? R88 responded the meals were served cold and…

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

Based on observation and interview the facility failed to ensure that the garbage storage area was maintained in sanitary conditions resulting in an increased potential for the harborage and feeding of pests. Findings include: On 4/30/24 at 2:18 PM, during a tour of the facility with Environmental Services Director, staff B, the exterior trash dumpsters were observed with lids in the open position, along with a variety of bagged trash and debris in this area. At this time the surveyor inquired with staff B on the current state of the area to which they replied, we can do better. At this time the surveyor asked staff B if the facility had a waste disposal policy to review to which they stated, not that I know of, but I can post a sign to remind people to keep the lids and doors shut. On 5/1/24 at 10:07 AM, during a tour of the facility with Dietary Manager, staff A, the exterior trash dumpsters were observed with lids in the open position, along with a variety of bagged trash and debris in the area. At this time the surveyor inquired with staff A on the current state of the area 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.

Based on observation, interview, and record review the facility failed to ensure confidentiality of resident's electronic medical records for two residents (R4 and R55) out of six residents reviewed for privacy. Findings Include: During an observation on 4/30/24 at 6:30 AM on Station Two, R55's electronic medical record was visible on short hall medication cart computer screen with no nurse in attendance, with the potential for any passerby to see R55's confidential information. Record review R55's electronic medical record revealed admittance into the facility on 1/24/24 with a diagnosis of debility. During an observation on 5/2/24 at 8:45 AM on Station Three, R4's electronic medical record was visible on short hall medication cart computer screen with no nurse in attendance, with the potential for any passerby to see R4's confidential information. It was observed that there were approximately 10 residents in area at the time of observation. Record review R4's electronic medical record revealed admittance into the facility on 4/21/22 with a diagnosis of end stage renal failure.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a clean and clutter free homelike environment for two residents (R27 and R88) resulting in soiled and cluttered resident rooms. Finding include: R27 Review of the Electronic Medical Record (EMR) revealed, R27 admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness, and history of falls. Review of a Minimum Data Set (MDS) assessment, with a reference date of 5/1/2024 revealed R27 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15. On 4/30/24 at 10 AM R27's room curtain divider was observed soiled with a red stain approximately six by eight inches and a blue fall mat folded in half stored at foot of the bed appeared soiled with numerous cracks in the covering of the mat. When asked how long your bed divider curtain has been stained R27 replied, for a while now. On 5/01/24 at 12:05 PM R27's room curtain divider 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 interview, and record review, the facility failed to ensure the Preadmission Screening/ Annual Resident Review (PASSAR) forms for Mental Illness/ Intellectual Disability/ Related Conditions Identification (DCH-3877) documents were reviewed, revised, and sent to the local state agency for annual evaluation for a Level II determination for two (R7 and R31) of eight residents reviewed for PASSARs, resulting in the potential for unmet psychosocial care needs. Findings include: R7 A review of R7's electronic medical record (EMR) did not reveal a Level ll evaluation. There was not a Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification (DCH-3878) form. (The DCH-3878 is a State of Michigan Department of Health and Human Services (MDHHS) form used to claim exemption for level ll screening). R7 was admitted to facility on 5/25/2018 with most recent readmission on [DATE] with pertinent diagnoses of major depressive disorder, anxiety disorder, and bipolar 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.

Based on observation, interview, and record review the facility failed to provide supervision for two unlocked medication carts out of 9 medication carts. Findings include: During an observation on 4/30/24 at 6:30 AM on Station Two, a medication cart for short hall was seen unlocked and no nursing staff in attendance. Medications drawers could be accessed. During an observation on 5/2/24 at 8:45 AM on Station Three, an unlocked medication cart for short hall was seen with medications on top of the cart. This area had approximately 10 residents during the time of the observation. During an interview on 5/2/24 at 8:50 AM with Unit Manager (UM) L, it was reported that medication carts should be locked, and medications should not be left on top of medication carts when a nurse is not in attendance. It was further reported that there could be the potential for residents to ingest medications accidentally. During an interview on 5/2/24 at 1:30 PM with the Director of Nursing, it was reported that all medications carts should be locked when the nurse is not in attendance. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the foley catheter tubing (a flexible tube for draining urine from the bladder) did not drag along the floor during ambulation in a wheelchair for one (R133) of four residents reviewed for catheter/UTI (urinary tract infection). Findings include: On 4/30/24 at 8:28 a.m. R133 was observed in the dining area of station two, sitting in a wheelchair at the dining table. R133 was observed to have a catheter as evidenced by the catheter tube was on the floor. A staff member came to the dining table, adjusted the catheter bag, but did not adjust the tube that remained on the floor. On 4/30/24 at 9:59 a.m. R133 was observed wheeling independently through the hall of station two with the catheter tubing dragging on the floor. The tubing was observed very close to the front wheel of the wheelchair, placing the tubing at risk to get trapped under the wheel. On 5/03/24 at 11:42 a.m. review of the clinical record documented R133 was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00137764. Based on interview and record review the facility failed to implement a skin care plan upon admission to facility for one resident (R250) out of 37 residents reviewed for care plans. Findings Include: Record review of R250's electronic medical records revealed admission into the facility on 5/26/23 with a pertinent diagnosis of discitis (inflammation of discs) of vertebra (spine). According to the Minimum Data Set (MDS) dated [DATE], R250 had intact cognition and review of Section G of MDS revealed resident was extensive assist with bed mobility and transfers. Record review of admission Assessment dated 5/26/23, R250 had redness to bilateral buttocks documented under skin integrity. Record review of Braden Scale (assessment for potential skin breakdown) dated 5/26/23, R250 scored 13/23 resulting in moderate risk for skin breakdown. Record review of R250's care plans revealed no at-risk base line skin care plan implemented on or during admission to the facility. During…

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 prepare meals in a clean and sanitary environment resulting in the potential for food-borne illness. This deficient practice has the potential to affect all residents that consume food from the facility kitchens. Findings include: On 3/19/23 at 8:50 AM upon entry of the kitchen for inspection there was only one staff member present [NAME] AA. [NAME] AA explained that there were a number of tasks to complete in preparation for the lunch meal but [NAME] AA would be available for any questions are concerns regarding the inspection. During the inspection the following was observed: While performing hand hygiene, the hand sink closest to the entry was the eye injury sink. The silver knobs were observed to be have a white-colored film and felt slimy and slippery to touch. A pool of water approximately 3 feet by 2 feet was observed on the floor next to the dish machine. On the base of the dish machine there was green and white colored sediment which did not easily wipe away. This was later identified by the Food…

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

Based on observation and interview the facility failed to maintain the kitchen dish machine in working condition. This had the potential to affect all residents who consumed food from the kitchen. Findings include: On 3/19/23 at approximately 9:00 AM, inspection of the kitchen revealed a pool of water approximately 3 feet by 2 feet on the floor next to the dish machine. On the base of the dish machine there was green and white colored sediment which did not easily wipe away. On 3/19/23 at approximately 10:00 AM, during observation and interview, the Food Service Director (FSD) acknowledged that the dish machine was in need of repair and that lime had accumulated on the dish machine. The FSD explained that a new dish machine had arrived. However, the new dish machine had arrived and was also in need of repair. On 3/28/23 at approximately 10 AM, the The Food Service Director acknowledged the pooled water underneath and next to the dish machine and explained the main kitchen dish machine is in disrepair. A work order or receipt was requested to demonstrate attempts at working to repair…

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 honor mealtime preferences for five out of five anonymous residents (attending resident council meeting) and one other resident (#113), resulting in expressed feelings of discontent with meal service. Findings include: A resident group meeting was held on 3/20/2023 at 1:30 PM with five residents, all of whom were alert and oriented and able to express themselves. When queried about meal service, all five residents verbalized displeasure that the beginning of dinner service was changed from 5:00 PM to 6:00 PM. The group attendees said many other residents agree with them. The group attendees said starting dinner at 6:00 PM interferes with other activities such toileting, showers, and bedtimes. The group attendees said their concerns regarding the dinner mealtime change was discussed with the Nursing Home Administrator (NHA) during the February 2023 Resident Council meeting. A review of a facility provided document titled, Resident Council Minutes, dated 2/15/2023, revealed the NHA attended the meeting but 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 observation, interview, and record review the facility failed to train an employee on testing the dish machine to ensure sanitation resulting in the potential for food-borne illness. This deficient practice had the potential to affect all residents who consumed food from the kitchen. Findings include: On 3/19/23 at approximately 9:00 AM, Dietary Aid BB was observed to use the dish machine to clean pots and pans and stored them on a rack in the kitchen. Dietary Aid BB was asked how to ensure the dish machine was in proper working condition and stated, The cook does it. Normally I'm on nights. I don't know how to run it (to ensure sanitation). At this time, Chef CC entered the kitchen and was queried regarding the dish machine. Chef CC explained the dish machine sanitized dishware by meeting the temperature of 160 degrees. Chef CC used a temperature disc to test the dish machine. The temperatures reached 145°F (Fahrenheit), 141.9°F, and 145.9°F. Chef CC explained that the dishware that was ran through the dish machine by Dietary Aid BB were not sanitized and stated, We will…

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 serve food at appropriate temperatures, resulting in dissatisfaction with food served from the sub-kitchens. This deficient practice has the potential to affect all residents who consume food from the facility kitchens. Findings include: On 3/19/23 beginning at approximately 10:50 AM the unit kitchens were inspected: Food temperatures were taken with DA (Dietary Aide) EE at 12:55 PM and yielded the following: ground turkey was 129ºF (Fahrenheit) and (green) peas was 130ºF. Food temperatures were taken with DA DD at 1:35 PM and yielded the following: scalloped potatoes was 110 ºF , mechanical/ground turkey was 97.8 ºF, and green peas was 114 ºF. On 3/20/23 at approximately 9 AM, during an observation of meal tray delivery, staff were overheard to hold the meat and eggs for the puree meal. This was requested by two unidentified staff. DA FF explained that the 4-5 residents who received a puree breakfast meal only wanted the oatmeal. When asked was protein part of the meal offered DA EE explained it was but the residents did 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.

Based on interview and record review, the facility failed to ensure an evening snack was consistently offered to five of five residents who attended the resident group meeting and one other resident (#113), resulting in resident dissatisfaction and the potential for unmet resident nutritional needs. Findings include: A resident group meeting was held on 3/20/2023 at 1:30 PM with five residents, all of whom were alert, oriented, and able to express themselves. When queried about evening snacks, all five residents said that anonymity regarding their answers was not necessary. The following resident responses were given to the question, Are you offered snacks at bedtime?: - Resident #30, No. I have my own. The reason we have our own snacks is because they don't offer us one. - Resident #47, No. - Resident #93, No. I have my own. - Resident #7, I ask for a snack and get it. Resident #7 said she receives ice cream. - Resident #39, I'm never offered a snack. During an observation and interview on 3/27/2023 at 3:35 PM, Concerned Family Member (CFM) for Resident #113 (R113) and R113 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 resident's personal belongings were inventoried and accounted for, affecting one resident (#12), of three residents reviewed for dignity, resulting in the potential for missing/unaccounted for items and resident dissatisfaction. Findings include: During an interview on 3/29/2023 at 3:40 PM, Resident #12 (R12) and a concerned family member (CFM) reported the following items had come up missing from R12's room: pants, clock, sweater, body lotion, toothbrush, shampoo, and hand lotion. The CFM said clothes have come up missing even though the family does R12's laundry. A review of the admission Record for R12 documented an admission to the facility on 9/25/2022 with diagnoses that included bladder cancer, chronic kidney disease, and diabetes mellitus-type 2. A Minimum Data Set assessment dated [DATE] documented intact cognition and one person extensive physical assistance for dressing and personal hygiene. During an interview on 3/29/2023 at 11:13…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop an individualized comprehensive hemodialysis care plan for one resident (#27) out of four residents reviewed for dialysis, resulting in the potential for unmet care needs related to end stage renal disease. Findings include: On 3/19/2023 at 2:17 PM, Resident #27 (R27) was observed awake and lying in his bed. R27 said last month the power went out in the facility which caused some interruption in his care. A review of the admission Record for Resident #27 (R27) documented an initial admission date of 9/26/2022 and readmission date of 2/7/2023. R27's diagnoses included end stage renal disease, diabetes mellitus-type 2, and chronic obstructive pulmonary disease. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of R27's electronic health record documented the following: - Physician orders documented in part: In house dialysis (company name). Dialysis Days: M.W.F (Monday, Wednesday, Friday) - Progress note dated…

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 MI00131944. Based on interview and record review, the facility failed to obtain an x-ray in a timely manner for one resident (#291) of nine residents reviewed for accidents, resulting in an unidentified fracture. Findings include: Review of an admission record revealed, Resident #291 (R291) admitted to the facility on [DATE] with pertinent diagnosis which included Displaced Intertrochanteric Fracture of Left Femur, Dementia, Alzheimer's Disease with Late Onset, and Fracture of part of neck of left femur. Review of a Minimum Data Set (MDS) assessment, with a reference date of 8/16/22 revealed R291 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 1 out of 15. Review of a progress note with a date of 8/23/22 at 11:30 p.m. revealed, Incident Note Objective Description : Writer and CNA (Certified Nursing Assistant) found guest on floor. Guest was on the floor by the bathroom floor, guest laying on right hip .Guest given Norco as ordered . (sic) Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that wound care treatments for pressure ulcers (damage to skin from prolonged pressure to skin) were consistently provided for one resident (#2) of seven residents reviewed for wound care, resulting in the potential for worsening of pressure ulcers. Findings include: Review of an admission record revealed, Resident #2 (R2) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included Pressure Ulcer of Sacral region Stage 4 (a wound with muscle, bones, or tendons that are visible) and Vascular Dementia. Review of a Minimum Data Set (MDS) assessment, with a reference date of 2/8/23 revealed R2 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 7 out of 15. Review of Physician orders for R2 revealed: -Cleanse sacral ulcer with wound cleanser, pat dry, apply silvasorb gel (used to promote wound healing), cover with dry dressing, check daily, change every other day and prn (as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure catheter tubing and catheter privacy bags were off the floor for two residents (#78, #108) and catheter tubing was properly positioned and secured for one resident (#78), out of two residents reviewed for urinary catheters, resulting in resident discomfort, the potential for additional discomfort due to excessive tension and pulling, and the potential for the introduction of infectious microorganisms to the bladder. Findings include: During an observation on 3/27/2023 at 3:27 PM, Resident #78 (R78) and Resident #108 (R108) were sitting in their wheelchairs in the large dining room watching television. The catheter tubing and privacy bags for both R78 and R108 were observed lying on the floor. On 3/27/2023 at 3:44 PM, Activity Director T was observed taking R108 from the dining room towards his residential unit. R108's catheter tubing and privacy bag were dragging along the floor during the transportation. Particles of dust had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess the effectiveness of a breathing treatment and to maintain, change, and store oxygen tubing for two (#10, #62) of two residents reviewed for respiratory care, resulting in the potential for respiratory infections, respiratory distress, and exacerbation (worsening of a disease) of respiratory conditions. Findings include: Resident #10 In an observation on 3/19/23 at 10:58 a.m., Resident #10 (R10) had on a nasal cannula and received oxygen. The tubing had a date of 3/2/23. A nebulizer machine (breathing treatment) sat on R10's bedside stand. The mask tubing had a date of 3/2/23. The mask laid in a basin and not in a bag. Review of an admission record revealed, R10 admitted to the facility on [DATE] with pertinent diagnosis which included Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia (absence of oxygen), and Dependence on supplemental oxygen. Review of a Minimum Data Set (MDS) assessment, with a…

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