Optalis Health & Rehabilitation of Wyoming

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2665891Based on observation, interview, and record review, the facility failed to follow professional guidelines for two of two resident's (resident #72 and Resident #91) reviewed for peripheral and central intravenous fluids. Findings:Resident #72 (R72)Review of an admission Record revealed R72 was a [AGE] year-old female, originally admitted to the facility on [DATE] with pertinent diagnoses of a right femur fracture. R72 was most recently hospitalized on [DATE] to 12/10/25 for an infected prosthesis in the right femur and had a central catheter placed to receive intravenous antibiotics. During an observation on 01/05/26 at 11:30 AM, R72 sat in a chair with an IV (intravenous) antibiotic hanging on an IV pole and the antibiotic was connected to a PICC (percutaneously inserted central catheter) in R72's right arm. R72 stated that the tubing that delivered the antibiotic fluid to the PICC was stuck inside the lumen (opening) of the PICC and nursing could not get it out. They…

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 account for controlled substances in one of one medication carts reviewed for narcotic reconciliation. Findings:Review of the Controlled Medication Shift Change Log for the medication cart Medbridge 1 revealed an incorrect total was documented on 1/3/26 at 7:30 AM. That incorrect total was carried forward through the next four shift change counts. Review of the Controlled Substance Shift Inventory sheets for the medication cart Medbridge 1 dated 11/22/25 to 12/30/25 revealed the following:Two nurses' signatures were not documented on (a) 11/25 at the 7 PM count, (b) 11/30 at the 7 AM count, (c) 12/04 at the 3 PM count, (d) 12/8 at the 3 PM count 12/16 at the 7 PM count, and on 12/19 at the 7 AM count. An end of shift total was not documented on (a) 11/25 at 11:15 PM, (b) 11/29 at 7 AM, (c) 12/1/ at 3 PM, (d) 12/3 at 7 PM, (e) 12/4 at 3 PM, (f) 12/10 at 7 PM, and (g) 12/11/ at 7 AM. Incorrect counts were noted on (a) 11/22 at 7 PM, (b) 11/28 at 7 PM, (c) 12/1 at 7 PM, (d) 12/2 at 7 AM, (e) 12/18 at 7 am, and (f) 12/29 at 7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 1) implement an effective and current system of surveillance of staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak, 2.) ensure appropriate personal protective equipment (PPE) for a resident in contact precautions, and 3.) ensure residents at risk of MDRO (multi-drug resistant organisms) acquisition were placed in enhanced barrier precautions for 3 residents (Resident #36, #58, and #40) out of 18 residents reviewed for infection prevention and control.Findings: Review of the December Employee Illness Log revealed: Certified Nursing Assistant (CNA) OO called off of work with an onset date of 12/4/25 for the reason of just said not feeling well. There was no documentation of specific symptoms or a return to work date. CNA LL called off of work with an onset date of 12/26/25 for the reason of none listed. There was no documentation of specific symptoms or a return to work date. CNA MM…

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 general cleanliness and repair of ceilings and ventilation covers of resident restrooms 11, 12 and 13. Findings Include:On 01/15/2026 at 2:00PM, observed cobwebs on the vent's cover in the restrooms for rooms 11,12,13. Record review of Healthcare Services Group, Housekeeping schedule, states, Cleaning resident rooms using the 5 and 7 step cleaning process. The 5 and 7 step cleaning process lists what needs to be cleaned and cleaning methods for those steps, such as horizontal surfaces, vertical surfaces, dust mop and damp mop. On 1/05/2025 at 2:00PM, observed in room [ROOM NUMBER]'s restroom, the ceiling tile is sagging and partially off the ceiling grid tracks allowing for an accessible space of half inch between the tile and the track. On 01/05/2026 at 3:15PM, interview with Maintenance CC disclosed they were unaware of the ceiling tile sagging in room [ROOM NUMBER]'s restroom.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation is related to intake #2674209Based on interview and record review, the facility failed to treat one resident (Resident # 72) in a dignified manner, out of three residents reviewed for dignity and respect. Findings: Resident #72 (R72) Review of an admission Record revealed R72 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses of an infected right hip replacement and difficulty walking. During an interview on 01/05/26 at 11:26 AM, R72 reported the following details regarding an incident that occurred very early in the morning on 11/12/25, that involved R72 and Certified Nurse Aide (CNA) Y: (a) during the night/early morning of 11/12/25 CNA Y came into her room and told R72 to stop putting on her call light and that CNA Y had been into R72's room multiple times tonight and was not coming back again, (b) R72 stated that CNA Y then messed around with her bed control and call light and left the room, (c) R72 fell back asleep, woke up sometime around 5 AM and needed to go 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 observation, interview, and record review, the facility failed to ensure call lights remained within reach for three of three resident's (Resident #43, Resident #93, and Resident #10) reviewed for accommodation of needs. Findings:Resident #43 (R43)Review of an admission Record revealed R43 was an [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of a stroke that caused left sided weakness and paralysis, a history of falls, and lack of coordination. During an observation on 01/05/26 at 8:58 AM, R43 laid in bed with her eyes open. When asked if she could locate her call light, R43 looked around her bed and stated that she could not find it. The call light sat on the floor under the head of the bed, out of sight and out of reach of R43. During an observation on 01/05/26 at 10:57 AM, R43's call light remained on the floor under the head of the bed, out of sight and out of reach. During an observation on 01/05/26 at 12:01 PM, R43's call light laid on the floor under 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 #: 2664254Based on interview and record review, the facility failed to notify the provider of 1.) a change in condition and 2.) abnormal vital signs for 2 of 18 residents (Resident #90 and #81) reviewed for notification of change.Findings:Resident #90 (R90)Review of an admission Record revealed R90 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: type 1 diabetes mellitus with hyperglycemia.Review of a Facility Reported Incident (FRI) dated 9/17/25 revealed, (Hospital) patient navigator emailed facility to inform us that (R90) alleged he was being abused at our facility regarding his insulin management.Review of R90's Order Summary dated 8/6/25 revealed, Obtain Blood Sugar before meals and at bedtime before meals and at bedtime for blood glucose monitoring Less than 60 or greater than 200, notify physician.Review of R90's Blood Sugar Summary revealed:On 8/11/2025 at 9:49 PM, R90's blood sugar was 533 On 8/11/2025 at 10:50 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #: 2641157Based on interview and record review, the facility failed to 1.) prevent misappropriation of resident medication and 2.) monitor and investigate the potential/ongoing misappropriation of resident narcotic medication for 2 residents (Resident #38 and #41) out of 7 residents reviewed for the misappropriation of medications, resulting in the diversion of medications and the potential for ongoing diversion of medications. Findings:Resident #38 (R38)Review of an admission Record revealed R38 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: type 2 diabetes.Review of R38's Facility Reported Incident (FRI) dated 10/29/25 revealed, .Verified The allegation was supported by evidence collected during the investigation.On 10/28/25 (Registered Nurse [RN] GG) accepted the Ozempic from the pharmacy at 11:30pm and had it in her possession. She received the medication from pharmacy then attempted to get (Licensed Practical Nurse…

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 adequately monitor and ensure residents were free from adverse drug reactions for 1 of 5 residents (Resident #41) reviewed for psychotropic medication use.Findings:Resident #41 (R41)Review of an admission Record revealed R41 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Bipolar II Disorder, Schizoaffective Disorder, and Schizophrenia.Review of the FDA (Food and Drug Administration) recommended ANC (absolute neutrophil count) monitoring frequency for Clozaril (clozapine) (last revised 7/21/25) revealed, ANC Level Treatment Recommendation ANC Monitoring Weekly from initiation to 6 months Every 2 weeks from 6-12 months Monthly after 12 months(See reference below)Review of R41's Order Summary dated 10/10/24 revealed, cloZAPine Oral Tablet 100 MG and cloZAPine Tablet 50 MG (Clozaril) Give 100mg by mouth three times a day for schizophrenia hs (bedtime) dose is taken with 50mg to equal 150mg.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 observation, interview, and record review, the facility failed to update a care plan for 1 of 18 sampled residents (R40). Findings include: A review R40's admission Record, dated 1/6/26, revealed R40 was a [AGE] year-old resident that was admitted to the facility on [DATE]. In addition, R40's admission Record revealed multiple diagnoses that included contacted with and suspected exposure to COVID-19. A review of a sign posted onto the outside of R40's door on 01/06/2026 at 8:45 AM, revealed R40 was in isolation and Special Droplet Contact Precautions (gown, gloves, face shield, and N95 respirator) were to be followed for anyone entering R40's room. During an interview on 01/06/2026 at 8:55 AM, Certified Nursing Assistant (CNA) B verified that R40 was in isolation and Special Droplet Contact Precautions were to be followed for anyone entering R40's room. CNA B also stated R40 was in isolation for COVID-19. A review of R40's Provider encounter note, dated 12/20/25, revealed, Patient is seen for COVID-19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that weights were obtained in accordance with physician orders for 3 of 5 residents (Resident #11, #23, and #55), reviewed for the provision of nursing services.Findings:Resident #11 (R11)Review of an admission Record revealed R11 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: edema.Review of R11's Order Summary dated 8/2/25 revealed, Monitor Weight WEEKLY every day shift every Mon for edema.Review of R11's Weight Summary summary revealed:11/4/2025 228.2 lbs11/10/2025 229.1 lbs11/17/2025 230.6 lbs12/8/2025 229.4 lbs1/5/2026 229.6 lbsReview of R11's November-January Medication Administration Record (MAR) revealed:No weight was obtained on 11/3/25 and the MAR was left blank.On 11/4/25 a weight of 228.2 lbs was documented in the Weight Summary.On 11/10/25 the weight of 228.2 lbs was documented in the MAR despite a weight of 229.1 lbs obtained on that date.On 11/17/2025 a weight of 230.6 lbs…

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 initiate bowel protocol for one of two resident's (Resident #43) reviewed for constipation. Findings:Resident #43 (R43) Review of an admission Record revealed R43 was an [AGE] year-old female who last admitted to the facility on [DATE], with pertinent diagnoses of dementia. During an interview on 01/05/26 at 12:19 PM, R43 reported constipation in the past month or so and could not recall if she had received any medications to help relieve the constipation. Review of Bowel and Bladder-Bowel Elimination Task Monitoring (a document that tracks when the resident has had a bowel movement) for R43 revealed R43 had a bowel movement on 12/10/25 in the afternoon. The next bowel movement was documented on 12/20/25 in the evening (10 days later). Review of an Electronic Medication Administration Record (Emar) for R43, dated December 2025, revealed the following order for medication to be given for constipation as needed: (1) Milk of Magnesium 2400 milligrams/30…

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 implement physician-approved pharmacy recommendations for 1 of 5 residents (R60) review for monthly medication regimen reviews. Findings include: A review of R60's admission Record, dated 1/8/26, revealed R60 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included dementia, post-traumatic stress disorder (PTSD), and chronic pain. A review of R60's Consultant Pharmacist Recommendation to Prescriber, dated 12/25/25, revealed the pharmacist noted that R60 had an order for Voltaren Gel (diclofenac sodium- a medication for knee pain). However, the pharmacist noted that there was not a specified quantity to be used for each dose and recommended that the physician write an order specifying the quantity (e.g., 4 grams) to be used with each dose with a maximum amount (e.g., 32 grams per joint per day) included per joint and per day. The physician agreed with the recommendation on 12/22/25. A review of R60'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 interview and record review, the facility failed to adequately monitor vital signs and ensure medications were administered in accordance with physician orders for 2 residents (Residents #6 and #10) out of 18 residents reviewed for unnecessary medication.Findings:Resident #6 (R6)Review of an admission Record revealed R6 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: heart disease and heart failure.Review of R6's Order Summary dated 7/29/25 revealed, Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 1 tablet via G-Tube three times a day for dialysis patient Do not give too early, just before leaving for HD (hemodialysis)/hold for SBP >120 (systolic blood pressure [top number] greater than 120). To be administered at 9:00 AM, 1:00 PM, and 9:00 PM.Review of R6's Blood Pressure Summary and January Medication Administration Record revealed:On 1/1/26 R6's blood pressure was last assessed at 1:11 PM. No blood pressure was assessed prior to the 9:00…

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 laboratory tests were completed and laboratory results were obtained for 3 of 18 residents (Resident #81, #101 and #10) reviewed for laboratory services.Findings:Resident #81 (R81) Review of an admission Record revealed R81 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: heart disease and presence of cardiac pacemaker. Review of R81's Order Summary dated 12/13/25 revealed: Coumadin (Warfarin Sodium) Give 5 mg by mouth one time a day every Mon, Wed, Thu, Fri, Sun for anticoagulation ENSURE COUMADIN FLOWSHEET IS ACTIVE IN ASSESSMENTS AND Coumadin Tablet (Warfarin Sodium) Give 2.5 mg by mouth one time a day every Tue, Sat for anticoagulation ENSURE COUMADIN FLOWSHEET IS ACTIVE IN ASSESSMENTS Review of R81's Electronic Medical Record revealed no Coumadin Flowsheet (used to track, trend, and monitor PT/INR [bloodwork] results for medication management.) Review of R81's Care Plan revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation refers to Intake 2643393. Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 18 sampled residents (R74). Findings include: A review of R74's admission Record, dated 1/7/26, revealed R74 was an [AGE] year-old that was admitted to the facility on [DATE]. In addition, R74's admission Record revealed multiple diagnoses that included dementia with agitation and psychotic disturbance, anxiety, and bipolar disorder. A review of R74's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 11/22/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R74 was cognitively intact. A review of the facility's investigation report, dated 9/30/25, revealed on 9/23/25 at 11:00 AM, the Nursing Home Administrator (NHA) was notified by a nurse aide that R74 alleged he was yelled at by Certified Nursing Assistant (CNA) G a few days ago and it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the antibiotic stewardship program for 2 of 7 residents (Resident #25 and #81) reviewed for antibiotic use.Findings:Resident #25 (R25)Review of an admission Record revealed R52 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: acute kidney failure.Review of a provider Progress Note dated 12/15/25 revealed, Patient is seen for cloudy malodorous urine, she denies dysuria (pain/discomfort with urination), urine is in bed pan in bathroom for me to visualize. meds rev (medications reviewed) vss (vital signs stable). Patient w/o (without) fever or chills.Plan: will check UA (urinalysis) with c/s (culture and sensitivity) if indicated, malodorous urine, cloudy in nature, patient mildly lethargic this am per staff, not at her baseline. No other diagnostic studies were ordered (bloodwork).Review of R25's Electronic Medical Record revealed no documented symptoms of a UTI outside of the provider'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.

This citation pertains to intake 2640739Based on observation, interview, and record review, the facility failed to thoroughly investigate an allegation of neglect for one resident (R1) out of four residents reviewed for abuse and neglect.Findings include:Review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 9/30/25 reflected, Incident Summary - Nurse reported to administrator that an outside door was alarming, and staff noticed resident (R1) was not in his room. Staff began searching and found him outside in facility parking lot. Resident was immediately brought back into the facility. No obvious injury observed. Resident was smiling. Head to toe assessment and 15-minute checks implemented. Investigation initiated.During an observation beginning at 9:29 AM on 10/21/2025 with Unit Manager/Licensed Practical Nurse (LPN) A it was discovered the list of residents at risk for elopement was not accurate as evidenced by a resident's room number for one resident who was at risk for elopement and wore a wander alert device was not correct on the audit sheet…

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 2640739Based on interview and record review, the facility failed to review and revise care plans for 3 residents (R1, R2, & R4) out of four residents reviewed for care planning. Findings Include:Resident #1 (R1)Review of a facility admission Record reflected R1 admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis following cerebral infarction, vascular dementia, muscle weakness, lack of coordination, and unspecified abnormalities of gait and mobility.Review of a General Progress Note dated 6/8/2025 reflected R1 had a hospital LOA (leave of absence) in order to have a MRI magnetic resonance imaging, and the hospital called, . asking if it would be OK to remove the patient's wander guard (a wearable sensor device used to trigger an alarm when a resident attempts to elope/exits a door equipped with a wander alert system) nurse stated to unsnap wander guard's strap and when done doing MRI to place back on patient as patient will need this when he…

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 2640739 Based on observation, interview, and record review, the facility failed to fully implement policy and procedure to prevent elopements and appropriately respond to an elopement incident for one resident (R1) out of four residents reviewed for elopement. Findings include:Review of a facility admission Record reflected R1 admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis following cerebral infarction, vascular dementia, muscle weakness, lack of coordination, and unspecified abnormalities of gait and mobility.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R1 was severely cognitively impaired as evidenced by a brief interview for mental status score of 6/15. The assessment indicated R1 was dependent on staff for lower body dressing and putting on and taking off footwear and required substantial to maximal assistance for upper body dressing. Review of a facility reported incident submitted to the state…

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 only trained staff paused and restarted enteral feeding (feeding directly into the gastrointestinal tract through a tube) for 1 resident (R102) of 4 residents reviewed for nursing services. Findings include: Review of an admission Record revealed R102 admitted to the facility on [DATE] with pertinent diagnoses which included esophageal cancer and esophageal obstruction. Review of R102's Physician's Orders active 2/4/2025 revealed he received enteral feeding. In a telephone interview on 5/27/2025 at 12:05 PM, former Certified Nursing Assistant (CNA) H reported late the evening of 2/3/2025 or early the morning of 2/4/2025 she provided care to R102. CNA H reported she paused his tube feeding prior to providing care and then restarted the tube feeding after care was completed. In an interview on 12/27/2025 at 12:30 PM, the Director of Nursing (DON) reported CNAs were not trained to pause and restart tube feeding. In a telephone interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00148807 Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for one of five residents (Resident #305 and the resident residing in bed 104-A) reviewed for accommodation of needs. Findings: Resident #305 (R305) Review of an admission Record revealed R305 was a [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of dementia, unsteadiness on her feet, cognitive communication deficit, and lack of coordination. R305 required assistance from at least one staff person for transfers, bed mobility, going to the bathroom, and getting cleaned up each day. During an observation on 01/14/25 at 9:46 AM, R305 sat in bed with eyes open and the call light laid on the floor under the bed, out of sight and out of reach of the resident. When asked how she would alert staff if she had any needs, R305 stated that she does everything for herself and would just do it. During an observation on 01/14/25 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 to intake #MI00148807 Based on interview and record review, the facility failed to adhere to professional standards for one of three residents (Resident #307) reviewed for medication administration of narcotics. Findings: Resident #307 (R307) Review of an admission Record revealed R307 was a [AGE] year-old male, last admitted to the facility on [DATE], with pertinent diagnoses of seizure disorder, frequent falls, weakness, and unsteadiness on his feet. R307 requires assistance from at least one staff person to get dressed, go to the bathroom, transfer, and bed mobility. Review of a Order Summary for R307 reflected an order for the controlled substance Vimpat (Lacosamide) 50 milligrams (mg) twice daily for seizure disorder. Review of a Control Substance Record for R307 revealed documentation for dates and times the medication Vimpat was given to the resident. The last date and time the medication was given, per this record, was 01/12/25 at 7:00 AM. At that time, the medication had run out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has 2 separate Deficient Practice Statements (DPS) #1 and #2. DPS #1 Based on observation, interview and record review the facility failed to ensure Enhanced Barrier Precautions (EBP) and Contact-Based Precautions were implemented for three residents (R23, R68 and R69) of 80 residents reviewed for infection control and follow policies and procedures for IV (intravenous) administration for 1 (R225) of 1 resident reviewed for IV antibiotics. Findings include: R23 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R23 admitted to the facility on [DATE] with diagnosis of (but not limited to) wound infection, pressure ulcer, diabetes and peripheral vascular disease. Brief Interview for Mental Status (BIMS) reflected a score of 12 out of 15 which represented R23 was cognitively intact. R23 required extensive staff assistance of 1-2 with all activities of daily living. The sign on R23's door reflected Enhanced Barrier Precautions and instructed staff and providers to wear gloves and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform a resident assessment, obtain a physician order for the self-administration of a breathing treatment for 1 (R225) of 4 residents reviewed for medication administration, resulting in a resident self-administering a nebulizer treatment without appropriate supervision and assessments. Findings include: Review of a Face Sheet revealed R225 admitted to the facility on [DATE] with pertinent diagnoses of pneumonitis, heart disease, lack of coordination, and blindness in one eye. During an observation on 10/28/24 at 7:49 AM, R225 was in his room starting a breathing treatment when Registered Nurse (RN) Q walked out of his room. RN Q did not assess R225 before his treatment and when she went back to his room when he finished the treatment, she did not do a post assessment. RN Q reported he received Arformoteral (Brovana) which is a nebulizer treatment. Review of the Medication Administration Record (MAR) for R225 revealed an order started…

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 monitor and assess the use of psychotropic medications for 1 (R19) of 5 residents reviewed for psychotropic medications. Findings include: Review of a policy titled Psychoactive Drug Use adopted 7/11/2018 revealed Purpose: . To ensure that no drug is used in excessive dose, for an excessive duration, or without adequate monitoring, or without adequate indications for its use. Review of a Face Sheet revealed R19 admitted to the facility on [DATE] with pertinent diagnoses of schizoaffective disorder, bipolar disorder, and post-traumatic stress disorder (PTSD). During an observation and an interview on 10/27/24 at 2:36 PM, R19 was in her room sitting at the edge of her bed alone. When asked general questions about her stay at the facility, she was very tearful and intermittently crying then laughed when asked about the food at the facility. Review of the Care Plan for R19 revealed the resident has a behavior concern r/t (related to) PTSD.…

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 label and date mark opened medications, dispose of expired medications, and secure a medication cart in 2 of 3 medication carts reviewed, in a total of 5 medication carts and stored personal belongings in 1 of 2 medication rooms reviewed. Findings include: Review of a medication cart on the 100 hall on 10/30/24 at 11:00 AM revealed the following: -Flex Touch 1000 insulin pen, not opened in the cart but is supposed to refrigerated until ready for use. -A vial of Lantus long-acting insulin did not have a label on the bottle with the resident's name or the date it was opened. - 2 bottles of Systane eye drops not labeled on the bottle with the names and dates it was opened. -Polymyxin antibiotic eye drops not labeled with the name and dates it was opened. -Dorzolamide/Timol eye drops had no open date. In an interview on 10/30/24 at 11:00 AM, Registered Nurse (RN) S reported the Flex Touch 1000 insulin pen should not be in the cart and should have been refrigerated because it was not opened. She reported the eye…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide collaborative hospice care for 2 Residents (R16 and R41) of 2 Residents reviewed for hospice care, resulting in a lack of coordinated care and the potential for care needs to be unmet. Findings included: R16 Review of R16's face sheet dated 10/29/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: multiple sclerosis, encounter for palliative care, and neuromuscular disfunction. R16 was observed in bed on 10/27/24 at 10:10 AM. R16 said she was in hospice care. R16 did not have any schedule in her room that indicated when the hospice staff visited her. R16 was aware the hospice aide came on Wednesdays but said she did not have a set time. R16 did not know when any other hospice staff visited or planned to visit. R16 said the only pain she had was in her left leg. During an interview with facility Social Worker (SW) R on10/29/24 at 9:00 AM, SW R said he does the initial…

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 administer the pneumococcal vaccine to one resident (Resident #29) of 5 residents reviewed for immunizations. Findings include: Review of an admission Record revealed Resident #29 (R29) admitted to the facility on [DATE] with pertinent diagnoses which included heart disease and hypertension. Review of R29's Michigan Care Improvement Registry (a database that consolidates immunization information for individuals in Michigan), dated as reviewed upon admission to the facility on 4/25/2024, revealed R29 was due for the pneumococcal vaccine PCV20 since his admission to the facility. Review of R29's Consent to Administer Pneumococcal Vaccine PCV20 revealed R29 consented to receive PCV20 upon his admission to the facility on 4/24/2024. Review of R29's Electronic Health Record immunization history, active 10/30/2024, revealed R29's pneumococcal status as pending. In an interview on 10/30/2024 at 10:27 AM, the Director of Nursing (DON) reported R29 was due 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 ensure care planned interventions were in place to prevent the worsening of contractures for 1 resident (Resident #11), out of 2 residents reviewed for limited mobility, resulting in the potential for avoidable worsening of contractures. Findings: Resident #11 Review of an admission Record reflected R11 admitted to the facility with diagnosis that included hemiplegia and hemiparesis following cerebral infarct (paralysis and weakness on one side of the body following a stroke), dystonia (abnormal muscle tone and abnormal posture), aphagia (difficulty speaking or understanding other people speaking), contracture (shortening and hardening of the muscles, tendons or other tissues often leading to the deformity and rigidity of joints) of the left elbow, left hip and left ankle. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected that from the time R11 admitted to the facility, R11 was dependent on staff for upper 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 keep essential kitchen equipment in a state of repair that would allow for the machine's operational requirements to be met. This deficient practice has the potential to increase the risk of contamination to items sanitized by the dish machine. During a tour of the kitchen, at 9:25 AM on 10/22/23, observation of the dish machine found that it would only achieve five pounds per square inch (psi) for the final rinse pressure. An interview with Dietary Aide E found that a vendor comes out to check and set up the chemicals but doesn't think anyone regularly services the dish machine. Over the course of running the dish machine another three loads, all observed rinse pressures would show five psi when engaged. A review of the dish machines data plate found that it requires 20 psi +/- 5 psi. During a revisit to the kitchen, at 10:15 AM on 10/22/23, an interview with Maintenance Director D, found that the rinse gauge was not working properly, but the gauge on the underside of the dish machine showed proper temperature and rinse…

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.