The Villa at Parkridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one (R135) of four reviewed.Findings Include: Review of the medical record revealed R135 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. Review of the Social Services Comprehensive Evaluation dated 3/4/26 revealed R135 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 3/3/26 revealed Wound Care (L [left] posterior leg): cleanse [with] normal saline, apply Medihoney (Activon) to wound bed, cover with foam dressing. The wound care was ordered to be completed every evening shift, every other day. On 03/08/2026 at 10:13 AM, R135 was observed sitting on the edge of his bed. R135 reported he had a wound on the back of his left calf, but the facility had not changed the dressing since 3/2/26 or 3/3/26. R135 pulled up his pant leg and a dressing 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 Based on observation, interview and record review the facility failed to prevent misappropriation of resident property for one (Resident #34) of one reviewed.Findings include:Review of the clinical record revealed R34 was admitted into the facility on 2/10/26 with diagnoses that included: difficulty in walking and partial intestinal obstruction. According to the Minimum Data Set (MDS) assessment dated [DATE], R34 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 3/8/26 at 12:24 PM, R34 was observed sitting at the edge of the bed, eating lunch. R34 reported that a staff member entered his room that morning while he was asleep, stated she needed to use his phone charger, removed R34's phone from his charger and plugged her phone in and left it at his bedside. A pink, iPhone was observed to be plugged in and charging at R34's bedside. R34 described the staff member, and it was determined the phone belonged to CNA U. On 3/8/26 at 12:55 PM, during an interview with 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 Based on observation, interview, and record review the facility failed to ensure comprehensive care plans were developed and implemented for three out of 24 residents (Resident #'s 12, 41, & 98). Findings Included: Resident #12: Per the facility face sheet R12 was admitted to the facility on [DATE]. Record review of R12's care plans revealed an active care plan that was in place with a Focus of .antidepressant medication r/t (related to) bipolar, depression. There was an intervention on R12's care plan to, Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt (weight) loss, n/v (nausea/vomiting), dry mouth, dry eyes Dated 6/20/2025. There…

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 an effective and consistent means of communication in one (Resident #98) out of two reviewed. Findings include. Review of the medical record reflected R98 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included apraxia following cerebral infarction (inability to make voluntary movements or gestures even though you have the physical ability and understanding to do so), dysarthria (motor speech disorder where damage to your nervous system causes the muscles that produce speech to become paralyzed or weakened) and weakness/paralysis affecting the right dominant side following a stroke. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/16/26, reflected R98 was rarely or never understood. On 03/08/2026 at 10:28 AM, Resident #98 (R98) was observed in his room wearing only an adult brief, lying flat on his back, heels not elevated off the mattress. R98's room was very warm. R98…

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 activities of daily living, including showers, shaving, grooming, and nail care, were being completed in one (Resident #98) out of two residents reviewed for activities of daily living. Findings include. Review of the medical record reflected R98 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included apraxia following cerebral infarction (inability to make voluntary movements or gestures even though you have the physical ability and understanding to do so), dysarthria (motor speech disorder where damage to your nervous system causes the muscles that produce speech to become paralyzed or weakened) and weakness/paralysis affecting the right dominant side following a stroke. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/16/26, reflected R98 was rarely or never understood. On 03/08/2026 at 10:28 AM, Resident #98 (R98) was observed in his room wearing only an adult brief,…

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 consistent availability of water at the bedside, failed to ensure hydration was offered, and failed to document fluid intake in one (resident 98) of 2 reviewed for hydration. Findings include.Review of the medical record reflected R98 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included apraxia following cerebral infarction (inability to make voluntary movements or gestures even though you have the physical ability and understanding to do so), dysarthria (motor speech disorder where damage to your nervous system causes the muscles that produce speech to become paralyzed or weakened) and weakness/paralysis affecting the right dominant side following a stroke. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/16/26, reflected R98 was rarely or never understood. On 03/08/2026 at 10:28 AM, Resident #98 (R98) was observed in his room wearing only an adult brief, lying flat on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents receive necessary respiratory care and services that was in accordance with professional standards of practice for 1 (Resident #41) of 1 resident reviewed for respiratory care resulting in the potential for respiratory distress and exacerbation of respiratory conditions. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) with a Assessment Reference Date(ARD) of 1/26/26, reflected R41 was a [AGE] year-old female admitted to the facility on [DATE], with recent re-admission 1/9/26 related to acute on chronic respiratory failure with hypoxia and hypercapnia, CO2 narcosis (dangerous, altered mental state caused by severe accumulation of carbon dioxide in the blood) and sleep apnea. R41 had other diagnoses that included morbid obesity, chronic obstructive pulmonary disease, respiratory failure with hypoxia dependent on oxygen, anxiety, and depression. The MDS reflected that R41 had a BIM (assessment tool)…

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 medical records were accurate and not falsified for one (R135) of 24. Findings include:Review of the medical record revealed R135 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. Review of the Social Services Comprehensive Evaluation dated 3/4/26 revealed R135 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 3/3/26 revealed Wound Care (L [left] posterior leg): cleanse [with] normal saline, apply Medihoney (Activon) to wound bed, cover with foam dressing. The wound care was ordered to be completed every evening shift, every other day. On 03/08/2026 at 10:13 AM, R135 was observed sitting on the edge of his bed. R135 reported he had a wound on the back of his left calf, but the facility had not changed the dressing since 3/2/26 or 3/3/26. R135 pulled up his pant leg and a dressing dated 3/3/26…

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 provide a functional window for one (Resident #98) out of 2 reviewed for environment. Findings include: Review of the medical record reflected R98 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included apraxia following cerebral infarction (inability to make voluntary movements or gestures even though you have the physical ability and understanding to do so), dysarthria (motor speech disorder where damage to your nervous system causes the muscles that produce speech to become paralyzed or weakened) and weakness/paralysis affecting the right dominant side following a stroke. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/16/26, reflected R98 was rarely or never understood. On 03/08/2026 at 10:28 AM, Resident #98 (R98) was observed in his room wearing only an adult brief, lying flat on his back, heels not elevated off the mattress. R98's room was very warm. R98 had a Styrofoam cup on his…

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 # 2589332.Based on interview and record review the facility failed to immediately assess and notify the physician and responsible party of a fall with major injury for one Resident (#3) of three reviewed.Findings include:Review of the clinical record revealed Resident 3 (R3) was admitted to the facility on [DATE] and transferred to the hospital on 8/6/20 where a fractured right hip was discovered. Further review of the clinical record scored 13 out of 15 on the Brief Interview for Mental Status. There was no documentation in the clinical record on 8/5/26 that indicated R3 had a fall. A late entry nursing progress note dated 8/07/25 revealed that on 8/5/25 R3 was observed sitting next to his bed and R3 was unable to articulate what happened. Licensed Practical Nurse (LPN) N and Certified Nursing Assistant (CNA) O placed R3 back to bed. LPN N documented R3 had no injuries, no pain and that a body assessment was conducted. There was no notation that R3's physician or Responsible…

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 MI00146710 Based on interview and record review, the facility failed to address and respond to a repeated concerns related to food palatability, satisfactory resolutions to grievances, being offered and provided an evening snack, and call light response, brought forth by Resident Council. Findings include: Review of the Resident Council Minutes, dated 2/2024 through 12/2024, reflected ongoing concerns with food palatability and call light response times, mainly during the afternoon and night shifts. During a confidential resident group meeting on 02/12/25 10:08 AM, 7 out of 8 residents reported they had discussed food taste concerns and afternoon/night shift staffing concerns with no changes to correct addressed concerns. The Resident Council group reported long waits for call light response from 45 minutes to 60 minutes, mainly during the afternoon and night shift. One of eight confidential residents reported staff is often heard chatting at the nurse's station at night for several hours while his call light is on. 3 of eight residents stated that…

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 #374 (R374) Review of the clinical record, including the Minimum Data Set (MDS) with an assessment reference dated of 7/29/24 reflected Resident # 374 was admitted to the facility on [DATE] with a readmission date of 7/22/24, diagnoses that included nontraumatic intracerebral hemorrhage, multiple localized, muscle wasting and atrophy, anxiety, major depression. Of note, R374 was transferred to the hospital on 9/11/24 and did not return to the facility. Review of R374's weight record revealed R374 weighed 105.6 pounds on 7/23/2024. On 6/11/24 R374 weighed 117.4 pounds revealing an 11.7% weight loss in one month. Review of R374's 7/29/24 MDS section K queried for weight if there was a 5% or more in the last month or loss of 10% or more in 6 months. This question was coded as 0 meaning No or unknown. On 02/13/2025 at 10:33 am, during an interview with the facility's Registered Dietician (RD) M reported she worked at the facility for approximately one month and was not familiar with R374. Review of R374s…

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 four (R25, R48, R75, and R109) of 25 reviewed. Findings include: Resident #48 (R48) Review of the medical record revealed R48 was admitted to the facility on [DATE] with diagnoses that included bullous pemphigoid (a skin condition that causes large, fluid-filled blisters on the skin and mucous membranes). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/11/25 revealed R48 had severely impaired cognitive skills for daily decision making. Review of the Physician's Order dated 7/25/24 revealed an order to monitor the alternating pressure mattress (APM), rotation on 2. Review of R48's Potential for Impairment to Skin Integrity care plan revealed an intervention of an air mattress dated 10/14/24. On 02/10/25 at 4:10 PM, R48 was observed in bed. The alternating pressure mattress was off. On 02/11/25 at 9:10 AM, R48 was observed in bed. The alternation pressure mattress…

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 MI00146664, MI000146710 Based on observation, interview, and record review the facility failed to maintain sufficient staff to meet residents' needs timely for three (R41, R65, R109) and Resident Council of ten reviewed for staffing. Findings include: Review of the Resident Council Minutes, dated 2/2024 through 12/2024, reflected ongoing concerns with call light response times, mainly during the afternoon and night shifts. During a confidential resident group meeting on 02/12/25 10:08 AM, 7 out of 8 residents reported they had discussed afternoon/night shift staffing concerns with no changes to correct addressed concerns. The Resident Council group reported long waits for call light response from 45 minutes to 60 minutes. One of eight confidential residents reported staff is often heard chatting at the nurse's station at night for several hours while his call light is on. Resident #41 (R41) Review of the medical record reflected R41 was admitted to the facility on [DATE], 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 intakes MI00148581, MI00147352. Based on observations, interviews, record reviews, 7 of 8 from the confidential group meeting, 3 (#65, #94, #103) of 25 sampled residents, and 1 (#105) non-sampled resident, the facility failed to provide palatable food products effecting 125 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline. Findings include: On 02/10/25 at 01:35 P.M., An interview was conducted with Resident #94 regarding facility food products. Resident #94 stated: The food could be better. Resident #94 also stated: They could do better than just hamburgers and hot dogs. Resident #94 was also queried regarding gluten free facility food products. Resident #94 stated: I receive gluten free food for the most part. On 02/10/25 at 01:45 P.M., An interview was conducted with Resident #105 regarding facility food products. Resident #105 stated: I want to eat specific vegetables that are nutritious (Zucchini, Asparagus, [NAME]…

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 MI00146710 Based on observation, interview, and record review, the facility failed to make prompt efforts to resolve grievances for one (R88) of 2 reviewed. Findings include: Review of the medical record revealed R88 was admitted to the facility on [DATE] with diagnoses that included adjustment disorder with depressed mood and Alzheimer's Disease. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/24 revealed R88 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 02/10/25 at 11:59 AM, R88 was observed sitting on the edge of their bed in their room. R88 reported they were missing a couple sweatshirts, half a dozen pair of pants (jeans and lighter pants), cotton t-shirts, and a green plaid jacket. R88 reported their clothing items go to laundry and don't come back. R88 reported their clothing items were labeled with their name and had been missing awhile. R88 reported they have…

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 bed bolsters as potential restraints for two (Resident #25 and #63) of three reviewed. Findings include: Resident #63 (R63) Review of the medical record reflected R63 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included schizoaffective disorder and unspecified dementia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/24, reflected R63 was rarely/never understood and had short-term and long-term memory impairments. Section P of the MDS, pertaining to Restraints and Alarms, did not reflect coding for restraint use. According to MDS question P0100. Physical Restraints, Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. On 02/10/25 at 9:20 AM, R63 was observed in bed,…

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 complete a significant change Minimum Data Set (MDS) assessment timely for one (R68) of 25 reviewed. Findings include: Review of the medical record revealed R68 was admitted to the facility on [DATE] with diagnoses that included dementia. The census tab in the medical record revealed R68 began hospice services on 11/1/24 and ended hospice services on 1/21/25. Review of R68's MDS assessments, revealed a Significant Change MDS with an Assessment Reference Date of 1/27/25 that was still in progress as of 2/10/25. The Significant Change Assessment was completed on 2/11/25. In an interview on 02/13/25 at 12:25 PM, MDS Coordinator N reported a Significant Change Assessment had to be completed within 14 days. MDS Coordinator N agreed R68's Significant Change Assessment was completed late. According to the Resident Assessment Instrument (RAI) Manual, a Significant Change in Status Assessment must be completed within 14 days of the determination that a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to revise the Care Plan for two residents (Resident #79 and 374) of 25 reviewed. Findings include: Resident #374 (R364) Review of the clinical record, including the Minimum Data Set (MDS) with an assessment reference dated of 7/29/24 reflected Resident # 374 was admitted to the facility on [DATE] with a readmission date of 7/22/24, diagnoses that included nontraumatic intracerebral hemorrhage, multiple localized, muscle wasting and atrophy, anxiety, major depression. Of note, R374 was transferred to the hospital on 9/11/24 and did not return to the facility. Review of R374's weight record revealed R374 weighed 105.6 pounds on 7/23/2024. On 6/11/24 R374 weighed 117.4 pounds revealing an 11.7% weight loss in one month. Review of R374's 7/29/24 MDS section K queried for weight if there was a 5% or more in the last month or loss of 10% or more in 6 months. This question was coded as 0 meaning No or unknown. Review of R374's nutritional care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes MI00146664, MI00146710 Based on observation, interview, and record review the facility failed to provide necessary care to assist two of five residents reviewed for grooming (R#29 and R#49) with necessary activities of daily living (ADLs), resulting in these residents not receiving the care needed to maintain their highest practicable well-being and potential for embarrassment and humiliation of residents. Findings Include: Resident #29 (R29) Review of the medical record reflected R29 was an initial admission to the facility on [DATE] and readmitted on [DATE]. Diagnoses of Acute and Chronic Respiratory Failure (a short term and long-term condition that is treated as an emergency and requires long term treatment), Type 2 Diabetes Mellitus, Cerebral Infarction (stroke), Chronic Obstructive Pulmonary Disease (COPD)(a lung condition caused by damage to the airways that limit airflow), Other Idiopathic Peripheral Autonomic Neuropathy (nerve damage with unknown cause), Acute on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide meaningful, individualized activities to one resident (#29) of two reviewed for activities, from a total sample of 25 residents, resulting in the potential for depression, boredom and feelings of lack of self-worth. Findings include: Resident #29 (R29) Review of the medical record reflected R29 was an initial admission to the facility on [DATE] and readmitted on [DATE]. Diagnoses of Acute and Chronic Respiratory Failure (a short term and long-term condition that is treated as an emergency and requires long term treatment), Type 2 Diabetes Mellitus, Cerebral Infarction (stroke), Chronic Obstructive Pulmonary Disease (COPD)(a lung condition caused by damage to the airways that limit airflow), Other Idiopathic Peripheral Autonomic Neuropathy (nerve damage with unknown cause), Acute on Chronic Combined Systolic and Diastolic Heart Failure (a condition where a patient experiences an acute exacerbation of heart failure that has both…

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 MI00146664. Based on observation, interview and record review, the facility failed to honor preferences for weight management for one (Resident #79) and prevent weight loss for one (Resident #374) of six reviewed. Findings include: Resident #79 (R79) Review of the medical record reflected R79 admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, unspecified protein-calorie malnutrition and gastrostomy status (artificial, external opening into the stomach, which can be used for nutritional support). The Admission/5-day Medicare Part A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/1/24, and the Quarterly MDS, with an ARD of 11/1/24, reflected R79 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and received 51 percent or more of their total calories via tube feeding. On 02/10/25 at 11:43 AM, R79 was observed in bed 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 ensure assessment and monitoring of a dialysis access site and updated Care Plans for one (Resident #75) of one reviewed. Findings include: Review of the medical record reflected Resident #75 (R75) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included end stage renal disease and dependence on renal dialysis. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/24/25, reflected R75 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 02/11/25 at 8:59 AM, R75 was observed lying in bed. They reported going to dialysis three times per week, on Tuesday, Thursday and Saturday. R75 reported their dialysis access site was in their left arm and denied that the nursing staff were monitoring the site routinely. R75 reported they were not to have blood draws or blood pressures taken from their left arm. R75 reported being…

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 medically related Social Services for one resident (#375) of two reviewed for Social Services. Findings include: Resident #375 (R375) Review of the medical record reflected R375 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction. A Brief Interview for Mental Status had not been completed due to R375's refusal to participate in the assessment. On 02/10/25 at 12:02 PM, R375 was observed in bed. R375 was wearing a sweatshirt which had food debris on the front of it. R375 actively listened to questions, participated in the interview, and appropriately answered questions. R375 was able to accurately answer questions about who he was, his personal information, where he was currently located, the current date, his medical history, what facility he previously resided at, and who his guardian was. It was clear that R375 was cognitively intact. R375 stated extreme frustration with his situation stating…

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 safe storage and administration of medications, in one of five residents (R#5) reviewed for sample of 25 resulting in unsafe medication administration, unsafe medication access, and the potential for lost medications/medication errors. Findings include: Resident #5 (R5) During medication administration on 02/12/25 at 8:20 AM, Registered Nurse (RN) C was observed removing a pre-filled med cup from the top drawer of her medication cart. RN C had filled it prior to this time with the 8:00 AM medications and set in the top drawer of medication cart. RN C pulled the medication cup out of the top drawer and began to pour a glass of water to give these medications to R5. This writer stopped RN C and asked her to identify every medication she was administering to R5 from that med cup. RN C recalled the medications she put in the cup; however, RN C did not have R5's Lithium Carbonate Oral Capsule 150mg tablet in the medication cup. Resident did not receive this morning dose of Lithium, resulting in a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately honor food preferences for one resident (#94) of six resident reviewed for food preferences. Findings include: Review of the medical record reflected R94 was admitted to the facility on [DATE], with diagnoses that included celiac's disease (gluten intolerance). The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/4/24, reflected R94 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 2/10/25 at 12:21 PM, R94 was observed in bed. R94 was on an air mattress and had her heels floated. R94 explained that she had several pressure ulcers that she admitted with. R94 expressed her frustration with the meals that the facility had been providing her. R94 stated that she had a gluten free diet order and required extra protein due to her pressure ulcers. R94 stated that the dietician visited with her when she admitted to the facility in November and 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 ensure collaboration of care and communication with the hospice provider for one (Resident #112) of one reviewed. Findings include: Review of the medical record reflected Resident #112 (R112) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included neuromyelitis optica and cerebral infarction. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/19/25, reflected R112 scored nine out of 15 on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and received hospice services. On 02/13/25 at 1:06 PM, R112 was observed lying in bed. A staff member was present in the room, providing feeding assistance. A Physician's Order, with a revision date of 1/13/25, reflected R112 was admitted to hospice services. In an interview on 02/12/25 at 11:01 AM, Social Services Director (SSD) I reported they helped coordinate hospice services within 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 interview and record review, the facility failed to administer a pneumococcal immunization per consent for one (R48) of five reviewed. Findings include: Review of the medical record revealed R48 was admitted to the facility on [DATE]. The MDS with an Assessment Reference Date (ARD) of 1/11/25 revealed R48 had severely impaired cognitive skills for daily decision making and that their pneumococcal immunization was not up to date but was offered and declined. Review of the Vaccine Consent and Administration Form revealed R48's Durable Power of Attorney (DPOA) for Healthcare gave consent on 4/17/24 for R48 to receive the pneumococcal immunization. R48 did not receive the pneumococcal immunization. In an interview on 02/12/25 at 10:33 AM, Assistant Director of Nursing (ADON)/Infection Preventionist (IP) Z agreed R48's DPOA consented to the pneumococcal immunization on 4/17/24. ADON/IP Z was not sure why R48 had not received the pneumococcal immunization after consent was given.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to notify the physician of a change in condition for 1 of 3 sampled residents (R101) reviewed for physician notification, from a total sample of 3 residents, resulting in R101 having a delay in treatment of a burn and increased risk for pain and infection. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, cerebral infarct with hemiplegia affecting right dominant side, hypertension (high blood pressure), chronic kidney disease requiring dialysis, heart failure, atrial fibrillation (irregular heart rate), kidney cancer with removal and weakness. The MDS reflected R101 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required set-up assist with eating, dependent on staff for dressing, toileting, transferring and bed…

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 the necessary care and services to maintain the highest practical physical level of well being (adequate care after a burn) in 1 of 3 sampled residents (R101) reviewed for accidents, resulting in second degree burns to R101 after spilling hot soup in his lap. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, cerebral infarct with hemiplegia affecting right dominant side, hypertension (high blood pressure), chronic kidney disease requiring dialysis, heart failure, atrial fibrillation (irregular heart rate), kidney cancer with removal and weakness. The MDS reflected R101 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required set-up assist with eating, dependent on staff for dressing, toileting,…

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 MI00145665 Based on observation, interview, an record review the facility failed to notify one Resident (#2) out of three Resident reviewed of grievance investigation and resolution of grievances. Findings Included: Resident #2 (R2) Review of the medical record revealed R2 was admitted to the facility 09/13/2023 with diagnoses that included cirrhosis of liver (scarring and liver failure), constipation, anxiety, alcohol abuse, anemia (low red blood cells), hepatic encephalopathy (loss of brain function because liver damage does not remove toxins) , hypertension, gastro-esophageal reflux, chronic pancreatitis (inflammation of pancreas), low back pain, depression, and cognitive communication deficit. Review of R2's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/20/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 08/27/2024 at 11:56 p.m. R2 was observed sitting up on the side of her bed. R2 explained that she had made two concern forms for issues…

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 the physical plant effecting 123 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and reduced illumination. Findings include: On 01/30/24 at 02:48 P.M., An environmental tour of the facility Laundry Service was conducted with Director of Housekeeping and Laundry Services M. The following items were noted: The flooring surface was observed soiled with (dust, lint, debris), directly behind the commercial washers (2) and commercial dryers (2). The ceramic tile wall surface was also observed raised and buckled, adjacent to the commercial washing machines. The damaged wall surface measured approximately 5-feet-high by 6-feet-long. The black vinyl coving strip was observed loose-to-mount and missing, adjacent to the commercial washers (2) and commercial dryers (2). On 01/30/24 at 03:10 P.M., An interview was conducted with Director of Housekeeping and Laundry Services M regarding the Laundry Aide schedule. Director of Housekeeping 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, interview and record review the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for the entire resident council members, resulting in anger, frustration and feelings of being ignored and ongoing unresolved concerns. Findings include: Review of the Resident Council meeting minutes dated 10/12/23 reflected the resident council members had no concerns for Nursing, Social Services, Activities, Housekeeping/laundry, and Dietary. The Resident Council notes further reflected New business addressed immediately. The minutes do not reveal what the new business concerns were. Review of the 11/21/23 Resident Council meeting minutes reflected no concerns for nursing, Activities, Housekeeping/Laundry or Dietary. One resident requested to see the Optometrist in which Social Services was notified. Review of the Resident Council meeting minutes dated 12/27/23 had no concerns for Nursing, Social Services, Activities, Housekeeping/laundry, and Dietary. During the confidential group meeting held on 01/31/24 at 10:33 AM 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 ensure accurate coding on the Minimum Data Set (MDS) assessment for three (Resident #41, #72 and #370) of 24 reviewed, resulting in the potential for inaccurate care plans and unmet care needs. Findings include: Resident #72 (R72): Review of the medical record reflected R72 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dementia. R72's MDS history reflected a quarterly MDS, with an Assessment Reference Date (ARD) of 11/18/23. A discharge return anticipated MDS, with an ARD of 1/1/24, reflected, Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent? was coded for one fall without injury. During an interview on 02/01/24 at 02:07 PM, Registered Nurse/MDS Coordinator (RN) C reported R72 had fallen on 12/10/23 and 12/30/23. RN C reported R72's discharge return anticipated MDS, with an ARD of 1/1/24, should have been coded for two…

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 follow-up with OBRA for one (Resident #110) of two reviewed, resulting in the potential for mismanaged mental health services. Findings include: Resident #110 (R110) admitted to the facility on [DATE] with diagnoses that included manic episode, anxiety, suicidal ideations, adjustment disorder and brief psychotic disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/23 revealed R110 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of R110's Preadmission Screening (PAS)/Annual Resident Review (ARR) completed on 11/7/23 revealed R110's Level I screening was Hospital Exemption Discharge. Section II of the screen revealed yes was marked to question 3 the person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. The form revealed R110 was prescribed Seroquel (antipsychotic medication). The Level I screening…

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 for one out of 24 residents (Resident #39) resident preferences were included in the plan of care, resulting in the potential for anxiety and resident preferences not being met. Findings Included: Per Resident 39's (R39) electronic medical record (EMR) R39 was initially admitted to the facility on [DATE]. In an interview on 1/30/2024 at 11:13 AM, R39 stated that he wanted to get up every morning at 6:15 AM. R39 said staff were aware of his preference, however stated that there had been a few days when it was after 7:00 AM and around 10:00 AM before the staff assisted him with getting up out of bed. In an interview on 2/01/2024 at 10:48 AM, Registered Nurse (RN) J stated that R39 would always be up when she would arrive to work at 7:00 AM. RN J said the third shift staff would get R39 up out of bed. RN J further stated that R39 was routine, and would get anxious when his routine was not followed, and would get upset and anxious when he was not up…

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 for one out of 24 residents (Resident #5) fall care plan was revised, resulting in the potential for additional falls to occur. Findings Included: Per the Resident #5's (R5) electronic medical record (EMR) R5 had resided at the facility since 6/16/2023. Review of a Post-Fall Evaluation dated 8/29/2023, revealed R5 had a fall on 8/29/2023. An immediate intervention put into place was. bed in low position, call light within reach, frequent rounding on resident (R5). However, the intervention of frequent rounding on resident was not added to R5's care plan, and the interventions of bed in low position and call light within reach were already interventions in place, but were both dated 2/27/2018, and did not have any revisions. Review of an Interdisciplinary Team note (IDT) dated 8/31/2023, revealed R5's fall on 8/29/2023 was reviewed. The note revealed, .Recent falls, no injury, interventions in place . No new fall intervention(s) were added to R5's care plans for fall prevention. Review of a Post-Fall Evaluation 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 Based on observation, interview, and record review, the facility failed to prime an insulin pen per manufacturer guidelines for one (Resident #74) of one reviewed, resulting in the potential for medication errors and adverse effects. Findings include: Review of the medical record revealed Resident #74 (R74) was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus. Review of the Physician's Order dated 9/9/23 revealed an order for Insulin NPH 70/30 inject 14 units subcutaneously one time a day for [diabetes mellitus] inject 14 units under the skin 2 (two) times a day before meals. Vials should be rolled between palms of hands ten times prior to each use. Administer 30 to 45 minutes before a meal. On 02/01/24 at 08:36 AM, Licensed Practical Nurse (LPN) D prepared Novolin 70/30 insulin pen by tilting it up and down. LPN D then dialed the pen to 16 units and pressed the button until the dial was at 14 units. There was not a needle on the pen. LPN D then applied a needle to the insulin pen.…

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 properly assess and follow podiatry services orders for one resident (R40) reviewed for foot care, resulting in resident frustration, the development of long thick brittle toenails, pain, skin breakdown and delay in needed treatment. Findings include: Resident #40(R40) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R40 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), spinal stenosis, osteoarthritis, dementia without behaviors, anxiety, and depression. The MDS reflected R40 had a BIM (assessment tool) score of 14 which indicated his ability to make daily decisions was cognitively intact, and he required partial to moderate assist with showering and substantial/maximal assist with hygiene and putting on and taking off foot wear. During an observation and interview on 1/30/24 at 3:01 PM, R40 was observed in his room sitting in 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.

Based on observation, interview, and record review, the facility failed to provide backflow protection devices in two locations, resulting in the potential for contamination of the domestic water supply, affecting two plumbing fixtures in the facility. Findings include: On 8/21/23 at 2:10 PM, during an inspection of the laundry facilities, a hose, connected to a spigot, was observed to extend down into the floor drain that is provided for the clothes washers, creating a cross connection between the potable water supply and sanitary sewer. A backflow protection device was observed to not be provided for the hose connection to preclude the backflow of solid, liquid, or gas contaminants. On 8/21/23 at 2:20 PM, during an inspection of the boiler room, a hose, connected to a spigot, was observed to be extend to a floor drain. The hose connection was observed to not be provided with a backflow protection device. At this time, Maintenance Director R stated they will remove the hoses until they acquire backflow protection devices for the two hoses. According to the 2018 Michigan Plumbing…

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 MI00135388. Based on observation, interview, and record review the facility failed to meet individualized activity needs in one (Resident #67) of four reviewed, resulting in the potential for boredom and decreased quality of life. Findings Include: Resident #67 (R67) According to the facility's admission record, R67 admitted to the facility on [DATE] with diagnoses that included unspecified dementia and anxiety disorder. A review of the MDS (Minimum Data Set) dated 07/21/2023 reflected R67 had a brief interview for mental status (BIMS), a short performance based cognitive screen for nursing home residents, score of 5 (0-7 severely impaired). Review of R67's MDS Annual assessment dated [DATE] section F-Preferences for Customary Routine and Activities question How important is it to you to go outside to get fresh air when the weather is good? indicates that it is very important to him. Review of the Activity Quarterly Assessment completed on 07/25/23 under resident leisure…

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 MI0013852. Based on interview and record review, the facility failed to assess and monitor wound dressings in one of three residents reviewed for quality of care (Resident #120), resulting in the potential for a wound infection not identified. Findings include: Resident #120 (R120) Progress Note dated 6/30/23 at 3:38 PM indicated R120 was not competent in making health decisions. Consultation Notes dated 6/19/23 indicated R120's wound treatments included Unna boots (compression dressing that could remain in place for up to seven days before changing), gauze and Ace wrap to both lower extremities. Hospital Progress Note dated 7/12/23 at 10:03 AM revealed R120 had a past medical history of neurocognitive disorder (decreased mental function). R120 was followed by burn service for chronic lower extremity wounds and underwent a below the knee amputation (BKA) of the right lower leg on 4/07/22. R120 was seen in the clinic on 7/03/23 and was placed in a surgical dressing, Unna boot,…

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.