Villa at Willow Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to formulate a Baseline Care Plan which included pertinent care needs for one (R114) of 18 reviewed.Findings include: Review of the medical record reflected R114 admitted to the facility on [DATE], with diagnoses that included ocular laceration of the left eye, diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/3/26, was in progress (not completed) as of 2/12/26. On 02/10/2026 at 11:22 AM, R114 was observed lying in bed. On 02/12/2026 at 10:35 AM, R114 was observed being propelled in the hallway, by staff, while seated in their wheelchair. R114's Care Plan reflected a focus area of, Resident requires assist with daily care needs r/t [related to] Date Initiated: 01/29/2026. The Care Plan goal was initiated on 1/29/26. Interventions were not added to the Care Plan until 2/11/26, which included R114 requiring assistance of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for three residents (#4,#43,#64) of 18 reviewed. Findings Included: Resident #4 (R4) Review of the medical record demonstrated that R4 was admitted to the facility 02/26/2025 with diagnoses that included end stage renal disease, pain right and left foot, ascites (abnormal build up of fluid in the abdomen), osteoarthritis (degenerative joint disease) of left knee and bilateral hips, paranoid schizophrenia, chronic constipation, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux, depression, schizoaffective disorder, dependence on dialysis, anemia (low red blood cells), insomnia (difficulty sleeping), cognitive decline, anxiety, gout (build up of uric acid in joints), hypertension, and atrial fibrillation. Review of R4's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/2025, revealed R4 had a Brief Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1) follow Physician Orders for vital signs monitoring; and 2) assess and monitor respiratory status with administration of an as needed nebulizer treatment for one (R114) of 18 reviewed.Findings include: Review of the medical record reflected R114 admitted to the facility on [DATE], with diagnoses that included ocular laceration of the left eye, diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/3/26, was in progress (not completed) as of 2/12/26. On 02/10/2026 at 11:22 AM, R114 was observed lying in bed and reported since having a pacemaker implant, they used oxygen at night, as needed. R114 reported when notifying staff of shortness of breath, staff would check their oxygen saturation and say it was fine. R114 stated that morning (2/10/26), they became short of breath in the Therapy Gym and were told to return 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 implement interventions to prevent the development and/or worsening of contractures for one (R20) of three reviewed.Findings include: Review of the medical record reflected R20 admitted to the facility on [DATE], with diagnoses that included Huntington's Disease, dementia and depression. The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/25, reflected R20 had short-term and long-term memory impairments and was coded as requiring substantial/maximal assistance to dependence on staff for activities of daily living (ADLs). The same MDS reflected R20 did not have any upper or lower extremity impairments that interfered with daily functions or placed them at risk for injury in the prior seven days. On 02/10/2026 at 10:54 AM, R20 was observed seated in a Broda chair, in their room, watching TV. A hoyer lift sling was observed beneath them. Both knees were in a flexed (bent) position. On 02/12/2026 at 11:18 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to consistently provide palatable food for one resident (R19) of 18 residents reviewed. Findings include:Review of the clinical record revealed R19 was admitted into the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), polyneuropathy (numbness/tingling/weakness due to nerve damage), bladder disorder, anxiety and left side hemiplegia (severe or complete paralysis) and hemiparesis (partial muscle weakness). According to the Minimum Data Set (MDS) assessment dated [DATE], R19 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 2/10/26 at 12:12 PM, R19 was observed sitting at the edge of his bed eating lunch. Lunch consisted of a corn dog, yellow squash and a cold pasta with elbow macaroni. R19 reported that they have been served corndogs twice in the same week, the squash was over cooked (resident was observed having difficultly picking it up with his fork) and that 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.

Based on observation, interview, and record review, the facility failed to properly dispose of waste and maintain dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility. Findings include:During an observation and interview during the initial kitchen tour on 2/10/2026 at 9:28 AM, Food Service Director (FSD) F reported had been in role for about four months. Kitchen tour continued outside and observed four dumpsters labeled with two company names. FSD F reported facility recently changed ownership in November 2025(four months ago) and prior garbage company had not picked up the dumpsters yet. Observed several items outside and around new yellow trash dumpster including full bags of trash. FSD F reported maintenance department responsible for maintaining trash receptacles and reported all trash should be in dumpsters not on ground around them with lids closed.During an interview on 2/13/2026 at 10:35 AM, Maintenance Director (MD) BB reported MD BB reported since ownership changed facility had communicated with prior garbage company but 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 ensure accurate documentation for one (Resident #64) of 18 reviewed for accurate medical records. Resident #64(R64)Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 12/11/25, reflected R64 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included dementia, urinary tract infection and spinal stenosis. The MDS reflected R64 had a BIM (assessment tool) score of 4 that indicated her ability to make daily decisions was severely impaired, and she required staff assistance with dressing, mobility, transfers, hygiene, bathing, and toileting.During an observation on 2/10/2026 at 10:45 a.m., R64 was observed in bed with two staff at bedside assisting with care. R64 appeared pleasantly confused and did not appear to be oriented. This surveyor overheard Licensed Practical Nurse (LPN) CC talking to R64 about plan to change wound dressing. Observed wound supplies at bedside. LPN CC…

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 administer oral chemotherapy medication as ordered for one (Resident #200) of three reviewed. This citation pertains to intake 2582143.Review of the clinical record revealed R200 was admitted into the facility on 4/23/25 with diagnoses that included: aphasia following cerebral infarction (impaired ability to understand or produce speech following a stroke), malignant neoplasm of upper third of esophagus (throat cancer) and vascular dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R200 scored 8/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).On 9/22/25 at 9:59 AM, during an interview with family member (FM) E, when asked to clarify which medication R200 was allegedly not being provided, they reported it was an oral chemotherapy medication and that when family had taken R200 to his oncologist appointment the oncologist could tell that he was not receiving 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 intakes MI00149170, MI00149191, MI00149342 and MI00150300. Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff to meet resident needs timely for four (Resident #2, #3, #8 and #9) of seven reviewed. Findings include: Resident #2 (R2) Review of the medical record reflected R2 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD), heart failure, unspecified urinary incontinence and overactive bladder. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/12/25, reflected R2 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was always incontinent of bowel and bladder. On 3/10/25 at 11:18 AM, R2 was observed in bed. R2 reported being incontinent of bowel and bladder, requiring staff to check and change them for incontinence purposes. R2 reported there have been occasions when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to clean and maintain food service equipment effecting 83 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 12/09/24 at 09:25 A.M., A comprehensive tour of the food service was conducted with Dietary Manager H and Registered Dietician I. The following items were noted: Walk-In Freezer: The automatic door closer assembly was observed weak, allowing the door to not close completely. Registered Dietician I indicated she would contact maintenance for necessary repairs as soon as possible. The Victory one-door reach-in cooler door gasket was observed (worn, torn, missing). Dietary Manager H indicated she would contact maintenance for necessary repairs as soon as possible. Two fry pans (one 18-inch and one 14-inch) were observed (etched, scored, particulate). Dietary Manager H stated: I will just throw the pans away. The 2017 FDA Model Food Code section 4-501.11 states: (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 observations, interviews, and record reviews the facility failed to effectively clean and maintain the physical plant effecting 83 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 12/09/24 at 10:48 A.M., One of two window sashes were observed drafty and leaking air, within resident room [ROOM NUMBER]. The drafty window sash was also observed to not shut completely, creating the cold air draft. On 12/09/24 at 12:13 P.M., The 300 Hall (Point Click Care Kiosk) chair backrest was observed covered with black duct tape. The inner backrest Styrofoam padding was also observed protruding from the black duct taped seams, creating a non-cleanable and non-sanitizable surface. On 12/09/24 at 12:20 P.M., The 300 Hall Shower Room spa tub wastewater connection line was observed detached, allowing wastewater to flow onto the flooring surface. On 12/09/24 at 12:42 P.M., Two base cabinet doors were observed missing, within the…

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

Based on observation, interview, and record review the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident (#39) of 18 residents reviewed for accurate assessments. Findings Included: Resident #39 (R39) Review of the medical record revealed R39 was admitted to the facility 11/01/2023 with diagnoses that included end stage renal disease, hyperlipidemia (high fat content in blood), diabetes mellitus, congestive heart failure (CHF), legal blindness, hyperkalemia (high potassium), insomnia, dyspepsia (shortness of breath), constipation, protein-calorie malnutrition, renal dialysis, absence of right great toe, and anemia (low red blood cell count). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/2024, revealed R39 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Section B-Hearing, Speech, and Vision of the MDS, with the same ARD, revealed b1000- Vision - Ability to see in adequate light (with glasses or other visual appliances) was documented as 1. Impaired. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to coordinate and complete a level II screening for one (Resident #59) of one resident reviewed for Preadmission Screening/Annual Resident Review (PASARR). Findings Included: Resident #59 (R59) Review of the medical record revealed R59 was admitted to the facility 10/10/2023 with diagnoses that included rheumatoid arthritis, diabetes mellitus, atrial fibrillation, post-traumatic stress disorder (PTSD), atherosclerotic heart disease (plaque buildup in artery walls), dysphagia (difficulty swallowing), bipolar disorder, paranoid schizophrenia, insomnia, right bundle branch block (disorder of electrical activity affecting heart), chronic headache, vitamin D deficiency, polyarthritis (arthritis affecting greater than five bone joints), depression, anxiety, and osteoporosis (condition making bones weak and brittle). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2024, revealed R59 had a Brief Interview of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #39 (R39) Review of the medical record revealed R39 was admitted to the facility 11/01/2023 with diagnoses that included end stage renal disease, hyperlipidemia (high fat content in blood), diabetes mellitus, congestive heart failure (CHF), legal blindness, hyperkalemia (high potassium), insomnia, dyspepsia (shortness of breath), constipation, protein-calorie malnutrition, renal dialysis, absence of right great toe, and anemia (low red blood cell count). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/2024, revealed R39 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Section B-Hearing, Speech, and Vision of the MDS, with the same ARD, revealed b1000- Vision - Ability to see in adequate light (with glasses or other visual appliances) was documented as 1. Impaired. During observation and interview on 12/08/2024 at 01:31 p.m. R39 was observed lying down in bed. R39 explained that he could not see and was legally blind. R39 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide alternative communication devices related to vision for one Resident (#39) that was legally blind out of one resident reviewed for activities of daily living abilities. Findings Included: Resident #39 (R39) Review of the medical record revealed R39 was admitted to the facility 11/01/2023 with diagnoses that included end stage renal disease, hyperlipidemia (high fat content in blood), diabetes mellitus, congestive heart failure (CHF), legal blindness, hyperkalemia (high potassium), insomnia, dyspepsia (shortness of breath), constipation, protein-calorie malnutrition, renal dialysis, absence of right great toe, and anemia (low red blood cell count). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/2024, revealed R39 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Section B-Hearing, Speech, and Vision of the MDS, with the same ARD, revealed b1000- Vision -…

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 Range of Motion (ROM) services to prevent the possibility of decreased ROM and mobility in one resident (#59) of one resident reviewed. Findings Included: Resident #59 (R59) Review of the medical record revealed R59 was admitted to the facility 10/10/2023 with diagnoses that included rheumatoid arthritis, diabetes mellitus, atrial fibrillation, post-traumatic stress disorder (PTSD), atherosclerotic heart disease (plaque build up in artery walls), dysphagia (difficulty swallowing), bipolar disorder, paranoid schizophrenia, insomnia, right bundle branch block (disorder of electrical activity affecting heart), chronic headache, vitamin D deficiency, polyarthritis (arthritis affecting greater than five bone joints), depression, anxiety, and osteoporosis (condition making bones weak and brittle). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2024, revealed R59 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation 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 prevent an elopement for one of one residents (R#74) reviewed for elopement. According to the clinical record including the Minimum Data Set (MDS) dated [DATE] reflected Resident # 74 (R74) was admitted to the facility on [DATE] with diagnoses of dementia, R74 scored 5 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Record review reflected R74 eloped from the facility on 07/09/2024 in the afternoon and was located approximately 100 yards from the building walking down a sidewalk. Further review of that facility reported incident reflected R74 eloped from the 200 hallway door. Record review completed on the certification survey reflected R74 eloped on 11/16/24 at approximately 4:40 PM. Review of the incident report reflected Certified Nursing Assistant (CNA) C was the first person to become aware of R74's elopement. On 12/10/24 11:56 AM during an interview with CNA C reported on 11/16/24 when she came…

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 follow pharmacy policy and acceptable clinical practice for medication usage and administration for one resident (#54) out of 83 current facility residents. Findings Included: Resident #54 (R54) Review of the medical record revealed R54 was admitted to the facility 06/30/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD), stroke, protein-calorie malnutrition, hypertension, depression, attention-deficit hyperactivity disorder (ADHD), urinary incontinence, bilateral cataracts, dementia, alcohol abuse, and chronic respiratory failure. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2024, revealed R54 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 12/08/2024 at 12:50 p.m. R54 was observed lying in bed. An over the counter breathing inhaler was observed on the over bed table beside R54's bed. The inhaler was observed to be Primatene Mist. R54 explained that his wife 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.

Based on observation, interview, and record review the facility failed to ensure proper medication storage of medications for one Resident (#54) out of 83 current residents residing at the facility. Findings Included: Resident #54 (R54) Review of the medical record revealed R54 was admitted to the facility 06/30/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD), stroke, protein-calorie malnutrition, hypertension, depression, attention-deficit hyperactivity disorder (ADHD), urinary incontinence, bilateral cataracts, dementia, alcohol abuse, and chronic respiratory failure. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2024, revealed R54 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 12/08/2024 at 12:50 p.m. R54 was observed lying in bed. An over the counter breathing inhaler was observed on the over bed table beside R54's bed. Another inhaler was observed to be on the over bed table. The first inhaler was observed to be Primatene Mist. The…

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

Based on observation, interview, and record review the facility failed to implement infection control practices to change oxygen tubing/nasal cannulas for one resident (#54) of three residents reviewed for oxygen usage. Findings included: Resident #54 (R54) Review of the medical record revealed R54 was admitted to the facility 06/30/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD), stroke, protein-calorie malnutrition, hypertension, depression, attention-deficit hyperactivity disorder (ADHD), urinary incontinence, bilateral cataracts, dementia, alcohol abuse, and chronic respiratory failure. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2024, revealed R54 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 12/08/2024 at 12:47 p.m. R54 was observed lying in bed and an oxygen concentrator was observed beside his bed on the floor. It was observed that his nasal cannula was on the floor and that the oxygen tubing was not dated. R54 explained 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.

This citation pertains to MI00143905. Based on observation, interview, and record review the facility failed to provide an environment free from physical and verbal abuse for one Resident (#3) of three Residents reviewed for abuse resulting in the potential of physical and mental harm of Residents. Findings included: Resident #3 (R3) Review of the medical record demonstrated R3 was admitted to the facility 03/25/2024 with diagnoses that included Huntington's disease (disease that brain cells break down in brain), dementia, abnormal involuntary movements, protein-calorie malnutrition, anemia (low red blood cells), low back pain, bilateral hearing loss, hyperlipidemia (high fat in blood), history of falls, and hypertension. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2024, revealed R3 did not have a Brief Interview for Mental Status (BIMS) because the resident is rarely/never understood. Section E (Behavior) of the MDS, with the same ARD, demonstrated that R3 had physical behavioral symptoms directed toward others (e.g. hitting, kicking,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 87 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies, and decreased illumination. Findings include: On 01/23/24 at 02:43 P.M., An interview was conducted with Director of Environmental Services F regarding current facility staffing levels. Director of Environmental Services stated: I have 2 full time Laundry Aides, 5 full time Housekeeping Aides, and I am the only Maintenance person. Director of Environmental Services F also stated: I currently have no part time Laundry Aides or Housekeeping Aides. Director of Environmental Services F additionally stated: I am allowed 4 full time Housekeeping Aides per day on first shift only. I have no Housekeeping Aides on second or third shift. Director of Environmental Services F further…

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 5 (Resident #3, #14, #26, #34, #56) of 22 reviewed, resulting in the potential for unmet care needs. Findings include: Resident #14 (R14) Review of the medical record revealed R14 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included spastic quadriplegic cerebral palsy (loss of use of whole body), dysphagia (inability to produce normal language), aphasia (inability to comprehend normal language), and multiple sclerosis (disease in which the immune system attacks the central nervous system). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/6/23 revealed R14 was rarely or never understood on the Brief Interview for Mental Status (BIMS). The same MDS reflected that R14 was a total assist with most activities of daily living. In an observation on 1/23/24 at 12:15 PM, R14 was in bed with her eyes open. R14 traced my…

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 and provide appropriate personal hygiene care was completed for four (R9, R31, R72 and R14) of five residents reviewed for Activities of Daily Living, of a total sample of 22, resulting in unshaven facial hair, unkept nails, missed showers and dissatisfaction with the care provided. Findings include: Resident #9 (R9) Review of the medical record revealed Resident #9 (R9) was admitted to the facility originally on 01/25/19 then readmitted on [DATE] with diagnoses that included Pneumonia, Respiratory failure, Kidney failure, Dementia, Major Depression, Anxiety, Muscle Weakness, Difficulty in Walking. According to Resident #9 (R9)'s Minimum Data Set (MDS) dated [DATE], revealed R9 scored 08 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R9 was dependent on all care provided, showers, repositioning, toileting, two-person mechanical lift…

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 consistent, daily, meaningful, individualized activities for four Residents (R9, R31, R34, R74) of four residents reviewed for care, of a total sample of 22 residents, resulting in a loss of interaction, sense of wellbeing, boredom, lack of meaning/quality of life. Findings include: Resident #31 (R31) Review of the medical record revealed Resident #31 (R31) was admitted to the facility originally on 12/03/16 then readmitted on [DATE] with diagnoses that included Stroke, Dysphagia, Aphasia, hemiplegia, and hemiparesis on left non-dominant side, Vascular Dementia, Muscle weakness, difficulty walking, Enteral feeding via g-tube and nothing by mouth. According to Resident #31 (R31)'s Minimum Data Set (MDS) dated [DATE], revealed R31 scored 00 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R31 requires extensive assistance with toileting, transfers,…

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

Based on observation, interview and record review, the facility failed to maintain sufficient staff necessary to provide care for seven out of eight anonymous resident council group from a total sample of 22, with the potential of affecting all 87 residents in the facility resulting in extended call light wait times, missed showers, and avoidable incontinence. During an observation on 01/24/24 at 08:09 AM, One CNA on 400 hall picking up breakfast trays, while two call lights were on for over 25 minutes before getting answered. During an interview on 01/24/24 at 0820 AM, anonymous CNA EE stated they used to have two CNAs on each hall before the budget cuts, now they have one to one and a half CNA's per hall. CNA EE stated hall 400 had six mechanical lift residents that require two people to transfer. CNA EE also stated there is no way they could complete the task assigned to them on a heavy hall like that one without additional help. During a resident council meeting on 01/24/24 at 11:00 AM, anonymous residents voiced concerns with facility being short staffed. Five of eight…

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 appropriate snacks for a resident with a diabetic diet for one Resident (#34) of 22 sampled, with the potential to affect 30 diabetic residents residing in the facility, reviewed for therapeutic diets, resulting in uncontrolled blood glucose levels with the potential need to have additional administered insulin and complications of hyperglycemia. Findings Include: Review of the medical record revealed R34 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included difficulty in walking, muscle weakness, type two diabetes with chronic kidney disease, hyperlipidemia, morbid obesity, and type two diabetes with neuropathy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/23 revealed R34 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The same MDS reflected that R34 required one person assistance for most activities of…

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

Based on interview, and record review, the facility failed to ensure that eight of eight anonymous residents from the resident council meeting, with the potential of affecting all 87 residents in the facility, who were not offered a nourishing HS (nighttime) snacks on a regular basis, resulting in residents verbalizing going to bed hungry, and diabetic residents verbalizing not receiving a HS snack and the potential for low Blood Glucose levels in the morning. Findings include: During a resident council meeting on 01/24/24 at 11:00 AM, anonymous residents voiced concerns with facility not providing nourishing snacks for diabetics. One resident stated she was a Diabetic and she asked for seconds because she was still hungry, and they ran out of food. This resident ordered food to be delivered to the facility. Anonymous resident also stated they run out of bread and cheese to make them grilled cheese sandwiches and chicken noodle soup. Anonymous residents reported the snacks they do offer were not for Diabetic residents. The facility offered graham crackers, oatmeal cakes, cheese…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to: (1) effectively maintain the walk-in freezer refrigeration unit, (2) effectively maintain the food production kitchen flooring and wall surfaces, (3) effectively clean the mechanical dish machine ventilation hood and return-air-exhaust ventilation grill, and (4) effectively maintain the overhead spray arm valve handle rubberized deflector orifice effecting 85 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and erratic water discharge patterns. Findings include: On 01/23/24 at 10:00 A.M., An initial tour of the food service was conducted with Dietary Manager J. The following items were noted: Walk-In Freezer: The refrigeration unit was observed with accumulated ice [NAME], located on the front and sides of the unit. The garbage disposal overhead spray arm valve handle rubberized deflector orifice was observed broken and missing, allowing the water spray pattern to extend beyond 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 observation, interview and record review, the facility failed to maintain the dignity of one (R34) of 22 sampled residents reviewed for dignity by limiting their clothing to a hospital-style gown, resulting in an undignified appearance for a resident who is able to express clothing choices and preferences. Findings include: Resident #34 (R34) Review of the medical record revealed R34 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included difficulty in walking, muscle weakness, type two diabetes with chronic kidney disease, hyperlipidemia, morbid obesity, and type two diabetes with neuropathy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/23 revealed R34 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The same MDS reflected that R34 required one person assistance for most activities of daily living. In an observation and interview on 01/23/24 at 10:01 AM, R34 was in her room…

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 accommodate the hearing needs/preferences for one (Resident #17) of 22 reviewed for accommodation of needs. This deficient practice resulted in feelings of frustration, conflict for the resident residing with R17, and the potential for a suboptimal quality of life. Findings Include: Resident #17 (R17) Review of the medical record revealed R17 was admitted to the facility on [DATE] with diagnoses that included bilateral hearing loss, anemia, repeated falls, essential hypertension (high blood pressure), and major depressive disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/23 revealed R17 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The same MDS reflected that R17 required one person assistance for most activities of daily living. In an observation and interview on 01/23/24 at 10:59 AM, R17 was observed in bed resting quietly with no television or radio on. 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 honor resident preferences related to showering for 2 (Resident #37, #65) of 2 residents reviewed for self-determination/choices, resulting in expressions of frustration and decreased fulfillment of personal autonomy. Findings include: Resident #37 Review of the medical record reflected that Resident #37 (R37) was readmitted to facility 1/2/24 with diagnoses including trigeminal neuralgia, atrial fibrillation, seizures, and benign neoplasm of brain. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/5/23 reflected that R37 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). Review of the Discharge MDS dated [DATE] reflected that R37 required setup assistance with oral hygiene, personal hygiene, toilet use, and shower/bathing. In an observation and interview on 1/23/24 at 11:29 AM, R37 was observed sitting in wheelchair, at bedside, watching television.…

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 a homelike environment in providing adequate personal clothing laundry services including a resolution for missing items in 1 of 22 sampled residents (Resident #28), resulting in feelings of frustration and unmet needs. Findings include: Resident #28 (R28) Review of the medical record revealed R28 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, insomnia, parkinsonism, and repeated falls. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/5/23 revealed R28 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). In an observation and interview on 01/23/24 at 12:03 PM, R28 was in her room seated in her wheelchair. R28 reported that she had loads of missing clothing items and had even witnessed other residents wearing her missing clothing. R28 verbalized her extreme frustration with the situation because it has been an ongoing problem, reported…

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, staff failed to report an injury of unknown origin timely to the Nursing Home Administrator and as a result to the State Agency for one (Resident #24) of four residents reviewed potentially resulting in the resident not being protected from abusive individuals. Findings include: Resident #24 (R24) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R24 admitted to the facility on [DATE] and had diagnoses of hypertension, type 2 diabetes, depression, anxiety, and adult failure to thrive. Brief Interview for Mental Status (BIMS) score was a 10 which indicated her cognition was moderately impaired (8-12 moderately impaired). During an interview on 01/23/2024 at 10:52 AM, R24 was lying in bed with a sleeveless shirt on and it was observed that she (R24) had bruises/discoloration on both her arms. Bruising on her right upper extremity looked newer. When asked what the bruises/discoloration was from, R24 said she didn't know. Review of R24's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the bed hold policy was provided for 1 (Resident #479) of 5 residents reviewed for hospital transfer, resulting in the potential for resident's and/or representatives to be uninformed of the facility's bed hold policy. Findings include: Review of the medical record reflected that Resident #479 (R479) was readmitted to facility 1/9/24 with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, hypertension, and acute on chronic congestive heart failure. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/23 reflected that R479 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). Review of the Discharge MDS dated [DATE] reflected that R479 had an unplanned discharge to an acute care hospital and that her return to the facility was anticipated. In an observation and interview on 1/23/24 at 10:39 AM, R479…

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 prevent weight loss in one (Resident #3) of five residents reviewed for nutritional status resulting in significant weight loss of 16.9 percent and inadequate nutrition. Findings include: Resident #3 (R3) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R3 admitted to the facility on [DATE] and had diagnoses of spastic quadriplegic cerebral palsy (condition that affects movement), dysphagia (difficulty swallowing), constipation and depression. Brief Interview for Mental Status (BIMS) score was a 13 which indicated his cognition was intact (13-15 cognitively intact). During an interview with R3 on 01/24/2024 at 8:30 AM, R3 was lying in bed and stated that he wasn't sure what his current weight was and whether he lost weight. Review of R3's electronic medical record (EMR) revealed Registered Dietitian (RD) assessment on 12/5/2023 which stated, 25-100% intake. meds/labs reviewed. receiving anti-depressants, which may stimulate…

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 staff had appropriate competencies and skill sets to provide nursing related services for one of four staff reviewed for competency, resulting in the potential for decreased quality of care and resident safety. Findings Include: Review of Nursing Home Administrator (NHA) A's employee file revealed that his date of hire was 5/28/2019. NHA A has a current Licensed Practical Nurse (LPN) license. He (NHA A) did not have an annual nursing competency completed. During an interview on 1/25/2024 at approximately 4:30 PM, Assistant Director of Nursing (ADON) C stated that NHA A didn't have a competency because he works as a NHA and not as an LPN in the facility. During an interview on 1/26/2024 at 10:06 AM, NHA A revealed that he was an LPN and helps staff out on the floor sometimes. NHA A stated he assisted with transferring residents with the use of lifting equipment and had not had a competency evaluation completed at the facility. NHA A said that he should have had a competency evaluation completed annually. On 1/26/2024…

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 address pharmacist recommendations timely in three of five reviewed for medications (Resident #26, #31, & #37), resulting in the potential for adverse effects and decreased quality of care. Findings include: Resident #26 (R26) R26's Minimum Data Set (MDS) dated [DATE] revealed she was admitted to the facility on [DATE] and had the diagnoses of hypothyroidism (underactive thyroid), Diabetes, Depression, and chronic embolism and thrombosis (blood clots). R26 had a Brief Interview for Mental Status (BIMS), a short performance based cognitive screener, score of 11 (08-12 Moderate Cognitive Impairment). In review of R26's electronic medical record, pharmacy recommendations 5/24/23 recommended laboratory blood draw for R26 due to medication Levothyroxine and underactive thyroid; and was not addressed or signed by the physician until 1/25/24. Pharmacy recommendation dated 6/27/23 indicated to consider a gradual dose reduction of R26's antidepressant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than 5% when four medication errors were observed from a total of 35 opportunities for three residents (Resident #56, #71 and #281) of seven reviewed for medication administration, resulting in a medication error rate of 11.43% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects. Findings include: Resident #71 (R71) R71's Minimum Data Set (MDS) dated [DATE] revealed he admitted to the facility on [DATE], had end-stage renal disease, and a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 14 (13-15 Cognitively Intact). In review of R71's January 2024 Medication Administration Record (MAR) and January 2024's Physician orders, Renvela 800 milligrams (mg) was ordered three times a day with meals scheduled at 8:00 AM, 12:00 PM and 6:00 PM starting on 1/17/24. During a medication pass observation with…

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

Based on observation, interview and record review, the facility failed to properly store and secure controlled drugs in one of four medication carts reviewed for medication storage and properly dispose of non-controlled medications, resulting in the increased likelihood for diversion. Findings include: During a medication observation on 1/26/24 at 8:24 AM with Licensed Practical Nurse (LPN) P, Tramadol (opioid pain medication), 50 milligram (mg) tablet was dropped during medication pass preparation. LPN P picked up the Tramadol tablet, placed it into a medication cup, and locked it in the medication cart prior to administering a resident's medications. The Tramadol tablet was not double-locked. During an interview on 1/26/24 at 8:45 AM, LPN P stated she did not know if there was a drug buster (instantly breaks down medications into safe solution for disposal) or other system in the medication cart or medication room; and stated she was going to have to ask another nurse. Director of Nursing (DON) B was interviewed on 1/26/24 at 10:34 AM and stated controlled medication must be…

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 demonstrate effective 24-hour communication and coordination of care and services for two hospice Residents (R26 and R72) of two hospice residents reviewed, resulting in an incomplete medical record of hospice visits, plan of care, progress notes, care coordination and the potential for care needs to go unaddressed. Findings include: Resident #26 (R26) Review of the medical record revealed Resident #26 (R26) was admitted to the facility originally on 03/23/15 then readmitted on [DATE] with diagnoses that included Parkinsonism, Metabolic Encephalopathy, Heart Disease, Spinal Stenosis, Kidney Disease, Diabetic, Osteophyte Vertebrae, Corticobasal Degeneration, Left Degeneration, Right Cervical Degeneration, Unspecified Cervical Region. According to Resident #26 (R26)'s Minimum Data Set (MDS) dated [DATE], revealed R26 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive 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.

Based on interview and record review, the facility failed to ensure continuing competence of nurse assistants for one of three nurse assistants reviewed for staff competency resulting in the potential for unmet resident care needs. Findings include: Review of employee file Certified Nursing Assistant (CNA) AA revealed that her date of hire was 12/20/2022. CNA AA didn't have any documentation of educational hours completed between 12/20/2022 and 12/20/2023. During an interview on 1/25/2024 at 10:14 AM, Assistant Director of Nursing (ADON) C stated that CNA AA didn't complete 12 hours of education from hire date of 12/20/2022 to anniversary date of 12/20/2023. On 1/26/2024 at 10:19 AM, NHA A was emailed and asked for the facility's policy regarding CNA education. He replied that they followed the State regulations related to 12 hours of continuing education for CNA's.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00141324 Based on interview and record review, the facility failed to honor an advance directive and the resident's right to refuse treatment in 1 (Resident #9) of 4 residents reviewed for Advanced Directives, resulting in CPR (Cardiopulmonary Resuscitation) being performed on a resident with a DNR (Do not Resuscitate) status. Findings include: Review of the medical record revealed that Resident #9 (R9) was admitted to facility [DATE] with diagnoses including acute on chronic congestive heart failure, cerebral infarction, stage 3 chronic kidney disease, chronic obstructive pulmonary disease, chronic atrial fibrillation, malignant neoplasm of right lung, left femur fracture, and COVID-19. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] reflected that R9 was understood by and able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact). Review of a second MDS dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00141825. Based on interview and record review, the facility failed to report an allegation of abuse to the State Agency for one (Resident #8) of three reviewed, resulting in an allegation that was not reported to the State Agency and the potential for further allegations to go unreported. Findings include: Review of the medical record revealed Resident #8 (R8) was admitted to the facility on [DATE]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/23 revealed R8 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), required assistance with self-care and was frequently incontinent of bowel and bladder. Review of the complaint submitted to the State Agency revealed This morning he [R8] disclosed he had been touched inappropriately by a staff member .Caller claims the victim told her that when someone came to change him this morning, while doing so, they inserted fingers/hand into his rectum…

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 MI00141324 Based on observation, interview, and record review, the facility failed to ensure residents received annual Level 1 PAS/ARR (Preadmission Screening/Annual Resident Review) in 1 (Resident #4) of 4 residents reviewed for PAS/ARR, resulting in the potential for unmet mental health treatment and services. Findings include: Review of the medical record revealed that Resident #4 (R4) was initially admitted to facility 1/26/2021 with diagnoses including unspecified depression and mood disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/23 revealed that R4 had clear speech and was both understood by and able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 8 (moderate cognitive impairment). Section N of the same MDS reflected that R4 was taking an antidepressant medication. In an observation and interview on 1/2/24 at 12:09 PM, R4 was observed lying in bed, dressed in a facility gown, with head of bed positioned at an approximate 90-degree angle. R4…

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 MI00141825. Based on interview and record review, the facility failed to provide pressure ulcer treatments as ordered for one (Resident #8) of 4 reviewed, resulting in the potential of a worsened pressure ulcer. Findings include: Review of the medical record revealed Resident #8 (R8) was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of the right heel. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/23 revealed R8 had a stage 4 pressure ulcer present on admission. R8 was discharged from the facility on 11/15/23. Review of the Wound assessment dated [DATE] revealed R8 had a right heel vascular wound, and the treatment was to cleanse with wound cleanser and apply a dry dressing. Review of the Physician's order dated 10/19/23 revealed cleanse the wound with wound cleanser, pat dry with gauze, apply dry dressing, and wrap with ABD pad and kerlix. This order was not scheduled to appear on the 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 This citation pertains to Intake MI00141570. Based on observation, interview, and record review, the facility failed to maintain a system to account for the accurate usage and reconciliation of all controlled medications for one (Resident #6) of three reviewed, resulting in the potential for medication errors and drug diversion. Findings include: Review of the medical record revealed Resident #6 (R6) was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and major depressive disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/1/23 revealed R6 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and received scheduled and as needed pain medications. On 1/2/24 at 11:22 AM, R6 was observed lying in bed. Review of the Control Substance Records for hydromorphone 2 milligrams (2mg) (Dilaudid-opiod pain medication) and the Medication Administration Records (MARs) revealed the following: On 10/5/23…

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 Numbers MI00135032 and MI00136796. Based on interview and record review, the facility failed to administer medications and ordered by the physician for two (Resident #2 and Resident #5) of three reviewed, resulting in missed medications and the potential for worsening medical conditions. Findings include: Resident #5 (R5) Review of the medical record revealed R5 admitted to the facility on [DATE]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/12/23 revealed R5 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). R5 discharged home from the facility on 5/18/23. Review of R5's hospital Discharge summary dated [DATE] revealed R5 had an exposure to scabies and was started on Ivermectin per dermatology recommendations. R5 also had maceration of his toes for which dermatology recommended Ketoconazole cream. The discharge medications list revealed to start taking Ivermectin 16,500 micrograms (mcg) once per week starting 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 administer pneumococcal immunizations per consent and Centers for Disease Control and Prevention(CDC) recommendations for two (Resident #6 and Resident #7) of five reviewed, resulting in the potential for serious illness and complications from pneumococcal disease. Findings include: Resident #6 (R6) Review of the medical record revealed R6 admitted to the facility on [DATE] with diagnoses that included diabetes and atrial fibrillation. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/23/23 revealed R6 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 7/31/23 at 10:14 AM, R6 was observed lying in bed. Review of R6's immunization history revealed she received the Pneumococcal polysaccharide vaccine (PPSV23) on 10/17/17. Review of the Resident Vaccination History and Consent Form revealed R6 received the PPSV23 on 10/17/17 and consented to a pneumonia vaccine. R6…

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.