Medilodge of Zeeland

This citation pertains to intake #2666838Based on interview and record review, the facility failed to implement and maintain a system for complete and accurate medical records for 5 (R4, R5, R7, R9, and R10) of 10 residents reviewed for medical records.Findings include:Review of the electronic medical records (EMR) for R4, R5, R7, R9 and R10 revealed a lack of documentation regarding the following incidents: R4Review of a Risk Management document dated 12/28/25 for R4 revealed No documentation regarding the incident on 12/28/25 when R4 was observed in R5's room laying on his bed exposing himself to her. No documentation indicating the physician or the guardian was notified or what interventions were put into place. R5Review of the EMR for R5 revealed no daily behavior documentation or documentation regarding resident-to-resident incidents on 10/22/25, 12/24/25, 12/28/25. Review of a Behavioral Health progress note dated 12/24/25 for R5 revealed: Previously, patient demonstrated significant behavioral disturbances including yelling/screening, kicking/hitting, pushing, grabbing,…

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 #: MI00153297 Based on interview and record review, the facility failed to ensure sufficient supervision and safety measures were in place to prevent an elopement for 1 of 4 residents (Resident #1) reviewed for accidents, safety, and supervision. Findings: Resident #1 (R1) Review of an admission Record revealed R1 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's Disease and psychotic disorder with delusions. Review of R1's Facility Reported Incident dated 3/27/25 (from R1's previous facility) revealed R1 had eloped .Resident exited the facility unsupervised at 0510 am. She exited the building through the left exit doors in the main dining room . Review of R1's Nursing admission Screening/History dated 3/27/25 revealed the reason for admission was elopement. Review of R1's baseline care plan section C revealed, MAY WANDER OR ATTEMPT TO LEAVE FACILITY UNATTENDED . Review of R1's Patient admission Information 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 maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting the following areas: Findings include: Rooms 409/411 During an observation on 2/25/25 at 9:52 AM and 12:17 PM, room [ROOM NUMBER] had a shared bathroom with room [ROOM NUMBER]. Inside the bathroom was a dirty exhaust fan and an oxygen concentrator with a nasal canula connected to it stored under the sink. During observations on 2/26/25 at 7:34 AM and 9:22 AM rooms 409/411 still had the oxygen concentrator in the bathroom with the nasal cannula attached to it. During an observation and an interview on 2/27/25 at 9:30 AM, Certified Nursing Assistant (CNA) B accompanied this surveyor to the connected bathroom for rooms 409/411 and saw the oxygen concentrator with the nasal cannula attached, stored under the sink next…

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 promote resident dignity for 1 (R21) of two residents reviewed for dignity. Findings include: Review of an admission Record revealed R21 admitted to the facility on [DATE] with pertinent diagnoses which included hemiparesis (muscle weakness or partial paralysis on one side of the body) and psoriasis (a skin condition in which skin cells build up and form scales and itchy, dry patches). Review of a Minimum Data Set (MDS) assessment for R21, with a reference date of 1/22/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R21 was cognitively intact. Further review revealed R21 required staff assistance with toileting. In an interview on 2/27/2025 at 8:22 AM, R21 reported she had a bowel movement the previous morning at 8:10 AM and pushed her call light. R21 reported Certified Nursing Assistant (CNA) J entered her room and she told him that she had soiled herself and needed to 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 implement dermatology recommendations in a timely manner for one resident (R21) of two residents reviewed for skin conditions. Findings include: Review of an admission Record revealed R21 admitted to the facility on [DATE] with pertinent diagnoses which included hemiparesis (muscle weakness or partial paralysis on one side of the body) and psoriasis (a skin condition in which skin cells build up and form scales and itchy, dry patches). Review of a Minimum Data Set (MDS) assessment for R21, with a reference date of 1/22/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R21 was cognitively intact. In an observation and interview on 2/25/2025 at 11:56 AM in room [ROOM NUMBER], R21 reported she had a rash, itching, and burning under her right breast that staff were not treating. R21 reported this was an ongoing issue and she had recently been to a dermatologist. This…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper tube feeding precautions were implemented and maintained for one resident (R37) of two residents reviewed for enteral feeding. Findings: Review of the Electronic Medical Record (EMR) reflected R37 originally admitted to the facility on [DATE] with diagnoses that included a history of stroke, dementia, and was receiving nutrition through a feeding tube. Review of the Doctor's Orders dated 2/14/25 for R37 reflected an enteral feed order and the Medication Administration Record (MAR) reflected or Glucerna 1.5 to be delivered at 100 cubic centimeters (cc) per hour. On 2/25/25 at 9:28 AM, a dressing change for R37 was observed in the Resident's room with Licensed Practical Nurse (LPN) R and Unit Clerk (UC) T. It was observed that the head of the bed was elevated approximately ten degrees and R37 was turned onto his left side during the dressing change that lasted approximately fifteen minutes. It was observed that the enteral…

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 infection control measures were maintained during a dressing change for one resident (R37) of three residents reviewed for infection control. Findings: Review of the Electronic Medical Record (EMR) reflected R37 originally admitted to the facility on [DATE] with diagnoses that included a history of stroke and dementia, Review of the EMR Progress Notes entry dated 1/28/25 at 2:32 AM reflected a three-centimeter (cm) lump was identified at the hairline of the neck of R37 and the medical provider was notified. On 2/5/25 the Progress Note entry at 3:39 PM reveal a change in the lump and R37 was transported to the hospital for evaluation. On 2/13/25, R37 returned from the hospital with a wound vac dressing (also known as vacuum assisted closure (VAC), a medical device sealed over a wound that uses negative pressure to pull fluid and debris out of the wound promoting granulation tissue growth). The entry reflected R37 was referred to 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 This citation pertains to intake MI00148411 Based on observation, interview, and record review, the facility failed to assess timely, monitor, treat and adequately control pain for 1 Resident (R1) of 3 Residents reviewed for pain. Review of R1's face sheet dated 2/6/25 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had diagnoses that included: 11/28/24 encounter for other orthopedic, polyneuropathy (peripheral nerve disorder that affects multiple nerves throughout the body simultaneously), pain in right shoulder, generalized anxiety disorder, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), Pseudobulbar affect (inappropriate involuntary laughing or crying due to nervous system disorder) and mild cognitive impairment. R1 was listed as her own responsible party. Review of R1's progress note dated 1/20/25 at 12:44 PM revealed R1 had a mental evaluation, and she score 15 out of 15 on her Brief Interview of Mental Status (BIMS). Normal…

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 #MI00145408. Based on interview and record review, the facility failed to prevent significant medication errors for 1 resident (Resident #101) of 3 residents reviewed for medication use, resulting in the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included seizures, fibromyalgia, and hypertension. In a telephone interview on 7/16/2024 at 9:05 AM, Hospital Case Manager B reported it was learned while preparing Resident #101 for discharge from the hospital back to the facility on 6/28/2024 that Resident #101 had not been taking all the medications according to discharge orders the last time she was discharged from the hospital back to the facility on 6/18/2024. Review of Resident #101's local hospital Hospitalist Discharge Summary, dated 6/28/2024, revealed .Patient well known with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00145408. Based on interview and record review, the facility failed to ensure nursing staff were competent and adequately trained to reconcile physician's orders and medications during the admission process, resulting in the potential for compromised resident safety and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included seizures, fibromyalgia, and hypertension. In a telephone interview on 7/16/2024 at 9:05 AM, Hospital Case Manager B reported it was learned while preparing Resident #101 for discharge from the hospital back to the facility on 6/28/2024 that Resident #101 had not been taking all the medications according to discharge orders the last time she was discharged from the hospital back to the facility on 6/18/2024. Review of Resident #101's local hospital…

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 #MI00145408. Based on interview and record review, the facility failed to ensure Medication Regimen Reviews, which noted irregularities or recommendations, were addressed by the physician in a timely manner for 1 resident (Resident #101) of 3 residents reviewed for medication use, resulting in the potential for unnecessary medications, negative medication side effects, and for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included seizures, fibromyalgia, and hypertension. Review of Resident 101's electronic medical record on 7/16/2024 at 1:05 PM revealed the pharmacist perform Medication Regimen Reviews for Resident #101 for each re-admission from the local hospital on 6/16/2024 and 6/28/2024. Review of Resident #101's Medication Regimen Review Note to Attending Physician/Prescriber, 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 ensure one medication cart was secure and medications were properly stored in two medication carts and failed to ensure proper labeling and dating of a biological medication in one medication storage room. Findings: On [DATE] at 7:14 AM a review of the 400-hall medication cart #2 revealed eight loose pills in the bottom of the second drawer amongst bubble packed medications. Registered Nurse (RN) P reported she could not identify what the variety of medications were or to which resident the medications belonged. On [DATE] at 7:38 AM a review was conducted on the 300 long hall medication cart with LPN O. Review of the second drawer revealed ten loose pills among medications in bubble packs. LPN O indicated he did not know to whom the loose medication belonged. The policy provided by the facility titled Medication Administration Subject Medication Access and Storage dated [DATE], was reviewed. The policy Procedure reflected 1. The provider…

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 reduce the risk of contamination in spa and laundry areas and have an ongoing and active plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in contamination of surfaces, clean linen, and for water borne pathogens to exist and spread in the facility's plumbing system. Findings include: During a tour of the laundry room, with Maintenance Director (MD) B and Housekeeping Manager (HM) C, at 1:15 PM on 2/5/24, it was observed that two light shields were missing over the dryer and folding area as well as two light shields missing in the dirty laundry room. When pointed out the MD B he stated he would get them fixed. During a tour of the 100 hall spa room, at 1:25 PM on 2/5/24, it was observed that a streak of brown bowel movement was found on the middle section of a blue shower chair. When asked if she could see the accumulation, HM C stated yes. When asked how cleaning is performed in the spa rooms, HM…

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 one Resident (Resident #3 (R3)) that had been provided a motorized wheelchair. Findings: R3 originally admitted to the facility 9/23/15. The Electronic Medical Record (EMR) reflects R3 has current diagnoses that include Quadriplegia and Neuromuscular Dysfunction. The Minimum Data Set (MDS) dated [DATE] and the MDS dated [DATE] were both reviewed. Section GG, Functional Abilities and Goal, of both MDS assessments reflected R3 has a motorized wheelchair. On 2/5/24 at 4:33 PM an interview was conducted with R3 in his room. R3 was observed to be in a motorized wheelchair. R3 demonstrated the chair can be tipped backward severely and reported that when he does this it scares people. R3 indicated he reclines the chair back to relieve the pressure on his buttocks. Review of the Care Plan for R3 reflected a Focus of .Activities of Daily Living (ADL)) self-care deficit (related to) immobility . (R3) Currently in Broda…

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 showers for 2 dependent residents (Resident #51 and Resident #101), of 2 residents reviewed for showers. Findings include: Resident #51 (R51) Review of a Face Sheet for R51 revealed she admitted to the facility on [DATE] and has pertinent diagnoses of fetal alcohol syndrome and the need for assistance with personal care. Review of the Minimum Data Set (MDS) dated [DATE] for R51 reveals that she is severely cognitively impaired and has functional limitations for range of motion (ROM) on bilateral upper and lower extremities. She is totally dependent for Activities of Daily Living (ADLs) including showers/bathing. During an observation on 2/5/24 (Monday) at 11:04 AM, R51 is laying in bed with greasy disheveled hair. The resident was nonverbal. During an observation on 2/6/24 (Tuesday) at 7:47 AM, R51 is laying in bed on her back partially covered, her hair is disheveled and has greasy appearance. In an interview on 2/6/24 at 4:50 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure quality care was provided to one resident (Resident #16 (R16)) of two residents reviewed resulting in a delayed assessment and subsequent hospital treatment. Findings: R16 initially admitted to the facility 10/23/15. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the Resident is cognitively intact. Review of the Electronic Medical Record (EMR) Progress Notes for R16 revealed a nurse entry dated 10/4/23 at 3:57 AM. The entry revealed that Resident had come up to nurses' station several times in the last 2 hours with different GI complaints. The entry reflected at 03:45 (AM), during the fourth time of voicing a complaint to the nurse, R16 vomited at the nurse's station. The documentation continued with It was then discovered that the resident's temp (sic) was 101.8 (Fahrenheit) The entry reflected within 10 minutes R16 was transported to the hospital.…

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 care and services for contractures for 1 (Resident #51) of 1 resident reviewed for contractures. Findings include: Resident #51 (R51) Review of a Face Sheet for R51 revealed she admitted to the facility on [DATE] and has pertinent diagnoses of a need for assistance with personal care. Review of the Minimum Data Set (MDS) dated [DATE] for R51 reveals that she is severely cognitively impaired and has functional limitations in range of motion (ROM) on bilateral upper and lower extremities. She is totally dependent for Activities of Daily Living (ADLs) including showers/bathing. During an observation on 2/5/24 at 11:04 AM, R51 is nonverbal, lying in bed and her right arm was bent at the elbow and her fingers clenched in her hand. No splints, slings, or positioning devices in place. During an observation on 2/5/24 at 11:42 AM, Certified Nursing Assistant (CNA) D is providing care for R51 who was not able to use her right upper extremity…

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 1 resident (Resident #155) from a total sample of 18 residents reviewed, was free from accidents and hazards when a functioning nurse call system was not available in the resident room. Findings: Resident #155 (R155) Review of an admission Record reflected R155 admitted to the facility on [DATE] with pertinent diagnoses that included a need for surgical aftercare, heart disease, severe obesity, acute posthemorrhagic anemia (blood loss), atrial fibrillation (abnormal heart rhythm), high blood pressure, weakness and a need for personal assistance. Review of an admission Fall Risk Assessment dated 2/1/2024 reflected R155 was at High Risk for Falling. Review of a Kardex (a care guide) as of 2/7/2024 reflected R155 was Full Weight Bearing and needed one person to assist with transfers, personal hygiene, dressing and bathing/showering. During an observation and interview on 2/6/2024 at 3:30 PM, R155 could not reach the call light. The cord…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow professional standards for tube feedings for 1 (Resident #51) of 2 residents reviewed for tube feedings. Findings include: Resident #51 (R51) Review of a Face Sheet for R51 revealed she admitted to the facility on [DATE] and has pertinent diagnoses of need for assistance with personal care. Review of the Minimum Data Set (MDS) dated [DATE] for R51 reveals that she is severely cognitively impaired. During an observation on 2/5/24 at 11:42 AM, Certified Nursing Assistant (CNA) D turned off the tube feeding machine for R51 before providing care and lowering the head of the bed. CNA D turned the machine back on and pressed a few buttons which changed the settings, then turned it off again and went to get the nurse. When the nurse came to the room, she turned the machine off and told the CNA she will turn it back on when he is done providing care. The tube feeding that was infusing was dated for 2/4/24 at 13:13 (1:13 PM) indicating 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 has two Deficient Practice Statements (DPS) DPS #1 This citation pertains to intake M100140945. Based on interview and record review, the facility failed to operationalize policies and procedures and have medications available for 1 (Resident #102) of 1 resident reviewed for new admissions. Findings include: Resident #102 (R102) Review of a Face Sheet revealed R102 admitted to the facility on [DATE]. In an interview on 2/6/24 at 2:15 PM, R102 reported she admitted to the facility post hospitalization on 11/8/24 and the facility did not have her medications when she arrived. She reported she received her Lyrica at 11 PM on 11/8/23 (not documented on the MAR). R102 reported the manager was supposed to talk to her before she left the faciity on [DATE] at 1:30 PM but nobody came to talk to her. She then left AMA (against medical advice). Review of a Hospital Discharge Summary document dated 11/8/23 and faxed to the facility on [DATE] at 2:36 PM for R102 revealed a list of medications the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to operationalize policies and procedures and provide informed consent and pertinent labs for 1(Resident #81) of 5 residents reviewed for unnecessary medications/psychotropic medications. Findings include: Resident #81 (R81) Review of a Face Sheet revealed R81 admitted to the facility on [DATE] with pertinent diagnoses of dementia, anxiety, remission of alcohol abuse, and cognitive communication deficits. Review of the February Medication Administration Record (MAR) for R81 revealed he is taking Depakote (Divalproex) and Klonopin (Clonazepam) which are psychotropic medications that require informed consent and monitoring. Review of the Divalproex/Depakote medication insert from the drug manufacturer revealed: Hepatotoxicity, including fatalities, usually during the first 6 months of treatment. Monitor patients closely and perform liver function tests prior to therapy and at frequent intervals thereafter (5.1) . 5.14 Monitoring: Drug Plasma Concentration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to operationalize their policy and procedures and provide vaccines for 2 (Resident #64 and Resident #65) of 5 residents reviewed for vaccines. Findings include: Resident #64 (R64) Review of a Face Sheet for R64 revealed he was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Electronic Medical Record (EMR) for R64 revealed his last influenza vaccine was 11/30/21 and his pneumovax was 12/2/20. Documentation does not reveal vaccines were offered and administered to the resident. Review of R65 Resident #65 (R65) Review of a Face Sheet for R65 revealed he was admitted to the facility on [DATE]. Review of the EMR for R65 revealed there is no documentation indicating he was offered and provided vaccines to make sure they are up to date for COVID-19, pneumonia, and influenza. In an interview on 2/7/24 at 1:41 PM, the Director of Nursing (DON) reported R64 and R65 missed the flu clinic in the fall and did not get offered 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.