Healthsource Saginaw, Inc

Inspectors wroteThis citation pertains to Intake Numbers 2999184 and 3006165. Based on interview and record review, the facility failed to prevent the opening of one resident's (Resident #104) postal mail of 3 sampled residents, resulting in Resident #104 receiving opened mail/letters while residing at the facility. Record review of the Health Care Association of Michigan (HCAM) 'Rights of Residents in Michigan Nursing Facilities' 2024, states that residents have the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility through a means other than a postal service, including the right to: Privacy of such communications . An interview was conducted on 7/13/2026 at 11:55 AM with Resident #104 about his opened mail. Resident #104 stated they opened my mail, slit it with a knife and then they taped it up and brought it to me. [...]

Inspectors wroteThis citation pertains to intake Number 3073791. Based on observation, interview and record review, the facility failed to ensure quality of care for one resident (Resident #102) of 3 residents reviewed, resulting in Resident #102 receiving duplicate wound care treatments and a lack of a documented physician's notification of a change in condition. Resident #102:Observation and interview on 7/13/2026 at 12:17PM with Licensed Practical Nurse (LPN) I and Registered Nurse (RN) J of Resident #102's coccyx region wound vac dressing change. Observe Resident #102 lying in bed turned to the left side, observed coccyx wound of 4.5cm x 6.5cm, 2cm depth, no drainage at time of observation. RN J stated the wound has drainage with wound vac of serosanguinous. Observation of wound care the area was cleansed and no tunneling noted. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to adequate care and treatment for one resident (Resident #101) of 4 residents reviewed, resulting in the resident having received the wrong medications during morning medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one resident (Resident #103) of 3 residents reviewed for implementation of care plan interventions (one-one-one for Resident #103), resulting in no one-on-one intervention leading to a resident-to-resident interaction with Resident #106 and scratches incurred by Resident #103. Findings Include: Resident #106:Review of the Face Sheet, and care plans dated 2021, revealed Resident #106 was 82 years-old, admitted to the facility on [DATE]/21, was cognitively impaired with a BIMS of 3 (Cognitive assessment score, 4 being impaired), and required staff assistance with all Activities of Daily Living/ADLs. The resident's diagnoses included, Alzheimer's, Dementia, Parkinson's, Schizophrenia, Bipolar stroke and Agitation. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent significant medication errors for two residents (R101 and R102) of 4 residents reviewed for medication errors, resulting in a staff nurse administering five (5) medications to the wrong resident (R101), which could have resulted in a negative outcome for the resident and for the uncertainty of the other resident (R102) receiving the prescribed doses of medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide quality care and services for 4 residents (Resident's #1, #27, #166 and #181) regarding urinary catheter care, applying [NAME] Hose (Resident #1), assessing and monitoring for motorized wheelchair seat belt (Resident #27), assess and treat for a wound/boil (Resident #166), and assess and treat per orders regarding skin integrity (Resident #181), resulting in increased potential for infection, safety concerns regarding safety belt with a motorized wheelchair, increased urinary tract infections and trauma to urinary catheter, safe use of [NAME] Hose, and increased discomfort/pain with possible hospitalization. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement control measures for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development of pressure ulcers for two residents (R15, R86) of 5 residents reviewed for pressure ulcers, resulting in Resident #15 and Resident #86 developing pressure ulcer/injuries while residing in the facility. Record review of the National Institue of Health (NIH) 2022 Pressure Ulcer staging:Stage 2: There is partial-thickness skin loss involving the epidermis and dermis. Stage 3: A full thickness loss of skin extends to the subcutaneous tissue but does not cross the fascia beneath it. Slough or eschar may be visible, and the lesion may be foul-smelling. Stage 4: Full-thickness skin loss extends through the fascia with considerable tissue loss. There may be muscle, bone, tendon, or joint involvement. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assess, monitor and document continued seepage and nonadherence for one resident's (Resident #7) ileostomy appliance (Ileostomy is a surgical procedure in which an opening is made in the abdominal wall for stool to leave the body through a stoma. An appliance is worn over the stoma to collect stool) of two residents reviewed for ostomy care. Findings Include: On 7/29/2025 at 4:12 PM, Resident #7 was observed watching television in his room. He had a pleasant demeanor and shared some concerns with this writer. He stated his ileostomy is not adhering and is leaking. The residents' ileostomy site was observed to have leakage that was pooling on his abdomen. When asked when it was last changed, he reported this morning. Resident #7 was uncertain how long it had been leaking but stated it was sore. [...]

Inspectors wroteBased on observation, interview and record review, failed to 1) Ensure hydration fluids were within reach for Resident #13 and 2) Ensure nutrition status monitoring for 2 residents (#7, #10) of 10 residents reviewed for nutrition, resulting in potential for dehydration and thirst for Resident #13, and weight loss not being identified with the potential for further weight loss and decline in overall health and wellbeing. Resident #10: Record review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental status (BIMs) score of 15 out of 15, cognitively intact. Medical diagnosis included hypertension, urinary tract infection, diabetes, hemiplegia, depression, bipolar and chronic obstructive pulmonary disease. Review of Section K: Swallowing/Nutrition status- noted weight of 183 pounds. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide enteral tube feeding per nursing standards for one resident (Resident #107) of one resident reviewed for tube feeding, resulting in the infusion of expired solution and improper positioning of the head of the bed with the likelihood of gastrointestinal upset, infection and/or aspiration.

Inspectors wroteBased on observation, interview and record review the facility failed to timely remove a peripheral IV (intravenous) for one resident (#169) of one reviewed for IV access. Findings Include:On 07/29/2025 at approximately 1:13 PM, Resident #169 was observed watching television in his room. The resident was asked what the peripheral IV (intravenous) in his right forearm was being utilized for. The resident stated, They don't use it for anything, it has not been used in over a week. The IV dressing was not dated nor initialed. On 7/29/2025 at approximately 3:10 PM, Nurse Manager T observed Resident #169's peripheral IV and was asked what it was being utilized for. He stated he believed it was for IV hydration. Resident 169's wife was in the room and explained he received IV hydration last week and was supposed to have follow up lab work, but was not certain if that had occurred. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:Facility [NAME], [NAME] (52634) - Kitchen On 7/29/2025 at 9:25AM A kitchen tour was conducted with the Regional Director of Operations I and the General Manager J. On 07/29/2025 at 9:42 AM Record review of the high temp dishwasher log temps had ranges at the rinse temp from 154-193 degrees Fahrenheit. The guidelines for temperature ranges at the top of the document state Rinse 180 degrees Fahrenheit. On 7/29/2025 at 9:45 Observed dishwasher temps at: final temp 184, wash 164, rinse 161, and dual rinse 173 degrees Fahrenheit. On 07/29/2025 at 9:55 AM Observed mixer visibly soiled with residue. [...]

Inspectors wroteThis citation pertains to Intake Number 2564956. Based on observation, interview and record review, the facility failed to implement care plan interventions for fall safety prevention for 2 of 5 residents (R21 & R114) reviewed to be at risk for falls, accidents and hazards, by not consistently ensuring the resident's call light was within reach and the fall mat was in place as outlined in the residents' care plans.

Inspectors wroteThis citation pertains to intake Number MI00149682. Based on interview and record review, the facility failed to provide adequate post fall assistance to one resident (R1) of three residents reviewed for falls, resulting in feelings of sadness and tearfulness.

Inspectors wroteThis Citation pertains to Intake Number MI00149011. Based on observation, interview and record review, the facility failed to supervise and prevent a fall for one resident (Resident #1) with a history of anticoagulants and falls, of 3 sampled residents, resulting in the lack of meaningful interventions to prevent repeated falls and the lack of ongoing supervision of a resident, who was a known fall risk, resulting in Resident #1 sustaining a fall from wheelchair and suffering a subdural hematoma with hospitalization and death.

Inspectors wroteThis citation pertains to Intake Numbers MI000147442 and #MI00147989. The facility failed to ensure professional quality of care regarding timely treatment, transfer to acute care for evaluation and treatment of an infected wound for 1 resident (Resident #104) of 3 residents reviewed for pressure ulcers, resulting in sepsis (severe infection throughout body), hospital admission with treatment for infected pressure ulcer, and antibiotic usage. Findings Include: Resident #104: Review of the Face Sheet, care plans and physician orders dated 5/31/24 through 6/29/24, physician and nursing progress notes dated 5/31/24 through 6/29/24, revealed Resident #104 was 57 years-old, alert with communication deficit due to stroke, admitted to the facility on [DATE] and discharged to acute care for evaluation and treatment of an infected coccyx pressure ulcer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent two residents (Resident's #415 and Resident #75) from developing pressure ulcers, resulting in discomfort/pain, the likelihood for infection, delayed healing, antibiotic usage, and weekly wound care. Findings Include: Resident #415: Review of the Face Sheet, Wound Documentation dated 6/6/24 through 8/6/24, and care plans dated 1/23, revealed Resident #415 was [AGE] years old, admitted to the facility on [DATE] and re-admitted on [DATE], alert and his own person and required staff assistance with Activities of Daily Living/ADL's. The resident's diagnosis included, dementia, stroke, muscle weakness, anorexia, malnutrition, chronic pain, chronic kidney disease, and heart failure. The resident developed a pressure ulcer on the right heel while at the facility due to shearing of bedding. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that previous survey results, State Hotline and Ombudsman contact information were accessible for all residents, resulting in the potential for all residents to be frustrated and/or uninformed of the previous survey results and unsure how and who to complain to.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the daily staff posting was accessible for all residents, resulting in the potential for all residents to be frustrated and/or uninformed of the daily available staff.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that the Arbor Cafe's refrigerator was clean and sanitary, and 2) Failed to ensure a clean and sanitized kitchen for a census of 162 residents who eat from the kitchen, resulting in the likelihood for resident illness from cross contamination, unsafe food items and weight loss. Findings Include: On 8/05/24 at 9:15 a.m., during the initial kitchen tour accompanied by Chef F and VP of Dietary G, the following observations were made: -At 9:43 a.m., a large trash bin with trash up to the top was found sitting next to the grill, with no lid on it. -At 9:44 a.m., the microwave was found to have dried food particles on the inside top, sides and door. -At 9:45 a.m., the large can opener had dried food on it and the paint was chipping off the blade. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a clean and safe environment for 3 Units (Wheel's, Patriot, and Garden) of 4 units observed and failed to ensure that one resident's refrigerator (room [ROOM NUMBER]) was clean and all food items were dated, resulting in the likelihood for cross contamination, resident illnesses, cluttered resident rooms, and an unsafe environment. Findings Include: Environmental tour done on 8/7/24 starting at 10:28 a.m., accompanied by the Director of Nursing/DON, Director of Maintenance C, and the Director of Housekeeping A. During the tour, the following concerns were found: On Wheels Neighborhood starting at 10:30 a.m.: -In room [ROOM NUMBER], the CPAP (continuous positive airway pressure) was sitting on the nightstand, not in the clear plastic bag next to the CPAP machine. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that grievances were followed up timely and ensure that all residents were invited to the Resident Council meeting for a confidential group of residents, resulting in feelings of being left out, frustration, crying, continued complaints of staff being loud, rude, slow and disrespectful call light responses.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment to ensure that residents' rooms, dining rooms and other facility areas were 1) Clean, uncluttered and in good repair including Rooms 383, 422 and 449; 2) Without pests; 3) Cleaning supplies were stored properly; and 4) A Confidential group of residents received proper silverware, resulting in an unclean and non-homelike physical environment, resident dissatisfaction and complaints. Findings Include: FACILITY Environment On 8/5/2024 at 9:58 AM, during a tour of the building room [ROOM NUMBER] was observed to have a yellow, urine-soaked wash rag, laid out flat on the floor in front of the toilet. The room smelled strongly of urine. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide Activities of Daily Living (ADL) care for five dependent residents (Resident #59, Resident #60, Resident #62, Resident #117 and Resident #135) of eight residents reviewed for ADL's resulting in long, dirty fingernails, female residents having facial hair, lack of assistance with oral care and timely assistance with toileting.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents' food preferences were honored for four residents (Resident #23, Resident #26, Resident #42, and Resident #79) of 7 residents reviewed for food and nutrition, resulting in residents' feelings of anger, frustration and dissatisfaction with the meal experience, which could lead to decreased nutritional intake and weight loss. Findings Include: Resident #23: Food A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #23 was admitted to the facility on [DATE] with diagnoses: history of a stroke, left sided weakness, GERD, depression weakness, epilepsy and hypertension. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide snacks, including bedtime snacks, for a confidential group of residents, resulting in complaints of the unit refrigerators being empty of snacks, no availability for snacks, no personal choice of snacks, familiy and friends having to purchase snacks with the feelings of frustration, sadness and hunger.

Inspectors wroteThis Citation pertains to Intake Number MI00143547. Based on observation, interview and record review the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1) Personal Protection Equipment/PPE use, 2) Hand Hygiene for Residents #56 and #143 and 3) Linen transport for a census of 162 residents, resulting in the potential for the spread of infection. Findings Include: On 8/05/24, at 1:35 PM, the in-room sanitizer for room [ROOM NUMBER] was not working. Resident #56: On 8/07/24, at 8:55 AM, an observation of Resident #56's incontinence care along with CENA X was conducted. CENA X had gloves on and assisted the resident with perineal care and placed a new incontinent brief on the resident. Resident #56 asked for a drink and CENA X picked up the bedside cup with their gloved hand and offered the bedside cup to the resident. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a Preadmission Screening and Annual Resident Review (PASARR) Level II completed by Community Mental Health with recommendations for specialized mental health services was incorporated into the residents' plan of care for two residents (Resident #26 and Resident #59) of 2 residents reviewed for PASARR, resulting in the potential for absence of available services for mental health disorders . Findings Include: Resident #26: PASARR A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #26 was admitted to the facility on [DATE] with diagnoses: Guillain-Barre syndrome, quadriplegia dysphagia, bipolar disorder, pneumonia, pain, depression, and hypertension. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update/revise individualized, person-centered care plans to reflect changing care needs for three residents (Resident #12, Resident #16, and Resident #117), of 32 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings Include Resident #16: Pressure Ulcer/Injury A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #16 was admitted to the facility on [DATE] and the most recent readmission of 4/16/2024 with diagnoses: History of brain injury, quadriplegia, seizures, hydrocephalus, dysphagia, multiple pressure ulcers, and anxiety. The MDS assessment dated [DATE] revealed the resident had severe cognitive decline and was dependent with all care. On 8/06/24 at 9:53 AM, Resident #16 was observed lying in bed. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00143547. Based on interview and record review the facility failed to monitor and treat blood glucose levels for one resident (Resident #165) of five residents reviewed for medication management, resulting in Resident #165 developing a change of condition due to low blood glucose levels and being transferred to the hospital. Findings Include: Resident #165: Hospitalization A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #165 was admitted to the facility on [DATE] with diagnoses: Diabetes, end stage kidney disease, renal dialysis, Alzheimer's disease, GERD, COPD, hypothyroidism, and hypertension. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 14/15 and needed assistance with all care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that management and monitoring of a left arm splint was provided for one resident (Resident #78), of 1 resident reviewed for splint use, resulting in Resident #78 having a soiled hand splint, that had not been laundered. Findings Include: Resident #78: Position, Mobility A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #78 was admitted to the facility on [DATE] with diagnoses: Dementia, history of a stroke, diabetes, depression, weakness, COPD, obesity, pain, seizure disorder, dysphagia and left sided weakness. The MDS assessment dated [DATE] revealed Resident #78 had full cognitive abilities with a BIMS score of 15/15 and needed assistance with all care. On 8/05/24 at 1:28 PM, Resident #78 was observed sitting in a chair in his room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety for one resident (Resident #12) of 4 residents reviewed for accidents and falls, resulting in a left eyebrow laceration, pain and the likelihood of further injury.

Inspectors wroteBased observation, interview and record review, the facility failed to document food acceptance, provide suitable utensils, and assess, monitor and notify the physician of a weight loss for one resident (Resident #143) of three residents reviewed for nutrition, resulting in a significant weight loss and numerous undocumented meal consumptions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that oxygen equipment for two residents (Resident #2 and Resident #60) and one continuous positive airway pressure (CPAP) mask and tubing for one resident (Resident #624) were clean, sanitized and stored properly after use of 4 residents reviewed for oxygen and CPAP equipment, resulting in the likelihood for cross contamination, respiratory illnesses/disease and increased antibiotic usage. Findings Include: Resident #624: Review of the Face Sheet, physician orders and care plans dated 8/2/24, revealed Resident #624 was [AGE] years old, admitted to the facility on [DATE], was alert and required staff assistance with Activities of Daily Living. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assess and monitor the dialysis port for one resident (Resident #54) of one resident reviewed for dialysis resulting in the resident starting on antibiotics.

Inspectors wroteBased on observation, and interview, the facility failed to ensure that 3 of 8 medication carts were free of crushed pills, pieces of loose paper, silver shards of foil from medication cartridges and dust on the bottom of the drawers, and one set-up of a resident's medications (room [ROOM NUMBER]) in a medication cup, resulting in the likelihood for cross contamination, low medications count with increased cost and missed resident medications. Findings Include: During observation of Patriot units cart 2 of 300 hall medication cart done on 8/5/24 at 1:43 p.m., accompanied by Nurse, RN I, revealed the second, third and fourth drawers were found to have crushed white pills, pieces of paper and dust on the bottoms of the drawers. During an interview done on 8/5/24 at 1:45 p.m., Nurse I stated I just cleaned this out last week, I am not sure who cleans the carts. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure that antibiotic orders identified the reason for use and antibiotic use was tracked for two residents (Resident #23 and Resident #79) of 3 residents reviewed for antibiotic use, resulting in the potential for inappropriate antibiotic use that could contribute to adverse effects, antibiotic resistance and the spread of infection. Findings Include: FACILITY Infection Control Resident #23: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #23 was admitted to the facility on [DATE] with diagnoses: history of a stroke, left sided weakness, GERD, depression weakness, epilepsy and hypertension. [...]

Inspectors wroteThis Citation pertains to Intake Numbers MI00143547 and MI00144442. Based on observations, interviews and record review, the facility 1) Failed to ensure that privacy was maintained for one resident (Resident #56), 2) Failed to ensure that residents are receiving timely, polite, and dignified assistance, 3) Failed to ensure that female residents with facial hair were shaven, 4) Failed to ensure that call lights are within reach, and 5) Failed to respond timely to call lights for nine residents (#6, #11, #12, #26, #28, #56, #78, #135, and #136) and the Confidential Resident Group meeting conducted on 08/06/24, resulting in verbalizations of concern and anger, an unsafe environment, and the likelihood for decreased self-esteem, shame and isolation. Findings Include: Resident #6: [...]

Inspectors wroteThis Citation pertains to Intake Numbers MI00143243 and MI00143245. Based on interview and record review the facility failed to complete a comprehensive fall investigation and notification to a physician of X-ray results for one resident (Resident #602), resulting in; 1. Resident #602 falling on 02/26/2024, X-rays being completed on 02/27/2024 with the resident sustaining a nasal bone fracture, left side of maxilla (bone that forms upper jaw) fracture with recommendation for CT (computed tomography) scan; 2. Facility's failure to notify physician of x-ray results and recommendations.; 3. Taking seven days for the facility's physician to review x-ray results and assessing Resident #602 seven days after the fall, after which Resident #602 was again sent to emergency room for evaluation with findings of subacute bilateral subdural hematomas and; 4. [...]

Inspectors wroteThis Citation Pertains to Intake Number MI00138983. Based on observation, interview and record review, the facility failed to institute and operationalize comprehensive monitoring, documentation, assessment, and interventions for three residents (Resident #20, Resident #44, and Resident #313) of three residents reviewed, resulting in a lack of timely assessment, documentation, and treatment of an injury of unknown origin for Resident #20, edema for Resident #44, and Resident #313 experiencing a displaced tibia (large bone in lower leg) fracture, lack of investigation, delayed care, unnecessary pain using the reasonable person concept, and the likelihood for decline in overall health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent facility- acquired pressure ulcers for one resident (Resident #4), resulting in Resident #4 developing a Stage IV pressure ulcer to the right heel, developed osteomyelitis (inflammation caused by infection), and required an intravenous antibiotic.

Inspectors wroteBased on interview and record review, the facility failed to notify the local ombudsman's office of a discharge for one resident (Resident #159), resulting in the lack communication to the local ombudsman office.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) ensure kitchen freezer door were properly maintained, resulting in an increased likelihood for food borne illness with hospitalization, and cross contamination affecting 151 residents who consumed oral nutrition from the facility kitchen of a total census of 165 residents. Findings Include: During the initial kitchen tour done on 8/22/23 at 11:00 a.m., accompanied by Dietary Manager/Chef U, the following observations were made: -At 11:00 a.m., a plastic cup with liquid in it was found in cooler #8; no name or date on it (it was a staff member drink). -At 11:04 a.m., the resident microwave was observed to have dried on food and drips inside on top and sides, and on the door. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize a comprehensive Infection Control (IC) program including outcome and process surveillance, data analysis and reporting, hand hygiene performance, environmental and equipment cleaning/sanitization processes/procedures for all 165 facility Residents resulting in lack of PPE use for a resident diagnosed with Clostridioides difficile (C-diff- contagious gram positive, spore-forming, anaerobic bacillus which causes severe diarrhea), lack of cleaning/sanitization of shared blood glucometers, cross contamination from exposed, bloody towels on the floor, lack of surveillance for potential infections, lack of consistent documentation and utilization of McGeer Criteria, incomplete infection analysis, and the likelihood for the development and transmission of communicable diseases and infections [...]

Inspectors wroteResident #73: Record review of Resident #73's electronic medical record revealed that the resident was receiving hospice services and was care planned to encourage the resident to verbalize feelings and concerns. Resident #73 requires hospice and was care planned to experience death with dignity and comfort. An interview on 08/22/23 at 10:42 AM with Resident #73 revealed the call light takes a long time, and when the girls come in, they talk over the top of me, and they complain about their job, and I have to tell them that they are here to work on me and not to get so rough. Resident #82: Record review of Resident #82's electronic medical record revealed that the resident was care planned for on 10/21/2020 for behavioral symptoms of: (Resident name) has periods of refusing care due to (resident name) believing she is able to do it on her own which is a safety concern. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer oxygen per orders, and store respiratory equipment in a sanitary and proper manner for six residents (#9, #65, #82, #88, #101, #130), resulting in the likelihood for cross contamination, increased risk for respiratory infections and prolonged illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for use, assessment, and ongoing evaluation of bed rails for 164 of 165 Residents reviewed resulting in lack of consent for use, identification and implementation of alterative interventions, lack of entrapment assessment, maintenance and monitoring of side rails, extremely loose and moveable rails, and the likelihood for injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to issue a beneficiary notice (ABN/Nomnic) for Resident #4 and notify an eligible resident in writing of the items and services which are or are not covered under Medicaid or by the facility's per diem rate, including the cost of those items and services: resulting in the likelihood for financial hardship.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate medical justification and ongoing evaluation and assessment of physical restraint use for one resident (Resident #313) of one resident reviewed, resulting in a lack of comprehensive reevaluation of necessity following readmission, physical restraint use per family request for fall prevention and positioning, lack of attempts of alternative interventions, lack of reevaluation and implementation of less restrictive devices, and the likelihood for injury and psychosocial distress using the reasonable person concept.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a discharge summary was created and provided for one resident (Resident #159) of one resident reviewed for discharge, resulting in the admitting hospital not having an updated plan of care and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the PASAAR and Level II OBRA evaluation was completed timely for one resident (Resident #313) of one resident reviewed for PASAAR, resulting in the likelihood of unmet needs and no communication with the local community OBRA coordinator.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) ensure urinary catheter tubing was off the floor and not dragging underneath a wheelchair, and 2) use an appropriate technique with the emptying of a urinary catheter bag, 3) ensure Activities of Daily Living (ADL) were done daily, and 4) maintain privacy by placing a urinary catheter bag in a privacy bag for 1 resident (Resident's #143), of 3 residents reviewed for urinary catheter, resulting in the high likelihood for cross contamination and urinary tract infection, embarrassment with possible dislodging of a urinary catheter. Findings Include: Resident #143: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper medication storage for one of four medication carts reviewed, resulting in the storage of a pre-drawn medication syringes with cloudy insulin with the likelihood of missed insulin.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Medical Director was present at least quarterly at the Quality Assurance and Performance Improvement meetings, resulting in the likelihood of the Medical Director not being made aware of quality concerns throughout the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide Certified Nursing Assistant (CNA) education hours for two of two CNA's reviewed during staffing task, resulting in the lack of the required 12 hour education hours.