Livingston County Center for Nursing and Rehabilit

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for four (4) of nine (9) resident's reviewed (Residents #166, #176, #185, and #225). Specifically, Resident #166 was observed on multiple occasions with overgrown facial hair. Resident #176 had long facial hair on the upper lip. Resident #185 had long chin hair and facial hair at the corners of their upper lip. Resident #225 had long facial hair. Additionally, the facility lacked documented evidence staff consistently offered, provided, or documented grooming services or refusals in accordance with the residents assessed needs and preferences.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure residents were treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life for two (2) of five (5) residents reviewed (Residents #13 and #166). Specifically, Resident #13 waited more than 45 minutes for their lunch meal after all other residents had been served resulting in emotional distress, and Resident #166 was repeatedly visible from the hallway while unclothed.

Inspectors wroteBased on interviews and record reviews conducted during an Abbreviated Survey (Incident #2610304) completed from 09/29/2025 to 10/10/2025, the facility did not ensure residents are free of significant medication errors for two (2) of five (5) residents (Resident #2 and #3) reviewed. Specifically, Licensed Practical Nurse #1 prepared medications for Residents #2 and #3 at the same time, left the medications intended for Resident #3 at Resident #2's bedside, and Resident #2 mistakenly took the medications. This resulted in actual harm to Resident #2 that is not Immediate Jeopardy.

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (Intake ID: 02610304) from 09/29/2025 to 10/10/2025, the facility did not ensure the residents' environment remained as free of accident hazards as possible for two (2) (Residents #2 and #4) of three residents reviewed. Specifically, medications were left unsupervised at the bedsides of Resident #2 and Resident #4, and there was no evidence the residents had medical orders or were assessed for their ability to safely and competently self-administer medications. Additionally, an unlocked medication cart was left unattended in a common hallway.

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey 11/2/23 to 11/8/23, it was determined that for 6 (Residents #'s 23, 54, 98, 128, 140, and 674) of 37 residents reviewed for care planning, the facility did not develop a person-centered Comprehensive Care Plan (CCP) that included measurable objectives and timeframes to meet the residents medical, nursing, mental and psychosocial needs and included goals, desired outcomes and preferences. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey from 11/2/23 to 11/8/23, it was determined that for one (Resident #61) of three residents reviewed for activities of daily living (ADLs), the facility did not ensure the resident received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #61 was observed on multiple occasions with sharp, jagged fingernails. This is evidenced by the following: The facility policy Nails, Care of (Finger and Toe), dated 3/13/15, included that the facility would provide residents with fingernail and toenail care in order to promote health and good hygiene. Certified Nursing Assistants (CNAs) could perform the procedure if the resident was not at risk for complications, and a licensed nurse would perform if the resident was high-risk. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 11/2/23 to 11/8/23 it was determined that for one (Resident #194) of two residents reviewed for pain management the facility did not manage the resident's pain to the extent possible in accordance with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Specifically, there was a lack of consistent pain assessments, monitoring of the effectiveness of the pain management plan of care, and the lack of medical provider notification after continued verbalization of pain and refusals of pain medications. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey from 11/2/23-11/8/23 the facility did not ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for one (Resident #128) of four residents reviewed for dementia care. Specifically, the facility did not ensure the development and implementation of a person-centered care plan that included interventions specific to Resident #128 dementia, did not address the resident's behaviors, goals, or interventions required and did not address the use of multiple psychotropic medications or the monitoring of. The is evidenced by the following: Resident #128 had diagnosis including non-Alzheimer's dementia, depression, mental disorder, and repeated falls. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 11/2/23 - 11/8/23 it was determined that for two (Resident # 144 and Resident #727) of five residents observed during medication administration, the facility did not ensure it was free of a medication rate of 5 percent (%) or greater. There were 2 medications errors for 26 opportunities resulting in a 7.7% medication error rate. The issues included the administration of one medication at the wrong time and the crushing a delayed-release medication that was labeled on the box Do not crush. This is evidenced by the following: 1. Resident #727 had diagnoses that include hypothyroidism (a condition of the thyroid gland that can cause multiple health issues including heart issues), dementia, and congestive heart failure. Current Physician orders included, but not limited to: [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey from 11/2/23 to 11/8/23, it was determined that for one (Resident #132) of five residents reviewed for immunizations, the facility was unable to provide documentation that Resident #132 (who was eligible) had been offered, declined, and/or educated on the Pneumococcal immunization or had received it prior to admission. This is evidenced by the following: The facility policy Infection Control, Pneumococcal Vaccine (Pneumovax 23, Prevnar 13), dated 10/25/22 documented, it shall be the policy of the [NAME] County Center for Nursing and Rehabilitation that all residents will be offered the pneumococcal vaccine (Pneumovax 23, Prevnar 13) to aid in preventing infections and pneumonia. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey 11/2/23 - 11/8/23 the facility did not ensure that within 14 days after completion of a resident's assessment (a comprehensive assessment of a resident's functional capabilities, problems and the care required) they electronically transmitted encoded, accurate, and complete Minimum Data Set (MDS) Assessment data to the Centers for Medicare and Medicaid Services (CMS) System for 22 of 22 residents (Residents #243, 180, 238, 86, 162, 247, 244, 237, 99, 235, 103, 239, 29, 200, 245, 72, 65, 150, 69, 212, 116, and 167) reviewed. Specifically discharge MDS Assessments were not completed and were not submitted to CMS within 14 of completion per the regulations. This is evidenced by, but is not limited to the following: [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey, completed on 1/28/22, it was determined that for one (first floor- Lilac) of two units reviewed for medication storage, the facility did not ensure that an accurate reconciliation of all controlled substances was maintained. Specifically, the Controlled Substance Record sheets which included reconciliation of narcotic medications and the signatures of staff members for each shift-to-shift count were not completed to validate the correct controlled substance count. This is evidenced by the following: The undated facility policy titled Narcotic Count documented that the facility will ensure that narcotic count is complete, and the keys are reconciled. Each medication administered must be logged on a controlled substance administration sheet and the balance must be reconciled between nurses. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for one (Resident #71) of four residents reviewed for pressure ulcer care and for five (Melody, Country, Park Ave, Lilac, and the Memory Unit) of six residential living units, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. Specifically, a staff member did not maintain proper infection control practices during wound care, and ice coolers used to transport ice and water for resident water pitchers were not consistently washed, rinsed, sanitized, or air dried between use. This is evidenced by the following: 1. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey, it was determined that for 8 (Resident #3, #21, #78, #94, #162, #179, #202, and #224) of 15 residents reviewed for Baseline Care Plans, the facility did not consistantly develop and implement a thorough Baseline Care Plan within 48 hours of admission that included instructions needed to provide effective person centered care and/or provide the resident or representative with a written summary of the Baseline Care Plan. This is evidenced by, but not limited to, the following: Review of the facility policy Baseline and Comprehensive Care Plan, dated 2/8/17, revealed the facility will develop and implement a Baseline Care Plan within 48 hours of admission and include minimum healthcare information including, but not limited to, physician orders, dietary orders and therapy services. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #33) of one resident reviewed for enteral nutrition, the facility did not have a mechanism in place to ensure that the administration of enteral nutrition and additional water ordered for flushes was consistent with and followed physician orders, and staff were not consistently using the feeding pump as directed. This is evidenced by the following: Resident #33 was admitted to the facility on [DATE] and had diagnoses including subarachnoid, intracerebral and subdural hemorrhages, chronic respiratory failure with hypoxia, and tracheostomy. The Minimum Data Set Assessment, dated 4/1/19, revealed the resident had severely impaired cognition, weighed 177 pounds with no history of recent weight loss or gain, and the daily use of a tube feeding. [...]

Inspectors wroteBased on interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #163) of six residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regimen remained free from unnecessary medications. The issue involved the lack of documentation of what precipitated the resident's behavior, non-pharmacological interventions attempted prior to the administration of a one time dose of an antipsychotic medication and the effectiveness. This is evidenced by the following: Resident #163 was admitted to the facility on [DATE] and had diagnoses including cerebral vascular accident (stroke), depression and anxiety. The Minimum Data Set Assessment, dated 5/15/19, revealed the resident was cognitively intact and exhibited no behaviors. [...]