Regency at Jackson

Inspectors wroteBased on observations and interviews the facility failed to effectively 1) date all ready-to-eat food. 2) remove expired food. 3) effectively clean equipment potentially affecting all residents who resided in the facility and received food from the kitchen. Findings Include; During initial walk through on 06/02/2026 at 8:44 AM, it was noted that there were spices that were not dated when they were opened, no date when they expired. Chicken seasoning, black pepper, Dietary Manager V stated they came in on 05/24/26 so she wrote that date on the 2 containers, but no open date or expiration date. Observation of 6- 16oz bags of On-Top whipped topping with no receive dates or expirations dates. Angel food cake dated 05/01/26, unopened, expired 06/01/2026 and was not discarded. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure effective administration was in place that monitored the Infection Prevention Control Program (IPCP) and Antibiotic Stewardship Program (ASP), ensure the facility assessment was reassessed at the needed time, assured the required staff were in attendance at the Quality Assurance Performance Improvement (QAPI) meetings, ensure IPCP data was presented to QAPI every meeting, and review of the facility policies and procedures were performed yearly. Findings Included: Review of the facility Infection Prevention Program policy and procedure revealed that the policy had not been reviewed for any revisions needed since 2/28/2025. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program that monitored the performance of the Infection Prevention Control Program (IPCP), and the Antibiotic Stewardship Program (ASP) in a current facility census of 60 residents. Findings Included: Review of the facility's Corporate QAPI (Quality Assurance Performance Improvement) Plan (QAPI) dated 10/24/2018 and last revised 1/25/2024 revealed under, Guiding Principle #4: QAPI focuses on systems and processes .The emphasis is on identifying system gaps . Further review of the facility's QAPI plan revealed the plan did not include the IPCP as part of the facility's QAPI plan as there was no documentation in the plan that included the IPCP. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an infection prevention control program (IPCP) and an Infection Preventionist (IP) were in place for six months out of the last eight months and failed to follow Enhanced Barrier Precautions for one (R72) of one resident reviewed. Findings Included: Resident 72 (R72) Review of the clinical record revealed R72 was admitted into the facility on 5/21/26 with diagnoses that included: depression and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R72 scored 13/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). On 6/2/26 at 2:45 PM R72 was observed lying in bed with urinary catheter bag hanging from the side of his bed. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure implementation of an ongoing antibiotic stewardship program for six months. Findings Include:Review of the facility Infection Control Antibiotic Stewardship and MDROs (multi drug resistant organicism) which had not been revised since 4/17/2025 revealed under, GUIDLINES AND RECOMMENDATIONS FOR SUCCESSFUL IMPEMENTATION OF ANTIBIOTIC STEWARDSHIP IN YOUR COMMUNITY., The program will encourage appropriate prescribing; and reduce adverse effects which often include gastrointestinal problems, C. Difficile diarrhea, yeast infections, and antibiotic resistance in aging adults. The policy further revealed, The medical director and director of nursing will use his/her influence as medical and nursing leaders to help ensure antibiotics are prescribed only when appropriate. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain a clean, homelike environment 1) drywall cut away from the wall 2) vents covered with dust on the inside and outside, 3) toilet riser covered in feces that could potentially affect all residents. This citation pertains to intake # 3025074Findings Include: During observations on 06/02/2026 at 12:25 PM, several residents' rooms and bathrooms were not clean, open holes in the wall and not a homelike environment: Bathroom between rooms [ROOM NUMBERS], the vent in the bathroom was covered with dust in the vent and up inside the vent. Bathroom between rooms [ROOM NUMBERS] wall/drywall was cut out above the sink and under the sink due to a leak a month ago or more and was not repaired. Bathroom between rooms [ROOM NUMBERS], the vent in the bathroom was covered with dust on the vent and up inside the vent. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician reviewed and acted upon identified medication regimen irregularities for four (Residents #1, 5, 39 and 59) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify one (Resident #61) of one reviewed for room change.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Advanced Directives were thoroughly completed for one (R72) of three reviewed.

Inspectors wroteThis citation pertains to intake #3031215 Based on observation, interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one (R39) of two residents reviewed.

Inspectors wroteThis Citation Pertains to Intake 3027512 Based on observations, interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one of two residents reviewed (Resident 14) and failed to report allegations of abuse to the Nursing Home Administrator/Abuse coordinator for resident (Resident #19).

Inspectors wroteThis citation pertains to Intake #3027512Based on observation, interview and record review the facility failed to thoroughly investigate an allegation of drug diversion for one resident (R14) of two residents reviewed.

Inspectors wroteThis citation pertains to Intake 3030189. Based on interview and record review, the facility failed to provide a written notice of transfer for one (R75) of two reviewed.

Inspectors wroteBased on interviews and record reviews the facility failed to provide accurate Minimal Data Set (MDS) assessments for one resident (R20) of 15 residents reviewed for accuracy of assessments.

Inspectors wroteBased on interviews and record reviews the facility failed to complete a yearly PASARR assessment on one resident (R6) out of resident reviewed for PASARR assessments. Findings Include;Resident #6 (R6)Review of the medical record reflected R6 was an initial admission to the facility on [DATE]. Diagnoses of displaced mid-cervical fracture of right femur, malnutrition, vascular dementia, adjustment disorder, schizophrenia and anxiety. The most recent Minimum Data Set (MDS) revealed R6 had a Brief Interview of Mental Status (BIMS) of 8 (moderate cognitive impairment) out of 15. Under section GG0115, Functional Limitation in Range of Motion revealed R6 required partial assistance with eating and use of an adapted cup. R6 was dependent on bed mobility, toileting, hygiene, Shower/baths, dressing lower body and transfers. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to administer medications timely and document accurately for one resident (R32) of 15 residents reviewed. Findings Include;Resident #32 (R32)Review of the medical record reflected R32 was an initial admission to the facility on [DATE]. Diagnoses of osteoarthritis in the right knee, acute embolism and thrombosis of the right knee, obesity, diabetes mellitus 2, obstructive sleep apnea, pain in left hip, major depression and anxiety. The most recent Minimum Data Set (MDS) revealed R32 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section GG0115, Functional Limitation in Range of Motion revealed R32 was independent with oral care and eating. R32 was dependent on care for toileting, hygiene, Shower/baths and transfers. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with routine showers for one dependent resident (R28) of three reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to review anti-anxiety medication to meet resident needs for one (R28) of two residents reviewed.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide medically related social services for one resident (R65) of one resident reviewed for services not received. Findings Include;Resident #65 (65)During an interview on 06/02/2026 at 1:06 PM, R65 stated she doesn't have her power wheelchair back yet. R65 stated again if I had my mother fucking chair fixed, I wouldn't have to be stuck in this damn bed all day! Writer asked R65 how long she had been without her powered wheelchair and R65 stated months, last fall sometime. On 06/03/26 at 3:00 PM, writer emailed Guardian Z related to the repair of her powered wheelchair, Guardian Z emailed back. Guardian Z stated no, she still had not heard anything back from repair company but was going to call them again. [...]

Inspectors wroteCitation pertains to intake #3030189Based on observation and interview the facility failed to ensure medication administration was observed with a nurse for one resident (R3) of one resident reviewed.

Inspectors wroteBased on interview and record review the facility failed to provide dental services on two residents (R3 & R5) of two residents reviewed for axillary services. Findings Include; Resident #3 (R3) Review of the medical record reflected R3 was an initial admission to the facility on [DATE]. Diagnoses of osteoarthritis in the right knee, acute embolism and thrombosis of the right knee, obesity, diabetes mellitus 2, obstructive sleep apnea, pain in left hip, major depression and anxiety. The most recent Minimum Data Set (MDS) revealed R3 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section GG0115, Functional Limitation in Range of Motion revealed R3 was independent with oral care and eating. R3 was dependent on care for toileting, hygiene, Shower/baths and transfers. [...]

Inspectors wroteBased on observations and interviews the facility failed to follow food preferences for one resident (R36) of one resident reviewed for food preferences. Findings Included;Resident #36 (R36)Review of the medical record reflected R36 was an initial admission to the facility on [DATE]. Diagnoses of osteoarthritis in the right knee, acute embolism and thrombosis of the right knee, obesity, diabetes mellitus 2, obstructive sleep apnea, pain in left hip, major depression, anxiety and practiced her Jewish religion. The most recent Minimum Data Set (MDS) revealed R36 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section GG0115, Functional Limitation in Range of Motion revealed R36 was independent with oral care and eating. R36 was dependent on care for toileting, hygiene, Shower/baths and transfers. [...]

Inspectors wroteBased on interview and record review the facility failed to perform a facility assessment when there was a change in the Infection Control Program (ICP) and the Antibiotic Stewardship Program (ASP). Findings Included:Review of the facility's facility assessment revealed the assessment was last performed on 8/1/2024 and went to 7/31/2025. In an interview on 6/05/2026 at 12:24 PM Director of Nursing (DON) B stated that when she started working as the DON in February of 2026 there was no Infection Control Preventionist (ICP) and no infection prevention control program (IPCP) in place, nor was there an active Antibiotic Stewardship Program (ASP) in place. DON B said there was no IPCP or ASP documentation for the months of September, October, November, and December 2025, and also for the months of January, February, or March of 2026. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Infection Control Preventionist (ICP) attended and reported to the Quality Assurance Performance Improvement (QAPI) committee meetings a report on the Infection Prevention Control Program (IPCP) including the Antibiotic Stewardship Program. Findings Included:Review of the facility's Corporate QAPI (Quality Assurance Performance Improvement) Plan dated 10/24/2018 revealed that the plan did not include nor have one word in the plan regarding the facility's Infection Prevention Control Program (IPCP) nor Antibiotic Stewardship Program (ASP). [...]

Inspectors wroteThis Citation Pertains To Intake 3020595 Based on observation, interview and record review the facility failed to ensure that grievances were documented, investigated, tracked and resolved for one Resident (#14) of three reviewed.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy and procedure for one Resident (#7) of one resident reviewed for alleged abuse. Findings Include:Resident #7 (R7)Review of the medical record reflected R7 was initially admitted to the facility on [DATE] through 05/01/2026 with diagnoses including displaced comminuted fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, epilepsy, diabetes mellitus type 2, symptoms involving the musculoskeletal system, and surgical aftercare. The most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/01/2026 revealed R7 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. [...]

Inspectors wroteBased off interviews and record review the facility failed to report alleged abuse for one Resident (#7) of one reviewed for alleged abuse. Findings IncludeResident #7 (R7)Review of the medical record reflected R7 was an initial admission to the facility on [DATE] through 05/01/2026. Diagnoses of displaced comminuted fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, epilepsy, Diabetes Mellitus 2, symptoms involving the musculoskeletal system, surgical aftercare. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/2026 revealed R7 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section GG0103, Activities of Daily Living (ADL) Assistance reveals R7 was maximum assist to dependent on personal care and used a wheelchair as an assistive device. [...]

Inspectors wroteThis Citation Pertains to Intake 3017894 and 2963604 Based on interview and record review the facility failed to thoroughly investigate an injury of unknown source for one Resident (#3) and failed to thoroughly investigate an allegation of verbal abuse for one Resident (#7) from a total of three residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to complete wound care as directed by physician orders for two Residents (#10 & #13) of three residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent an avoidable fall for one Resident (#2) of three residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform catheter care consistent with professional standards for one Resident (#10) of three residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document wound care for one Resident (#13) of three residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare and serve food in sanitary conditions resulting in an Immediate Jeopardy due to the likelihood of foodborne illnesses to affect 72 resident who ate meals out of the kitchen. Findings Included:During an observation on 2/19/26 at 8:42 a.m., garden hoses were observed coming from an open Dinng Room window to drain located near main entrance of the facility with what appeared to be water coming from the hose. Plumbing contractor van was parked in front of the Dining Room window. After entering the facility very loud sound of what sounded like jack hammering could be heard on the ground floor. During an interview on 2/19/26 at 8:45 a.m., Nursing Home Administrator (NHA) A reported had been employed at the facility for about five months. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure grievances were promptly documented, investigated, tracked and resolved for four residents of four resident reviewed for grievances (R107, R111, R112, and R113).

Inspectors wroteBased on observations, interviews, and record review the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate allegations of abuse for four residents (R107, R111, R112, R113) of seven reviewed.

Inspectors wroteThis citation pertains to intake: 2747784, 2727148, 2724902, 2720062Based on observation, interview, and record review the facility failed to ensure seven out of seven residents (R105, R106, R107, R110, R111, R112, R113) received activities of daily living (ADL) care per the plan of care. Findings Included:Resident #107 (R107) Review of the Face Sheet and Minimum Data Set (MDS), with Assessment Reference Date, dated 2/10/26, reflected R107 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included severe morbid obesity, cervical disc degeneration, muscle wasting and atrophy, major depression and anxiety. The MDS reflected that R107 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for transfers, showering and toileting. [...]

Inspectors wroteThis citation pertains to intake: 2740492, 2724902, 2747784, 2720062Based on observation, interview, and record review, the facility failed to ensure adequate staff to meet the resident needs for 7 residents (R105, R107, R110, R111, R112, R113) reviewed for staffing, resulting in resident care and needs not being consistently met and the potential for negative outcomes for all residents.

Inspectors wroteThis citation pertains to intake 2747784Based on interview and record review, the facility failed to notify the family of one of one resident (R106) nor the on-call provider of a change in condition requiring to be sent out to the hospital. Findings Include;Resident #106 (R106)Review of the medical record reflected that R106 was admitted to the facility on [DATE]. Diagnoses of Pneumonitis due to inhalation of food and vomit, severe protein-calorie malnutrition, non-pressure related ulcers in the lower extremities, Dementia and peripheral vascular disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/11/2026 revealed R106 had a Brief Interview of Mental Status (BIMS) of 03 (Severe cognitive impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R106 needed substantial assistance with showering and personal care. [...]

Inspectors wroteThis citation pertains to intake 2743515Based on observations, interviews, and record review the facility failed to protect the resident's(R103) right to be free from sexual abuse by another resident (R104).

Inspectors wroteBased on interview and record review, the facility failed to give the bed hold policy, transfer/discharge paperwork to one of one resident (R106) as he was transferred to the hospital with a change in condition. Findings Include;Resident #106 R106Review of the medical record reflected that R106 was admitted to the facility on [DATE]. Diagnoses of Pneumonitis due to inhalation of food and vomit, severe protein-calorie malnutrition, non-pressure related ulcers in the lower extremities, Dementia and peripheral vascular disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/11/2026 revealed R106 had a Brief Interview of Mental Status (BIMS) of 03 (Severe cognitive impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R106 needed substantial assistance with showering and personal care. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure comprehensive care plans were in place for two out nine residents (Residents 104 & 108) related to leave of absence (LOA). Findings Included:Resident #104 (R104):Per the facility face sheet R104 was admitted to the facility on [DATE]. Record review of a Determination to Leave the Facility Against Medical Advice not dated, revealed R104 was not cleared by the Physician to be allowed to leave the facility due to being a high risk for an accident, falls, or other acute illness/condition as a result of being outside of the facility unsupervised, which may result in a serious negative health outcome. R104 signed the document with the understanding of any consequences. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for one out of three residents (R108) an evaluation was completed to determine ability for leave of absence (LOA). Findings Included:Per the facility face sheet Resident #108 (R108) was admitted to the facility on [DATE]. Record review of a Minimum Data Set (MDS) dated [DATE], revealed R108 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicated R108 cognition was intact. During an interview with R108 on 2/25/2026 at 12:02 PM, R108 was observed lying in bed and answered all questions appropriately. Per progress notes dated 2/11/2026, R108 had signed out LOA with another resident, and upon returning to the facility R108 did not use the crossed walk to cross back over the street. [...]

Inspectors wroteThis citation pertains to intake number 2720063. Based on interview and record review the facility failed to ensure immunizations were administered for one out of three residents (Resident #108) who consented to receiving the Pneumococcal (PCV) and the Respiratory Syncytial Virus (RSV) vaccinations. Findings Included:Per the facility face sheet Resident #108 was admitted originally admitted to the facility on [DATE]; with a most recent admission date of 2/14/2026. Review of a consent form revealed R108 had signed the consent on 10/28/2025 to receive the vaccination. Review of a consent form revealed R108 had signed a consent on 10/28/2026 to receive the vaccination. Review of R108's electronic medical record (EMR) revealed under immunizations that the RSV and PCV20 immunizations were pending immunization with a confirmation date of 10/28/2025. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure the hiring process, orientation and competencies were completed per regulation requirements. Intakes 2710396, 2710425, 2701621Findings IncludeDuring an interview and record review on 01/08/2026 at 3:35 PM, Nursing Home Administrator (NHA) A brought in the requested personnel file of Certified Nursing Assistant (CNA) K. Record review of the personnel file revealed CNA K was hired on 10/09/2025 and was terminated on 12/15/25, with her last day worked was 12/14/25. CNA K Personnel file did not contain the completed orientation plan nor new hire paperwork as state and federally mandated. CNA K personnel file did not have a completed background check, certification verification, I-9, fingerprinting or drug screening with pre-hire physical. Requested this information from the NHA A. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure one dependent resident (Resident #9) of one resident received bed baths and personal careFindings Include:This pertains to Intake 2701621Resident #9 (R9)Review of the medical record reflected that R9 was admitted to the facility on [DATE] and admitted to hospice on 06/17/2024. Diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Major Depression, Chronic Pain Syndrome, Fractures with routine healing of T5-T6, T9-T10, T11- T12, Compression Fracture of first lumbar vertebra and generalized weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R9 had a Brief Interview of Mental Status (BIMS) of 14 (Cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R9 was dependent of all personal care. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect resident #7's (R#7) from a fall from bed with staff. Findings IncludeIntake: 2702557Resident #7 (R7) Record review of the facility reported incident revealed the incident accrued on 12/15/2025, R7 fell out of bed or rolled out of bed, landed on her face, split her lip open and broke off a tooth, incident was reported and R7 was sent to ER. Transfer report documented that R7 only needed assistance with toileting and transfers and was not dependent on care. Facilities response was to report the incident to the State of Michigan in the form of a facility reported incident also known as FRI. CNA involved was suspended pending the outcome of the investigation. Inservice scheduled and the police were notified. Action to be taken, resident told policy she rolled out of bed. [...]

Inspectors wroteBased of interview and record review the facility failed to enforce the use of a mask as mandated by their infection control program related to Covid. Findings IncludeDuring an interview and observation on 01/09/2026 at 7:55 AM, writer toured the kitchen as breakfast was being served. Observation made of Dietary Manager G not wearing the mask as deemed mandatory from the Infection Preventionist following two other staff testing positive for Covid. Dietary Manager G looked at writer and smiled and giggled stating I was just going to put a mask on. During an interview on 01/09/2026 at 12:20 PM, DON B stated when staff reported they had covid, management team requested they conduct a second covid test, if it was positive, they tested all staff and residents. DON B stated they follow the CDC guidelines and tested on the first day, third day and fifth day. [...]

Inspectors wroteThis citation pertains to intake 2677950Based on interview and record review the facility failed to provide adequate nursing staffing to meet residents' needs for 14 days out of 30 days reviewed for nursing staff.

Inspectors wroteThis citation pertains to Intake numbers: MI00152521 and MI00152424. Based on observation, interview, and record review, the facility failed to thoroughly and accurately conduct an investigation of a fall that sustained a left hip fracture for one Resident (R#501) of four (4) sampled residents reviewed for fall.

Inspectors wroteThis citation pertains to Intake numbers: MI00152521 and MI00152424. Based on observation, interview, and record review, the facility failed to thoroughly assess and monitor for pain and neurologic assessment after two falls (unwithnessed and witnessed) that sustained a left hip fracture for one Resident (R#501) of four (4) sampled residents reviewed for fall resulting in delay in treatment, increased experience in physical distress and worsening of pain.

Inspectors wroteThis citation pertains to Intake numbers: MI00152521 and MI00152424. Based of interview and record review, the facility failed to timely revise/update care plans for one resident (R#501) of four residents reviewed for care plan revision resulting in care plans not being revised as the status and needs of the residents changed related to pain and post surgical site skin care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active and ongoing 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 water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services to ensure a resident's abilities in activities of daily living (ADL) did not diminish in two (Resident #20 and Resident #24 ) of two residents reviewed for comprehensive care planning, resulting in increased levels of assistance provided by staff with ADL care. Findings Include: Resident #20 (R20) Review of the medical record reflected R20 was an initial admission to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide for one out of one resident (Resident #6) care and services to prevent and promote healing of pressure ulcers resulting in worsening wounds. Findings Include: Resident #6 (R#6) Review of the medical record reflected R6 was an initial admission to the facility on [DATE] and readmitted on [DATE]. R6 was admitted to hospice on 08/24/2024. Diagnoses of cerebral atherosclerosis, Diabetes Mellitus with neuropathy, pressure ulcer of the sacral region, stage 4, history of a stroke, benign prostatic hyperplasia with urinary symptoms and suprapubic catheter, spinal stenosis in the cervical region, left side hemiplegia and hemiparesis following the stroke and muscle weakness. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician documented in the medical record the rationale for not implementing the pharmacy recommendation for one (R11) of five reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication laboratory monitoring was completed for one (R46) of five reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide clinical justification for the continued use of PRN (as needed basis) psychotropic medication (Lorazepam) for one resident (#16) out of five residents reviewed for the potential of unnecessary medication. Findings Included: Resident #16 (R16) Review of the medical record revealed R16 was admitted to the facility 09/16/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD) respiratory failure, asthma, dysphagia (difficulty swallowing), chronic pain, hypomagnesemia (low magnesium), myocardial infarction (heart attack), recurrent dislocation of right shoulder, venous insufficiency, persistent mood disorder, hearing loss, constipation, spinal stenosis, bipolar disorder, major depression, anxiety, and gastro-esophageal reflux. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food at the preferred temperature for one resident (#16) of one resident reviewed for food palatability resulting in dissatisfaction during meals. Findings Included: Resident #16 (R16) Review of the medical record revealed R16 was admitted to the facility 09/16/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD) respiratory failure, asthma, dysphagia (difficulty swallowing), chronic pain, hypomagnesemia (low magnesium), myocardial infarction (heart attack), recurrent dislocation of right shoulder, venous insufficiency, persistent mood disorder, hearing loss, constipation, spinal stenosis, bipolar disorder, major depression, anxiety, and gastro-esophageal reflux. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of five medication carts were locked while unattended. Findings Included: During an observation on 1/29/2025 at 12:17 PM on the second floor, a medication cart was observed at the end of the hall next to room [ROOM NUMBER] unlocked. No staff were observed to be in sight of the cart or on the hall. At 12:19 PM, no staff were observed to approach the medication cart, and the cart remained unlocked. At 12:21 PM, no staff were observed to approach the medication cart, and the cart remained unlocked. At 12:23 PM, there was no change in observation. At 12:30 PM the cart remained unlocked with no staff in attendance of the cart. At 12:35 PM the medication cart was locked by Assistant Director of Nursing (ADON) C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely identify the formation of pressure ulcers and consistently implement ordered wound care treatments for 2 (Resident #3 and #5) of 2 residents reviewed for pressure ulcers, resulting in the development of a facility acquired Unstageable Pressure Ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) for R3 and a Deep Tissue Injury (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister) for R5, and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a fall with major injury for one (Resident #38) of three reviewed, resulting in Resident #38 falling out of bed during care and sustaining a femur fracture.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 53 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure four out of four observed resident room call lights were answered timely, resulting in the potential for unmet needs. Findings Included: In an observation on 5/14/2024 at 11:44 AM, the call light for room [ROOM NUMBER] was observed to be on. Two staff members were observed to pass by room [ROOM NUMBER] and not stop to answer the call light. At 11:47 AM the call light for room [ROOM NUMBER] was observed to be on, and one staff member was observed to walk by room [ROOM NUMBER] and not stop to answer the call light. At 11:48 AM a nurse was observed to walk past room [ROOM NUMBER], and go into room [ROOM NUMBER] without addressing the call light for room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one (Resident #359) of three reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse to the State Agency for one (Resident #359) of three reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent further potential abuse for one (Resident #359) of three reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 1 (Resident #14) of 14 reviewed resulting in the potential for decreased safety, increased injury risk, and unmet care needs. Review of the medical record revealed that Resident #14 (R14) was readmitted to facility 1/10/24 with diagnoses including vascular dementia, catatonic schizophrenia, specified disorder of bone density and structure, muscle weakness, and abnormalities of gait and mobility. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/24 revealed that R14 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 6 (severe cognitive impairment). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) ensure blood glucose values were documented in the medical record for one (R22) and failed to implement assessment/intervention for bowel constipation for one resident (R408) of 14 reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two out of three residents (Resident #6 and 32) had water available at the bedside, resulting in the potential for dehydration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication was administered within the prescribed parameters and not in excessive dose for one (Resident #38) of six reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate infection control practices during wound care for two (Resident #3 and #5) of two reviewed for wound care, resulting in the potential for cross contamination and the spread of infection. In a wound care observation on 5/15/24 at 1:34 PM, Licensed Practical Nurse (LPN) I removed her gloves, entered R3's bathroom, and washed her hands with soap and water for approximately four seconds. In an observation on 5/15/24 at 1:41 PM, Licensed Practical Nurse (LPN) N removed her gloves, entered R3's bathroom, and washed her hands with soap and water for approximately five seconds. In a wound care observation on 5/15/24 at 1:55 PM, LPN I removed her gloves, entered R5's bathroom, and used soap and water to wash her hands for approximately five seconds. [...]

Inspectors wroteThis citation pertains to intake MI00142408. Based on interview and record review, the facility failed to ensure the physician documented required transfer/discharge information for one (Resident #3) of three reviewed.

Inspectors wroteThis citation pertains to intake MI00142408. Based on interview and record review, the facility failed to permit a resident to return to the facility after hospitalization for one (Resident #3) of three reviewed, resulting in R3 being denied return/readmission to the facility and having to find alternate placement at another facility.

Inspectors wroteThis citation pertains to intake MI00140183. Based on interview and record review, the facility failed to timely assess, accurately monitor and treat a resident with a history of known insulin-dependent diabetes mellitus (high blood sugar) for one resident (R101) out of three residents reviewed for quality of care, resulting in critically elevated blood sugars requiring emergency hospital treatment and admission.