Regency at Whitmore Lake

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for 96 out of 115 residents a homelike dining experience was maintained. Findings Included: On 5/12/2026 12:02 PM, a sign was observed to be at the main dining room door that stated that the dining room was closed for the week for all meals due to a week long activity from the activity department. Activity Director (AD) W was interviewed during the observation in which AD W stated, the residents all had to eat lunch in their rooms because the dining room was being used for a spirit week activity. On 05/13/2026 at 8:41 AM, 100 hall residents were observed being served their breakfast in their rooms. At the time of the observation Certified Nurse Aid (CNA) V was interviewed and stated that the residents eat breakfast and supper meals in their rooms but eat lunch in the dining room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs, affecting all 115 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date food from the pantry and walk in cooler, store perishable items properly, ensure kitchen staff wore beard guards and maintain a clean ice machine. This deficient practice had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased potential for food borne illness in a current facility census of 115 residents.

Inspectors wroteBased on interview and record review the facility failed through its quality assurance and performance improvement program (QAPI) to identify and put systems in place to correct deficiencies at F584, F730, F881 and F947 in a current facility census of 115 residents. On 5/15/2026 at 3:11 PM, Nursing Home Administrator (NHA) A was asked why the dining room was closed off to residents for breakfast and dinner. NHA A said only a handful of residents would go to the dining room to eat so the dining room was closed down, and that is how it has been for at least the last 1.5 years. NHA A said there was an attempt to reopen the dining room, but no residents went to the dining room to eat. NHA A had no answer for the lunch and dinner meals, and therefore the dining room continued to remain closed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that four of five Certified Nurse Aides (CNA) E, F, G, and I completed the required 12 hours of annual training to ensure adequate resident care.

Inspectors wroteBased on observation, interview and record review the facility failed to promote an environment that ensures dignity in 1 of 2 sampled residents (#117) reviewed for dignity, resulting in the potential for Resident #117 to feel embarrassment and worthless when facility staff fail to assist with toileting timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's right to determine own schedule for showering for one resident (R18) of one reviewed for self-determination.

Inspectors wroteBased on observation and interview the facility failed to protect resident's personal private information and confidentiality of records for two residents' (R92 and R97) of two residents reviewed for privacy of information. Findings Include;Resident #92 (R92)During an observation and interview on 05/14/2026 at 2:11 PM, the computer sitting on the medication cart was open with R92's personal private information and confidentiality of records visible to anyone walking by. There was not a nurse within sight of the medication cart. Writer stood by the medication cart and waited for the nurse to return to her cart. LPN P came out of the room stating she had spilt water and was trying to clean it up. LPN P looked up to notice she had left the computer open and she at that time closed it. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that two of five Certified Nurse Aides (CNA) H, and I had annual competencies completed to ensure adequate resident care.

Inspectors wroteBased on observation and interviews the facility failed to ensure 4 outdated medications and supplies were removed from the central supply room with the potential to be used on residents. Findings Include:During an observation and interview on 05/14/2026 at 4:35 PM, Central Supply staff U stated she stocked the shelves with all the over-the-counter medication, wound care dressing supplies, supplemental feeding supplements, and basic items for personal care. Central Supply staff U stated she monitors the shelves for expiration dates and it there is a medication or supply that is in the month that it will expire, she will see if the nurses use this item frequently and if so, to use it before it expires. If this isn't something they use often, they will throw it away. [...]

Inspectors wroteBased on observation and interview the facility failed to follow infection control measures during medication administration for three residents (R97, R66, R65) resulting in potential of spreading germs to other residents. Resident 97, Resident 66, Resident 65 (R97, R66, R65) During an interview and observation on 05/15/2026 at 7:00 AM, Licensed Practical Nurse (LPN) O stated he had already given some patients their medication but had not signed them out. LPN O stated he works nights and was still trying to catch up on his medication administration. LPN O prepared medications to administer to R97, no hand hygiene was performed prior to setting up the medications, or after medications were prepared. LPN O picked up his medication cup from the medication cart and walked into R97's room. LPN O donned gloves and checked R97's blood sugar on left hand 1st finger wearing gloves, read 119. [...]

Inspectors wroteBased on interview and record reviewed the facility failed to follow an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two Residents (#30, #39) out of four residents reviewed. Findings Included: Resident #30 (R30)Review of the medical record revealed R30 was admitted to the facility 06/07/2024 with diagnoses that included peripheral vascular disease (PVD), dementia with severe mood disturbance, abnormal posture, contracture of left hand, dysphagia (difficulty swallowing), malnutrition, traumatic brain injury, constipation, depression, anxiety, benign prostatic hyperplasia (enlarged prostate), and cognitive communication deficit. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of three residents (Resident #12) received activities of daily living (ADL) care per the plan of care. Findings Included: Review of a Minimum Data Set (MDS) dated [DATE] on page #21 under section GG revealed, R12 was dependent on staff for Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. The MDS defined dependent as, Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. On 12/23/2025 at 10:16 AM, Certified Nurse Aid (CNA) J was observed to perform catheter care for Resident #12 (R12) while R12 was in bed. [...]

Inspectors wroteBased on Observation, interview and record review, the facility failed to thoroughly investigate for two out of two residents (Resident #1, and Resident #3) allegations of abuse. Review of a facility reported incident (FRI) dated 07/07/25 at 5:45pm and reported to the state on 07/07/25 at 6:31 PM. 5 day follow up dated 07/10/25. R2 and CNA L were walking on hall 200 when R2 told R1 oh you look like you need a kiss, bent down and kissed R1 on the lips. R1 responded to R2 by telling R2 he was going to tell on her and called her a bitch. CNA L separated them and took R2 to another area. Social workers met with both residents. R2 did not recall the incident and remained ambulatory throughout the facility. R1 did recall the incident and was educated about the use of profanity and the need to call for staff for assistance. R1 was witnessed by LPN M yelling at R2, Get the fuck away from me. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise resident care plan's, in three of three residents reviewed for care plans (Resident #2, Resident #1 and Resident #3), resulting in potential for not maintaining or obtaining their highest practicable physical and emotional wellbeing.

Inspectors wroteThis citation pertains to Intake(s) 1216042, 1216038, 1216041Based on observations, interviews, record reviews, and 1 (200) of 4 sampled residents, the facility failed to maintain ambient room temperatures within the acceptable regulatory parameters (71-81 degrees Fahrenheit) affecting 116 residents, resulting in the increased likelihood for resident dehydration and physical/emotional discomfort.

Inspectors wroteThis citation pertains to Intake 1216041Based on observations, interviews, record reviews, reviewed for food product palatability, the facility failed to provide palatable food products affecting 116 residents who consume food, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline.

Inspectors wroteThis citation pertains to Intake 1216041Based on observations, interviews, record reviews, and 1 (200) of 4 sampled residents, the facility failed to provide timely meal service affecting up to 116 residents who consume food, resulting in the increased likelihood for delayed meal service, increased emotional/psychosocial distress, and decreased food acceptance/nutritional decline.

Inspectors wroteThis citation includes intake MI000152150. Based on interview and record review the facility failed to revise a comprehensive care plan for one out of three residents (Resident #1). Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease. Review of R1's Brief Interview for Mental Status (BIMS) score revealed that on 12/7/2026 R1 scored a six, and on 2/7/2025, R1 scored a three, both score were indicative of a severe mental impairment. Review of a Physician's Statement of Competency dated 12/27/2024, revealed R1 was deemed to be incompetent and not able to make his own medical decisions. Review of R1's progress notes revealed that on 3/30/2025, R1 was found to be lying in a bed with another female resident. [...]

Inspectors wroteThis citation includes intake MI000152150. Based on observation, interview, and record review the facility failed the provide one on one supervision for one out of two residents (Resident #1). Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease. Review of R1's Brief Interview for Mental Status (BIMS) score revealed that on 12/7/2026 R1 scored a six, and on 2/7/2025, R1 scored a three, both score were indicative of a severe mental impairment. Review of a Physician's Statement of Competency dated 12/27/2024, revealed R1 was deemed to be incompetent and not able to make his own medical decisions. Review of R1's progress notes revealed that on 3/30/2025, R1 was found to be lying in a bed with another female resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent and correctly identify pressure ulcers for two out of seven residents (Residents 101, and 108) resulting in misidentifying of pressure ulcers, and worsening of pressure ulcers. Findings Included: Resident #101 (R101): Per the facility face sheet R101 had resided at the facility since 4/4/2023. Diagnoses included spinal cord injury, contractures of both hands and fingers, and muscle contractures. Review of a photo dated 12/17/24, of R101's buttocks area reveal moisture associated skin damage (MASD-damage of the skin caused by being constantly moist from things such as urine), and a stage III pressure ulcer (PU) (full thickness tissue loss, fat may be visible). The photo also had an assessment documented which revealed the PU was a stage III (3) in-house acquired PU. [...]

Inspectors wroteBased on observations, interviews, record reviews, and 8 (R18, R27, R28, R30, R50, R75, R97, R117) of 30 sampled residents who consume food, the facility failed to provide palatable food products effecting 119 residents, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 119 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on interview and record review the facility failed to ensure a representative from the Governing Body had contributed to the facility assessment, and failed to ensure the facility assessment was re-assessed based on a change in resident acuity status potentially affecting all 119 residents who resided at the facility. Findings Included: Review of the facility assessment revealed that the last assessment was conducted on 7/16/2023, and was good through 7/15/2024, however the facility within the last 30 days had seven pressure ulcers with treatments, 42 residents who had falls; with two of the residents having a major injury from a fall, and 13 residents with catheters who required catheter care. The facility assessment was not re-assessed in order to determine if the facility was able to meet the care needs of the residents on a daily basis. [...]

Inspectors wroteBased on observations, interviews, record reviews, and 1 (R50) of 30 sampled residents, the facility failed to effectively clean and maintain the physical plant effecting 119 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of staff to resident abuse to the State Agency for one (Resident #107) of two reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure comprehensive care plans were developed and implemented to meet the needs for two (Residents 101, and 108) out of 30 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 30 residents care plan interventions were appropriately revised. Findings Included: Per the facility face sheet Resident 101 (R101) had resided at the facility since 4/4/2023. Diagnoses included contractures of right, left hand, and muscles. Review of a care plan dated 1/20/2025, revealed, I (R101) have contractures to: Bilateral ankles Bilateral wrists/hands, Bilateral elbows. The interventions were, Provide the following assistive devices as tolerated, .Right and Left hand splints, Right and left elbow splints., dated 01/20/2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure podiatry care was provided for one (Resident #107) of one reviewed for foot care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for one out of two residents (Resident 101) hands splints were placed on, and a positioning wedge was put into place. Findings Included: Per the facility face sheet Resident 101 (R101) had resided at the facility since 4/4/2023. Diagnoses included contractures of right, left hand, and muscles. On 3/25/2025 at 9:42 AM, R101 was visited but was asleep, however it was observed R101 had severe hand and finger contractions with the right fingers contracted into a z shape, and the left hand was observed to have all fingers contracted into the palm with the wrist severely bent backwards. A wash clothe was observed to be inside of R101's left hand. R101 was observed to be on his back. Review of a care plan dated 1/20/2025, revealed, I (R101) have contractures to: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician documented in the medical record that identified medication irregularities were reviewed, the action taken, and/or the rationale for no changes to the medications for one (Resident #72) of five reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide for resident's food choices for 2 residents (R117 and R 28) of 14 reviewed. Resident 28 (R28) On 03/24/25 at 4:30 PM R 28 was upright in bed and able to participate in an interview. R28 pointed out that chef salad is on the meal ticket to be served every day and yet I only get it about once a week. Sometimes it's a nice salad and other times it is just plain lettuce. R 28 said the chef salad is enjoyed when served with toppings. R 28 considers it healthy and said the doctor has encouraged R28 to eat healthy. On 03/26/25 at 9:05 AM during observation and interview R 28 said yesterday at lunch they sent barbecue chicken, and it states on my ticket I can't eat Barbecue sauce. It was covered in sauce. When asked about a salad R 28 said I did not get a salad. [...]

Inspectors wroteBased on interview and record review the facility failed to identify via the Quality Assurance Performance Improvement committee (QAPI) the need for an action plan for pressure ulcers. Findings Included: Per the facility policy and procedure titled Quality Assurance Performance Improvement Committee dated 7/1/2010 and last revised on 4/5/2024 revealed, The QAPI Committee meets quarterly or, more often as necessary to: .develop and implement a QAPI plan .,Develop and implement appropriate plans of action to correct quality deficiencies; and .determines what performance data will be monitored and the scheduled frequency for monitoring the data. [...]

Inspectors wroteThis citation pertains to MI00149592 Based on observation, interview and record review, the facility failed to prevent misappropriation for one (Resident #202) of three reviewed for misappropriation, resulting in feelings of loss of independence and potential mistrust.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of convenience in 1 of 1 resident (Resident #1) reviewed for restraints, resulting in the restriction of mobility and a potential for decline in physical functioning and psychosocial wellbeing. Findings Include: Review of the medical record revealed Resident #1 (R1) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness, dementia, and left femur fracture. The Minimum Data Set (MDS) dated [DATE] revealed R1 scored 1 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and required partial to moderate assist for rolling left to right in bed and substantial to moderate assist for transfers. On 10/9/24 at 9:35 AM, R1's door was shut. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain an x-ray in a timely manner for 1 (Resident #1) of 3 reviewed for delay of care, resulting in a resident not receiving timely treatment for a hip and femur fracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement interventions to prevent falls for one (Resident #1) of three reviewed for falls, resulting in a fall with major injury.

Inspectors wroteThis citation pertains to intake: MI00145821 Based on observation, interview and record review the facility failed to: 1.) ensure the safety, 2.) implement care-planned interventions, 3.) ensure that those interventions were functional and in place; and 4.) provide timely assessment and treatment for 1 of 3 sampled residents (R104) reviewed for supervision from a total sample of 4 residents, resulting in actual harm for R104's fall with left femur fracture on 6/7/24, delay in assessment, pain and transfer to the hospital.

Inspectors wroteThis citation pertains to Intake Number(s): MI00144739. Based on observation, interview, and record review, the facility failed to implement effective interventions to prevent repeated falls for one (R802) of three residents reviewed for accidents and supervision.

Inspectors wroteThis citation pertains to Intake Number(s): MI00144739 Based on observation, interview, and record review, the facility failed to ensure care and supervision was provided based on professional standards of practice for one (R802) of eight residents reviewed . This had the potential to affect all 21 residents who resided on Unit 3 on 5/26/24.

Inspectors wroteThis citation pertains to Intake Number(s): MI00144739 and MI00133567. Based on interview and record review the facility failed to monitor blood pressures to ensure medications were administered according to physician ordered parameters for one (R802) of two residents reviewed for medications.

Inspectors wroteBased on observation, interview and record review facility failed to: 1) accurately assess, monitor, treat and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for one Resident (R38) of three reviewed for pressure ulcers, resulting in facility acquired stage 4(full thickness skin and tissue loss), and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status.

Inspectors wroteThis citation pertains to intake MI00142988. Based on interview and record review, the facility failed to thoroughly supervise, assess and investigate incident and accidents in three of five residents reviewed for accidents (Resident #77, #79 & #89), resulting in a change of condition, transfer to the hospital followed by death (R77), and avoidable accident (Resident #79) and safety risks with elopement (Resident #89).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management service of Botox injections in one of three residents (Resident #317) reviewed for pain, resulting in unrelieved pain.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) clean and maintain food service equipment, and (2) date and label all food products effecting 112 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 sufficient levels of nursing staff to meet resident needs for three residents (Resident #79, #81, and #317) and in five of five residents reported in confidential resident council meeting, resulting in extended call light response times, cold food, delayed assistance with meal consumption, the potential for unmet care needs and all 112 facility residents to not attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to intake MI00142988. Based on interview and record review, the facility failed to notify the responsible party following an incident in two of three residents reviewed for notification of change (Resident #77 & #20) resulting in a delay in care decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for two residents of two residents reviewed for grievances (Resident #42 and #105), resulting in anger, frustration and unresolved grievances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report allegations of abuse that involved two residents (Resident # 20 and 105) of 3 reviewed, resulting in allegations of abuse that were not reported and the potential for further allegations of abuse to go unreported.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the protection of residents and thoroughly investigate allegations of abuse that involved 3 residents (Resident #20, #77 and #105) of 3 reviewed for abuse, resulting in the potential for further abuse to occur and allegations of abuse not being thoroughly investigated. Resident #20 (R20) Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] reflected Resident #20 (R20) was an [AGE] year old female with diagnoses of Alzheimer's disease, adjustment disorder and anxiety. R20 scored 00 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) MDS section E0200 question B Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) coded as1. occurred 1-3 days. C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident (#45) of 23 residents reviewed for accurate MDS assessments. Findings Included: Resident #45 (R45) Review of the medical record revealed R45 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancer) of the colon, depression, dementia, insomnia, gastro-esophageal reflux, chronic obstructive pulmonary disease (COPD), cerebral infarction (stroke), atrial fibrillation, hypertension, and anemia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2024 demonstrated a Brief Interview for Mental Status (BIMS) of 13 (intact cognition) out of 15. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the resident care plan in one of 23 residents reviewed for care plans (Resident #75), resulting in unmet needs.

Inspectors wroteDuring observation, interview, and record review, the facility failed to ensure residents receive showers according to their personal preferences for one residents (#42) of four residents reviewed for hygiene and grooming, resulting in missed showers and the potential for inadequate hygiene and feelings of embarrassment. Resident #42 (R42) Review of the medical record revealed R42 was admitted to the facility 02/05/2021 with diagnoses that included chronic obstructive pulmonary disease (COPD), depression, anxiety, difficulty walking, chronic kidney disease, history of falling, type 2 diabetes, hypertension, anemia, lymphedema (blockage of lymph nodes causes swelling), asthma, dermatitis (skin condition causing swelling or irritation of the skin), hyperlipidemia (high fat content in blood), bilateral osteoarthritis of knee, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain placement of a wound vacuum, per physician order, for one resident (Resident #75) and failed to complete a physician ordered suprapubic catheter change for one resident (Resident #81) of 23 residents reviewed for quality of care, resulting in residents not receiving care and treatment in accordance with professional practice.

Inspectors wroteBased on observation, interview and record review the facility to provide services to prevent further decrease in range of motion for one (Resident #317) of one reviewed for range of motion, resulting in a decrease in range of motion, contractures, and pain.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent weight loss in 1 of 4 sampled residents (#79) reviewed for weight loss, resulting in Resident #79's significant weight loss of 16 pounds in 52 days. Review of an admission Record revealed Resident #79 (R79) admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pneumonitis due to inhalation of food and vomit, major depressive disorder, nausea, syncope and collapse, and difficulty in walking. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/5/24, reflected R79 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Care Plan reflected R79 did not ambulate and required supervision/touching assistance of one person to eat. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that two Certified Nursing Aides (Q, BB) of three Certified Nursing Aides received annual performance evaluations to adequately meet the needs of the 112 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) Q had a hire date of 02/11/2021 and did not have an annual performance evaluation completed in 2024. Personnel records demonstrated that CNA BB had a hire date of 12/08/2010 and did not have an annual performance evaluation completed in 2023. In an interview on 03/05/2024 at 12:55 p.m. Human Resource Director DD explained that it is the facility policy and practice that all staff have an annual performance evaluation completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications were administered for the treatment of a specific condition and monitored for side-effects in one of six reviewed for medications (Resident #77), resulting in a decline in mental and physical condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage of medications for two resident (R50 and R265), and 2 of 3 medication carts and 1 of 3 medication rooms reviewed, resulting in the increased likelihood for decreased medication efficacy and adverse side effects in a current facility census of 112 residents

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident call system was functioning for one (R38) of 23 sampled residents, resulting in decreased emergent response time and potential resident adverse clinical outcomes. Findings Include: Resident #38(R38) Review of the Face Sheet and Minimum Data Set (MDS) with ARD date 12/25/23, reflected R38 was a [AGE] year old female admitted to the facility on [DATE] related to chronic obstructive pulmonary disease, stage 4 facility acquired pressure ulcer with chronic osteomyelitis, hypertension (high blood pressure), diabetes mellitus, cerebral vascular infarction with left non-dominant hemiparesis, anxiety, and depression. The MDS reflected R38 had a BIM (assessment tool) which reflected moderately impaired. The MDS assessment reflected R38 had no behaviors related to rejection of care. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 112 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the actual daily Nursing Staffing Data resulting in the potential for all 112 Residents and/or family and/or visitors to be well informed of the facility's staffing information. Findings Included: During observation on 03/05/2024 at 01:12 p.m. the facility document entitled Report of Nursing Staff Directly Responsible for Patient Care was observed to be posted outside of the therapy gym, after entering the facility double doors to the units. That document demonstrated a date of 03/05/24 and demonstrated Total Certified Nursing Aide (CNA) Worked for day shift as 99.2 hours, afternoon shift as 84 hours, midnight shift as 72 hours. The same document demonstrated Total Licensed Practical Nurse (LPN) hours worked for 7a.m.7p.m as 48 hours and Total Registered Nurse (RN) hours worked 7am/7pm as 12 hours. [...]

Inspectors wroteThis citation pertains in intake #MI00139231 Based on observation, interview, and record review, the facility failed to ensure a resident (R#2) was free from abuse by not implementing a care plan intervention for Resident (R#1) of two residents reviewed for abuse, from a total sample of 11 residents. This deficient practice resulted in an avoidable resident to resident altercation between Resident #1 and Resident #2. Findings Include: Resident #1 (R1) Review of the medical record reflected R1 was an initial admission to the facility on [DATE]. Diagnosis includes nontraumatic intracerebral hemorrhage, mood disorder and Dementia classified elsewhere, unspecific severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. [...]

Inspectors wroteThis citation pertains to intake #MI00138784 Based on observation, interview, and record review, the facility failed to prevent, accurately assess pressure ulcers and promote healing in one of one resident reviewed for pressure ulcers (Resident #11), in a total sample of 11 total residents, resulting in delayed wound healing and development of a facility acquired pressure ulcer.