Villa at Beecher Place

Inspectors wroteThis citation pertains to Intake Number 3051417. Based on interview and record review, the facility failed to implement care plan interventions for one resident (Resident #2), complete a thorough investigation for an elopement for one resident (Resident #70), and ensure a safe transfer using a mechanical lift for one resident (Resident #20) of six residents reviewed for accidents, resulting in a fall with a fracture for Resident #2.

Inspectors wroteThis citation pertains to Intake Numbers 3051417 and 3052791. Based on observation, interview, and record review, the facility failed to maintain a clean sanitary environment by maintaining plumbing fixtures, dining rooms and the structural integrity of the facility.

Inspectors wroteThis citation pertains to Intake Number 3032293. Based on interview and record review, the facility failed to ensure that facility employees did not falsify one resident's (Resident #26) medical records of one resident reviewed for professional standards, resulting in approximately 33 fallacious entries. Findings Include:On 6/14/2026 at approximately 1:00 PM, a review was conducted of Resident #26's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Chronic Kidney Disease, Abdominal Aortic Aneurysm, Amnesia, Heart Disease, Chronic Obstructive Pulmonary Disease and Hypertension. Resident #26 has a guardian and was not allowed to leave facility premises without staff supervision. Review was conducted of the Resident Sign In & Out form that per facility management is used when residents go outside to smoke. [...]

Inspectors wroteThis citation pertains to Intake Number 299655. Based on interviews and record review, the facility failed to ensure that wishes for no life-sustaining treatment (Do-Not-Resuscitate) were followed for one resident (Resident #101) of 4 sampled residents reviewed for advance directives, resulting in an unwanted resuscitation and prolonged suffering. Immediate Jeopardy:The Immediate Jeopardy (IJ) began on [DATE]. The Immediate Jeopardy (IJ) was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 3:10 PM. A plan to remove the immediacy was requested. The Immediate Jeopardy was removed on [DATE], based on the facility's implementation of the removal plan. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure to protect the residents' right to a safe, organized environment for 41 residents residing on the 4th floor when the nurse abandoned her assignment, leaving 41 residents without licensed nursing staff supervision, medication administration, or an emergency care capability for a period of over 2 hours (4:19 AM- 6:30 AM), without notifying the nursing assistants on the 4th floor and properly endorsing the keys to the two (2) medication carts, the medication room and narcotic boxes to a licensed nurse placing all 41 residents on the 4th floor at risk for serious injury or harm.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a continuity of care was provided for 41 residents on the 4th floor and that the early morning medications and treatments were provided for 13 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#11, R#12, R#13, R#14 and R#15) of 41 residents reviewed for medications and treatments not administered, when the licensed nurse left for over 2 hours without a nurse relief and without a licensed nursing staff to assess and respond to medical needs and emergencies.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that controlled medications were reconciled in each medication cart on the 4th Floor (East and West) when the nurse left the facility unauthorized on 2/11/26 at 4:19 AM and did not return.

Inspectors wroteThis citation pertains Intake Numbers 2749071 and 2786475. Based on observation, interview and record review, the facility failed to permit readmission of a resident following a hospital evaluation and discharge, affecting one resident (Resident #101) of five residents reviewed for safe and appropriate discharge, resulting in Resident #101 lacking a safe discharge and being readmitted to the hospital pending a safe placement.

Inspectors wroteThis citation pertains to Intake Number 2704522. Based on observations, interviews, and record review, the facility failed to protect two residents' (R401 and R403) right to be free from physical abuse by a resident (R402) of 8 residents reviewed for abuse, resulting in potential for psycho-social decline, fear of recurrent assault, and fear of pain and discomfort from physical assault.

Inspectors wroteThis citation pertains to Intake Number 2704522. Based on interviews and record review, the facility failed to ensure that the alleged violations involving two (2) incidents of resident-to-resident altercations for 3 residents (R401, R402, and R403) were thoroughly investigated and reported timely as required after allegations were made of three (3) residents reviewed for abuse.

Inspectors wroteThis citation pertains to Intake Number 2704522. Based on interviews and record review, the facility failed to ensure that behavioral health services were provided in a timely manner to 2 residents (R402 and R403) after a witnessed resident-to-resident (physical) altercations of three (3) residents reviewed for behavioral health follow-up assessments and services.

Inspectors wroteThis citation pertains to Intake Number 2698598. Based on interview and record review, the facility failed to notify a responsible party of a change in condition for one resident (R1) of three residents reviewed for change in condition, resulting in the responsible party not being informed of a wound developing and being started on an antibiotic.

Inspectors wroteBased on interview and record review, the facility failed to revise care plans for skin integrity for one resident (R1) of three residents reviewed for care plans, resulting in skin integrity care plans that did not accurately reflect the current condition of the resident.

Inspectors wroteBased on the interview and record review, the facility failed to ensure that the resident's dignity and respect were maintained when the call light was not answered in a timely manner and incontinence care was delayed, causing the resident to lie on a soiled linen for one resident (Resident, #503 [R503]) of 3 residents reviewed for dignity and respect.

Inspectors wroteThis citation pertains to Intake Number 2597296. Based on observation, interview and record review, the facility failed to ensure that air conditioning units were operational and that the environment was clean and comfortable for eight residents (1, 2, 4, 5, 6, 7, 8 and 9) of nine residents reviewed for a comfortable environment.

Inspectors wroteThis Citation pertains to Intake Number 2584838. Based on observation, interview and record review, the facility failed to protect Resident 101 (R101) and Resident 102 (R102)'s rights to be free from verbal and physical abuse and Resident 103 (R103) and Resident 104 (R104)from physical abuse during two resident-to-resident altercations, for four (R101, R102, R103, R104) of four residents reviewed for abuse, resulting in the potential for feelings of disrespect for R102; fear of an impending threat for R104 and an emergency room (ER) visit for R101 and R103 related to injuries sustained during the resident-to-resident altercations. Resident #103: A record review of the Face sheet and Minimum Data Set, indicated Resident #103 was admitted to the facility on [DATE] with diagnoses: [...]

Inspectors wroteThis Citation Pertains to Intake#: MI00153447 Based on observation, interview and record review, the facility failed to ensure a wheelchair was safe and in good working condition for one resident (#1) of 3 residents reviewed for safety. Findings Include: Resident #1 A review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: Diabetes, peripheral vascular disease, right and left below the knee amputations, COPD, alcohol abuse, Dementia, absence of 4 right fingers, depression, hypertension, and muscle weakness. The MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status/BIMS score of 15/15- full cognition and the resident needed some assistance with care. He was able to transfer self and motor his own wheelchair. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents were treated in a dignified manner for five residents (R6, R14, R21, R31, R36, R45, R59, R70) and a confidential group of residents, resulting in residents being cold due to no blankets on the bed, soiled pillows, call lights not in reach, call lights not answered timely, needs not met timely and frustration

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 on the 300 hall and 400 hall including room [ROOM NUMBER], were clean without foul odors, uncluttered, and in good repair, resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness. Findings Include: FACILITY Environment On 5/18/2025 at 10:46 AM during a tour of the facility, the 400 hallway near room [ROOM NUMBER] had a strong ammonia smell of urine. Upon entering room [ROOM NUMBER], the smell was much more intense. The first bed in the room nearest the doorway was empty, with the top sheet and blankets pulled back in a pile near the footboard. The bed had visible urine stains on the bottom sheet and the blanket and top sheet. The smell was overwhelmingly foul. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure meaningful activities were provided to one resident (Resident #36) of one resident reviewed for activities, resulting in Resident #36 lying in bed without attending activities programs. Findings Include: Resident #36: Activities On 5/18/2025 at 12:15 PM, Resident #36 was observed in his room lying in bed, awake and talkative. When asked if he attended any of the facility's Activity programs, he said no one asked him if he would like to go. He said he likes bingo and would like to go to bingo. Resident #36 said he would like to go and talk and meet new people. When asked if he normally gets out of bed, he said he had not been up lately. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound dressings were completed for three residents (Res.#17, Res.#21, and Res.#45) and failed to ensure that the resident was assessed and provided pain relief for one resident (Res.#70) who had recently underwent back surgery of four residents reviewed for quality of care resulting in the potential for wound infection, delay in wound treatment, and Res.#70 experiencing a delay in evaluation, and treatment and unnecessary pain.

Inspectors wroteBased on interview and record review, the facility failed to complete performance evaluations every 12 months for three certified nursing assistants (CNA, F, CNA G, CNA H) of five reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that HS (evening/night time) snacks were provided on a regular basis to one resident (Resident #60) and a Confidential Group of Residents, resulting in residents verbalizing feelings of anger, frustration, going to bed hungry, and diabetic residents having the potential for low blood glucose levels. Findings Include: Nutrition Snacks Resident #60: A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #60 indicated admission to the facility on 4/30/2019 with diagnoses: Diabetes, chronic kidney disease, right below the knee amputation, protein-calorie malnutrition, peripheral vascular disease, history of seizures, and heart disease. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a clean, sanitary kitchen was maintained and monitor food temperatures prior to serving. This deficient practice could affect all Residents that eat meals served from the facility kitchen of a census of 108.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents' rooms were free from flying insects for three rooms on the 3rd floor, potentially affecting the residents who reside on the 3rd floor/300 Unit, resulting in the potential for pest-transmitted diseases to a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of advance directives for one resident (R315) of two residents reviewed for advance directives, resulting in the potential for unmet life sustaining needs.

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly and accurately conduct an investigation of a fall, which resulted in hospital admission for one resident (Resident #70) of three sampled residents reviewed for the fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered per standards of practice for 2 residents (R#60 and R#70) reviewed for medication administration, resulting in the administration of medications outside of the physician-prescribed orders for Resident #60 and Resident #70 who were left to self-administer without an appropriate self administering of medication assessment from IDT and careplans, which could lead to adverse effects. Findings Include: Medication Administration Resident #60: A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #60 indicated admission to the facility on 4/30/2019 with diagnoses: Diabetes, chronic kidney disease, right below the knee amputation, protein-calorie malnutrition, peripheral vascular disease, history of seizures, and heart disease. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that activities of daily living (ADL) care was completed for one dependent resident (R17) of five residents reviewed, resulting in long dirty fingernails and a splint not being applied as ordered.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure breakfast was offered, prior to leaving for dialysis, to one resident (Resident #75) of 8 residents reviewed for food and nutrition, resulting in Resident #75 buying his own food for breakfast which led to feelings of frustration and anger. Findings Include: Resident #75: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #75 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Diabetes, End stage renal disease, dependence on dialysis, pressure ulcers, peripheral vascular disease, right below the knee amputation, anemia, hypertension, respiratory failure, and pneumonia. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that oxygen orders were followed as ordered and oxygen therapy care plans were updated for one resident (R315) of two residents reviewed for respiratory care, resulting in the resident receiving the incorrect amount of oxygen and an inaccurate care plan.

Inspectors wroteBased on interview and record review, the facility failed to: 1). ensure dialysis communication forms were complete and included pre-dialysis and post-dialysis assessment for 1 resident (#75); and 2.) accommodate the resident's medication regimen with the dialysis treatment schedule for 1 Resident (# 27) of 2 residents reviewed for Dialysis care, resulting in the potential for a decline in condition and the inability for a prompt response to care needs, medication not given as prescibed and exacerbation of medical conditions. Findings Include: Dialysis Resident #75: On 5/19/2025 at 9:28 AM, Resident #75 was not observed in his room. A breakfast meal tray was observed on the bedside table. Nurse K was interviewed on 5/19/2025 at 9:30 AM, she said Resident #75 was at dialysis. [...]

Inspectors wroteBased on the observation, interview and record review, the facility failed to ensure food temperature and palatability were maintained for 3 Residents (Res.#6, Res.# 70, & Res.# 74) of 6 residents reviewed for food temperature and palatability.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow facility policy of storing food brought into the facility by family, visitors and/or residents affecting residents using the 2nd, 3rd, and 4th floor refrigerators out of a census of 108 residents.

Inspectors wroteBased on interview and record review, the facility failed to analyze and respond to elevated Legionella water sample levels per Infection Prevention and Control Standards of Practice, resulting in the potential for an unidentified outbreak of infectious illness for a facility census of 108 residents. Findings Include: Based on interview and record review, the facility failed to analyze and respond to elevated Legionella water sample levels per Infection Prevention and Control Standards of Practice, resulting in the potential for an unidentified outbreak of infectious illness for a facility census of 108 residents. Findings Include: FACILITY Infection Control Centers for Disease Control and Prevention (CDC): [...]

Inspectors wroteThis Citation pertains to Intake Numbers MI00151112 and MI00151113. Based on observation, interview, and record review, the facility failed to provide adequate and appropriate wound care: Percutaneous Endoscopic Gastrostomy (PEG) tube site, assess, monitor, document wound status, and provide interventions as care planned for three residents (R#501, R#502 and R#503) of 4 residents reviewed for wound care, treatments and interventions.

Inspectors wroteThis citation pertains to Intake Number MI00148880 Based on interview and record review the facility failed to contrive a plan to maintain the safety of one resident ((Resident #704) of one resident reviewed for wandering, after his Wanderguard was removed resulting in him eloping from the facility six days later. Findings Include: Resident #704: On 12/12/2024 at 11:15 AM, Resident #704 was observed sleeping peacefully in bed, hisWanderguard was affixed to his right ankle. On 12/12/2024 at approximately 12:00 PM, record review was completed of Resident #704's chart and it revealed he admitted to the facility on [DATE] with diagnoses that included, Vascular Dementia, Diabetes, Hypertension, Mood Disorder and Diabetes. Further review was completed of Resident #704's records and it yielded the following: Physician Orders: Wanderguard order was initiated in July 22, 2024 Care Plan: [...]

Inspectors wroteThis citation pertains to Intake Number MI00148300. Based on observation, interview and record review, the facility failed to document a urinary catheter change and follow up on a positive urinalysis for one resident (Resident #706) of three residents reviewed for urinary catheters, resulting in a positive urinalysis, bluish purple tinged Foley catheter tubing and urinary drainage bag.

Inspectors wroteThis Citation pertains to Intake Numbers MI00144801, MI00146247, MI00146288 and MI00146298. Based on observation, interview, and record review, the facility failed to provide equipment (mechanical lift) which was safe and ensure that it was in good repair to transfer residents for one resident (Resident #12) of three residents reviewed for falls, resulting in a fall, while being transferred using a mechanical lift, resulting in multiple fractures at T11, L1, L2, L3, L4, and L5 and left shoulder dislocation, requiring hospitalization, pain control management for severe pain, surgical intervention, and potential for complications and a decline in medical condition.

Inspectors wroteThis Citation pertains to Intake Number MI00144608. Based on observation, interview and record review, the facility failed to prevent the development of a pressure wound and implement timely interventions and documentation for two residents (Resident (#9 and Resident #10) of three residents reviewed for pressure ulcers, resulting in Resident #10 developing an unstageable facility-acquired pressure wound to the left plantar foot and the potential for worsening of wounds, infection, pain and decline in overall well-being for Resident #9 and Resident #10.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident's right to be free from neglect for one resident (Resident #46), of one resident reviewed for neglect, resulting in Resident #46 having necessary medications, including narcotics, withheld without his knowledge or his physician's approval, which lead to pain, suffering, distress, and the potential for narcotic diversion. Findings Include: Resident #46: A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #46 indicated the resident was readmitted to the facility on [DATE] and again on 8/16/2023 with diagnoses: history of a stroke, dysphagia, irritable bowel syndrome, epilepsy, dementia, depression, hypertension diabetes, atrial fibrillation, bipolar disorder, COPD, gastrostomy tube, asthma, chronic pain, acquired absence of left leg below knee, GERD and heart disease. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident's pain medication was administered as ordered to treat pain for one resident (Resident #46 ) of 1 resident reviewed for pain management, resulting in the resident's verbalizations of unrelieved pain, frustration and helplessness. Findings Include: [...]

Inspectors wroteThis Citation pertains to Intake Number MI00144249. Based on observation, interview and record review the facility failed to provide sufficient staffing levels, including days with less than eight hours of Registered Nurse (RN) coverage, to meet the residents' needs for the facility census of 118, 6 residents (#27, #33, #49, #62, #101, #104) and a Confidential Group of residents, resulting in late medication administration, long call light wait times and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to maintain a sanitary kitchen by not properly cleaning and drying cookware/food containers/food trays/hot plate dispenser prior to stacking/storing, and ensuring dish machine sanitation of washed items; 2) Failed to dispose of expired food items; 3) Failed to ensure that plates were safe for use; and 4) Failed to maintain sanitary and safe cereal containers, resulting in the potential contamination of food, bacterial harborage, the increased potential for food borne illness and injury from chipped plates. This deficient practice had the potential to affect all residents that consume food prepared in the kitchen.

Inspectors wroteThis Citation has 2 Deficient Practice Statements (DPS): Deficient Practice Statement #1: Based on interview and record review, the facility failed to follow Standards of Practice for Infection Control, including collection of infection surveillance data, analysis of surveillance data to identify trends and patterns, and routine reporting of the surveillance findings to aid in preventing the spread of infection, which could result in infectious illness and unidentified outbreaks. Findings Include: FACILITY Infection Control On [DATE] at 11:17 AM, the Infection Prevention and Control program was reviewed with the Director of Nursing/DON and the new Infection Prevention and Control/IPC Nurse I. The DON said IPC Nurse I was new to the role and had been working in it about 1 month. He said over the past year, there had been 3 or 4 staff in the role. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program, resulting in uncontrolled pests throughout the entire facility, affecting all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Residents dignity was maintained for Resident #'s (5, 16, 49, 58, 59, 62, 71, 72, 102,104 and R#223) and a group of Residents that attended a Resident group meeting, of a sample of 25, resulting in thread bare gowns, long call light wait times, Residents not provided a snack when the meal was late, unaware of an appointment, lack of snacks available, frustration, positioned in bed with the head of the bed lower than feet with no bed controller, call light in reach, and the potential for unmet care needs, hunger and embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that call lights were easily accessible and within reach for three residents (Resident #16, Resident #46, and Resident #55) of four residents reviewed for call light placement, resulting in the inability to summons help when needed.

Inspectors wroteThis Citation pertains to Intake Number MI00144249. Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment to ensure that hallways, resident rooms, floors and other facility areas were clean, uncluttered, and in good repair for one Resident #33 and four resident rooms (401, 410, 413, 421), resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness. Findings Include: FACILITY Environment A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #31 indicated admission to the facility on 8/2/2023 with diagnoses: Diabetes, kidney disease, left ankle pressure ulcer Stage 3, spine disorder, depression, history of seizures, prostate enlargement, right leg amputation below the knee, hypertension, and anemia. [...]

Inspectors wroteResident #12 Accidents On 5/28/24 at 12:30 PM, R12's Electronic Medical Record (EMR) revealed that he was admitted on [DATE] with a diagnosis of Aphasia secondary to Cerebral Infarction, Hemiparesis, and Hemiplegia affecting the dominant left side and Dementia in addition to other diagnoses. The Brief Interview for Mental Status (BIMS) Score dated 5/21/24 assessment was four. A score of zero to seven indicates the person is severely impaired. R12's Determination of Decision-Making Ability, signed on 2/15/2024 by the attending physician and psychologist, determined that R12 was NOT able to make decisions to participate in medical treatment decisions and handle his own financial affairs. Smoking Assessment according to review of records on 5/21/24 at 12:30, R12's Smoking Assessment was last performed dated 8/22/22. No recent assessment was done after 8/22/22. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely assistance with activities of daily living (ADL's) including showers, bathing, dressing, transferring to wheelchair, nail care and shaving for 8 residents (#16, #22 #27, #35, #40, #46, #49, and #101), from a sample of 12 residents reviewed for ADL care, resulting in residents' feelings of frustration, discouragement, and embarrassment. Findings Include: Resident #35 Activities of Daily Living A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #35 was admitted to the facility on [DATE] with diagnoses: Diabetes, COPD, anxiety, depression, hypertension and cataracts. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 1.) correctly document a fall timely and complete neurological monitoring for Resident #104, who had a fall with a head injury; 2.) ensure fall prevention interventions were in place for Resident #58; 3.) ensure supervision and safety interventions were in place for Resident #12, who went out of the facility to smoke; and 4.) ensure safe water temperatures, of four reviewed for accident and falls and one reviewed for smoking safety, resulting in the lack of documentation accuracy in the medical record and the potential for signs and symptoms of a head injury to not be detected or treated, falls to reoccur, injury, burns and pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to reconcile narcotic medication storage, maintain accurate and legible documentation of four medication cart Narcotic Count Sheets of four carts reviewed for narcotic storage and ensure narcotics were secured in the medication refrigerator on the third-floor medication room of two medication rooms reviewed, resulting in the potential for narcotic diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice: 1.) for three of three (3 or 3) medication rooms 2.) ensure medication refrigerator temperatures outside of acceptable parameters were addressed; 3.) ensure medication carts and treatment carts were secured and locked when unattended; 4.) ensure medications were not expired in all three medication (med) storage room and med carts; and 5.) ensure the freezer in the 4th floor med room was maintained regularly without ice build-up, resulting in the potential for contamination of medications, incorrect administration of medications, a lack of therapeutic benefits necessary to promote healing for residents, increased potential for adverse effects, and resident, staff or visitor access to unsecured medication cart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a substantial evening snack was consistently offered to one Resident (#55) and a group of confidential residents that attended the Resident group meeting, potentially affecting all residents who receive meals in the facility with 14 or more hours between the last evening meal and breakfast the next day, resulting in Resident dissatisfaction, frustration and potential uncontrolled blood sugars, signs and symptoms of hypoglycemia, feelings of hunger, and weight loss.

Inspectors wroteBased on interview, and record review the facility failed to ensure that resistance patterns of infectious organisms were identified, analyzed and reviewed in the Antibiotic Stewardship Program, potentially affecting all residents with exposure to unnecessary medications, antibiotic resistance and infection. Findings Include: FACILITY Infection Control On 5/21/24 at 11:17 AM, the Infection Prevention and Control program was reviewed with the Director of Nursing/DON and the new Infection Prevention and Control/IPC Nurse I. The DON said IPC Nurse I was new to the role and had been working in it about 1 month. He said over the past year, there had been 3 or 4 staff in the role. During the interview, the DON said the facility used McGeer's Criteria for surveillance of infections, to determine a Healthcare Associated Infection/HAI vs a Community Acquired Infection/CAI. [...]

Inspectors wroteOn 05/19/24 at 9:55 AM, an initial tour of the 200 unit was conducted: -It was noted the 200 unit had a strong smell of urine upon exiting the elevator near the nurses station. -room [ROOM NUMBER] had a strong scent of urine, no resident was present during observation. The hallway outside of room [ROOM NUMBER] had a strong smell of air freshener to mask the urine smell. -room [ROOM NUMBER]-1 had a mattress in poor condition, the top coating was cracked and chipping off. -room [ROOM NUMBER]-2 had a bedside table in poor repair, the top of it was bubbled and peeling. There was mold noted on the floor by the bathtub. -room [ROOM NUMBER]-2 had a mattress in poor condition, the top coating was cracked and peeling. The bathroom needs drywall repair over the toilet. the toilet was turned on an angle and not secured to the floor, no bag in the garbage can. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Code Status was assessed, documented and accessible in the medical record for 2 residents (#'s 35 and 55) of 3 reviewed for Advance Directives, resulting in the potential for the resident's lack of informed knowledge related to options for code status and miscommunication of code status which could lead to a lack of appropriate interventions for care. Findings Include: Resident #35 Advance Directives A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #35 was admitted to the facility on [DATE] with diagnoses: Diabetes, COPD, anxiety, depression, hypertension and cataracts. [...]

Inspectors wroteBased on interview and record review the facility failed to complete and transmit a discharge minimum data set (MDS) assessment timely for one resident (#60) of one resident reviewed for MDS assessments, resulting in the late completion and transmission of an MDS discharge assessment.

Inspectors wroteBased on interview and record review, the facility failed to complete yearly PASARR (Pre-admission Screening/Annual Resident Review) Level II Screening and/or exemption criteria certification for one Resident #6 of two reviewed for PASARR documentation, resulting in the lack of yearly follow-up PASARR and the possibility for the Resident to forgo specialized behavior/mental health services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure comprehensive care plans were developed and implemented for two residents (#41,#62) of 23 residents reviewed for comprehensive care plans resulting in incomplete care plans, dignity concerns and potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly identify changes in skin, complete accurate skin and wound assessments, and implement timely interventions for one resident (Resident #5) of one resident reviewed for non-pressure injury wounds, resulting in the lack of assessment, monitoring and potential worsening of the condition and delayed healing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate interventions were in place to prevent facility acquired pressure ulcers for 2 residents (#'s 31 and 55) and interventions were utilized as ordered to promote prevention and healing for 3 resident (#31, #55 and #101) of 5 reviewed for skin and pressure ulcers, resulting in Resident's # 31 developing a pressure ulcer on his toe; Resident #55 developing multiple pressure ulcers and Resident #101 lacking positioning devices to aid in pressure ulcer prevention. Findings Include: Resident #31 Pressure Ulcer/Injury A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #31 indicated admission to the facility on 8/2/2023 with diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and implement interventions, to address changes in Range of Motion/ROM for one resident (#31) of one reviewed for range of motion, resulting in Resident #31 developing limited movement in 4 fingers and his thumb on the right hand. Findings Include: Resident #31 Position, Mobility A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #31 indicated admission to the facility on [DATE] with diagnoses: Diabetes, kidney disease, left ankle pressure ulcer Stage 3, spine disorder, depression, history of seizures, prostate enlargement, right leg amputation below the knee, hypertension, and anemia. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assess and maintain an indwelling urinary catheter for three residents (#30, #41, #55) of three residents reviewed for indwelling catheters, resulting in unmet care needs, missing dignity bags and the potential for infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure interventions were enacted to promote nutrition and prevent weight loss for two residents (# 30 and #70) and provide hydration for one resident (#55), of 7 reviewed for food, nutrition, and hydration, resulting in Resident # 30 developing significant weight loss, #70 developing weight loss and Resident #55 lacking access to fresh water, which could lead to a decline in condition and a decreased quality of life. Findings Include: Resident #55 Hydration On 5/19/24 at 12:04 , Resident #55 was observed lying in bed, awake. The resident said he was waiting for lunch. The resident was observed to have no water at the bedside, when asked about it he stated, Why don't they bring me water anymore. He had an empty clear cup on the bedside table. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1. Enteral nutrition (tube feeding/nutrition through a feeding tube into the stomach or intestines) was provided as ordered for Resident #46; 2. the feeding tube was managed and documentation provided per standards of care for 1 resident # (62); and 3. Enteral feeding equipment was properly labeled for Resident #62, resulting in Resident #46 receiving the wrong dose of Enteral feeding, Resident's #62 lacking documentation of care of the Enteral feeding and Resident #62 had unlabeled/dated equipment that could lead to infection. Findings Include: Resident #46 Tube Feeding A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #46 indicated the resident was readmitted to the facility on [DATE] and again on 8/16/2023 with diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1.) emergency tracheostomy equipment was readily available at the Resident's bedside, ensure tracheostomy equipment was properly dated and oxygen humidification and tracheostomy equipment was discarded timely for Resident #62 and 2.) nebulizer equipment was stored in a sanitary manner for Resident #33, of four reviewed for tracheostomy and respiratory care, resulting in tracheostomy cannula not readily available for emergent use for decannulation and the potential for respiratory distress, exposure to infectious organisms, and respiratory infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure coordination of dialysis care for one Resident (#2) of 1 reviewed for Dialysis services, resulting in a lack of assessment for the left arm Dialysis fistula, dressing and site, resulting in the potential for unidentified complications. Findings Include: Resident #2 Dialysis A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Respiratory failure (5/14/2024), COPD, end stage renal disease, dependence on renal dialysis, heart disease, anemia, atrial fibrillation, pain, depression, hypothyroidism, history of venous thrombosis and GERD. [...]

Inspectors wroteBased upon interview and record review, the facility failed to act upon recommendations regarding medication irregularities timely and produce pharmacy recommendation reports from monthly medication regimen reviews for two Residents (#42 and 49), of five reviewed for unnecessary medication regimen reviews, resulting in the potential for inadequate monitoring, missed gradual dose reductions of psychotropic medications, medication side effects and adverse reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were 1) consistently assessed for Influenza, Pneumococcal and COVID-19 immunization on admission, 2) offered Influenza, Pneumococcal and COVID-19 vaccinations, , 3) documented the vaccinations were accepted or declined for one (Resident #2), of 5 residents reviewed for respiratory care and immunizations, resulting in a potential for widespread Influenza, Pneumonia and COVID-19 exposure and infection throughout the facility. Findings Include: FACILITY Infection Control Resident #2 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: [...]

Inspectors wroteBased on observation and interview the facility failed to ensure that nurse staffing information was posted in a prominent area of the building that is accessible to residents and visitors.

Inspectors wroteThis Citation pertains to Intake Number MI00143932 Based on observation, interview, and record review the facility failed to: 1. Assess, monitor, and document after witnessed resident fall for Resident #127 and 2. Ensure competency of agency staff working in the facility, resulting in Resident #127 sustaining a fall on 3/24/24 at approximately 12:05 AM, without facility intervention until 3/26/24 at approximately 10:15 (56 hours), which resulted in a hip fracture that required surgical intervention and undue suffering due to neglect of duties. The agency nurse assigned to Resident #127 admitted she failed to complete required assessments/documents and that they lacked orientation/training from the facility prior to scheduled shifts. Findings Include: Resident #127: [...]

Inspectors wroteBased on interview and record review, the facility failed to: (1.) Re-weigh and update interventions on the nutritional care plan timely for one resident (Resident #116), who had a significant weight loss and (2.) Follow Physician orders and care plans for two residents (Resident #129, Resident #130) for meal assistance and supplements, resulting in weight loss not being identified and the likelihood for further weight loss and a decline in overall health and likelihood of hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to store and reconcile narcotics properly and legibly for the facility and 2) Failed to ensure proper disposal of discontinued narcotics, resulting in narcotic counts not reconciled accurately, undated and scribbled counts, unsigned reconciliation documents and 1919.5 doses of various narcotics disposed of with no documented proof and the likelihood of narcotic diversion going unnoticed.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to maintain a sanitary kitchen and resident dining room, Failed to maintain the plumbing system, 3) Failed to ensure an air gap for the ice machine, and 4) Failed to maintain cleanliness of food contact surfaces and appliances, resulting in sewage back up on the kitchen floor, dirty blenders and cooking appliances, unkept walls, no air gap to the ice machine with an increased risk of contamination of waterborne and foodborne illnesses and /or hospitalization.

Inspectors wroteThis Citation pertains to Intake Number MI00142019. Based on observation, interview and record review the facility failed to administer medications timely for one resident (Resident #126), resulting in Resident #126 being administered more than twenty-five medications over ten hours late. Findings Include: Resident #126: On 4/16/2024 at approximately 11:30 AM, an interview was conducted with Resident #126 regarding medication administration and staffing. Resident #126 explained her medications are frequently late when there is only one nurse for their floor. She indicated when a nurse works the 7 PM-11 PM their medications are timelier. On Sunday, the resident waited from 7:30 PM to 10:30 PM to be changed as there were only two aides working. Resident #126 stated she was saturated with urine by the time they arrived she had urinated two more times. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and monitor a Percutaneous Inserted Central Catheter (PICC) for one resident (Resident #122), resulting in no ongoing documented assessments, flushes and dressing changes for the PICC with the likelihood of complications going unnoticed.

Inspectors wroteBased on interview and record review, the facility failed to provide Physician-ordered medications timely for one resident (Resident #120), resulting in complaints of late medications, pain and disappointment with the likelihood of ongoing symptoms of health conditions such as pain, wheezing, and gastrointestinal complaints.

Inspectors wroteBased on record review, the facility failed to provide a 14 day stop date for a PRN (as needed) psychotropic drug (Alprazolam) for one resident (Resident #123), resulting in the ongoing PRN use of the medication and unassessed ongoing need longer than 14 days.

Inspectors wroteThis Citation pertains to Intake Numbers MI00142411 and MI00142450. Based on observation, interview, and record review the facility failed to provide monitoring and supervision to prevent the elopement from the facility of one resident (Resident #701) of three residents reviewed for wandering/elopement, resulting in Resident #701 exiting the facility with the independent smokers unbeknownst to facility staff. Facility residents alerting facility staff he had eloped from the facility. The facility is being cited at Past Non-Compliance. The Compliance Date is [DATE]. Findings Include: Resident #701: On [DATE], a review was conducted of Resident #701's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Cerebral Infarction, Adjustment Disorder and Dementia. Resident #701 has a guardian and was assessed as being cognitively impaired. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00139583 Based on observation, interview, and record review the facility failed to prevent a fall with fracture for one resident (Resident #502), that resulted in a clavicle fracture and multiple rib fractures when an inappropriate level of assistance was utilized during incontinence care. Findings Include: Resident #502: On 9/28/2023 at 12:26 PM, Resident #502 was observed to have a sling on his left arm while resting in bed. When asked what occurred for him to need to the sling, he shared he dislocated his arm when he rolled out of bed and onto the floor while being changed. Resident #502 was asked how many CNA (Certified Nursing Assistant's) there were when he fell and he stated, one. He further stated during incontinence care there is normally only one CNA completing it and this day was no different. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00139793 Based on observation, interview, and record review the facility failed to prevent misappropriation and exploitation of one resident (Resident #512) by Certified Nursing Assistant (CNA) J, resulting in CNA J allowing Resident #512 to believe they were in a relationship with one another to incentivize him to complete daily care tasks and accepting gifts from the resident with a high probability of decline in current quality of life and psychosocial harm. The surveyor confirmed by observation, interview, and record review that the deficient practice was corrected on 09/26/2023, prior to the start of the survey, and, therefore, past noncompliance was granted. Findings Include: Resident #512: [...]

Inspectors wroteThis Citation contains two Deficient Practice Statements (DPS). Deficient Practice Statement #1: Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its 1) Failure to provide extra Tracheostomy (TRACH) tubes at bedside for three residents (Resident #37, Resident #48, and Resident #101) out of three residents reviewed for Tracheostomy care; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to initiate pressure relief interventions prior to wound development and timely assess skin/wound for one resident (Resident #81), resulting in Resident 81 developing a left heel, Stage III wound (sore that has broken through the top two layers of skin and into the fatty tissue below) at the facility and the potential for worsening of pressure ulcers, pain and delayed wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the dish machine, maintain a sanitary kitchen, and maintain nourishment refrigerators, resulting in the potential contamination of food and equipment, affecting all residents who consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to specify testing protocols and acceptable ranges for control measures for the Water Management Plan and document the results of testing and corrective actions taken when control limits are not maintained, resulting in potential resident exposure to Legionella bacteria, affecting all residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain a sanitary, home-like environment, resulting in the potential contamination of the facility and equipment, and a non-home-like environment, affecting the residents on the 2nd and 3rd floors.

Inspectors wroteBased on interview and record review, the facility failed to review and revise care plans with resident-centered changes, to ensure that interventions necessary for care and services were provided for 2 residents (Resident #8 and Resident #20) of 67 residents reviewed, resulting in the potential for unmet care needs. Findings Include: Resident #8: Activities of Daily Living: A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #8 was originally admitted to the facility in 2015 and readmitted [DATE] with diagnoses: history of a stroke, dementia, left sided weakness, history of seizures, difficulty swallowing, has a feeding tube, GERD, malnutrition, a history of septic shock, depression, hypertension and chronic pain. [...]

Inspectors wroteResident #27: A review of Resident #27's medical record revealed an admission into the facility on 2/15/18 with diagnoses that included multiple sclerosis (MS), muscle weakness, paraplegia, diabetes, depression, and dementia. A review of the Minimum Data Set assessment, dated 3/10/23, revealed a Brief Interview of Mental Status score of 15/15 that indicated intact cognition and the Resident needed extensive assistance with bed mobility, transfers, dressing, personal hygiene and was total dependent of one-person physical assist for bathing. On 4/18/23 at 11:46 AM, an observation was made of Resident #27 lying in bed and dressed in a gown. The Resident is interviewed, answered questions and conversed in conversation. The Resident was asked about bathing. The Resident indicated he gets bed baths but would prefer showers and reported they just come in and do the bed bath. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assess and monitor weight changes, implement timely nutritional interventions for weight loss, complete nutritional assessment and obtain weights per facility policy for three residents (Resident #50, Resident #63 and Resident #220) reviewed for nutrition, resulting in, substantial weight loss, lack of assessment and interventions for Resident #50 and Resident #63 and failure to obtain weekly admission weights for Resident#220 with the potential for continued weight loss, facility inaction and death.

Inspectors wroteThis Citation, in part, pertains to Intake Number MI00135512. Based on interview and record review, the facility failed to ensure that licensed nurses and Certified Nursing Assistants (CNA) received yearly training/competencies to assure resident care and safety, and attain or maintain the highest practicable physical, mental and psychosocial well-being of residents in accordance with the facility assessment and residents' plans of care for two nurses and five CNA's reviewed for yearly competencies, affecting all 117 Residents residing in the facility, resulting in potential nursing staff lacking necessary training and competencies to adequately care for the needs of the residents residing in the facility and unmet resident needs.

Inspectors wroteThis Citation, in part, pertains to Intake Number MI00135512. Based on observation, interview and record review, the facility failed to ensure appropriate narcotic medication practices including: destruction of narcotics, administering medications late, storage of narcotics with the nurses personal belongings, medications found unattended on the floor, administration of back up medication, and nursing failure to observe the resident consume medication, for five residents (Resident #1, Resident #27, Resident #35, Resident #48 and Resident #68) and residents on the 2nd and 4th floors from a census of 117 residents, resulting in the potential for resident, staff and visitor access to medications including narcotics, residents not receiving medications as ordered, and a lack of therapeutic effect or adverse side effects. Findings Include: Medication Administration: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Ensure proper labeling of medications, 2) Maintain clean and sanitary medication storage, and 3) Dispose of expired medication and medical supplies for two medication carts, one medication room and one treatment cart on the 200 Halls reviewed for medication labeling and storage, resulting in the lack of clean space to store and prepare medications, and the potential for residents to receive expired medication with altered potency and efficacy and medical procedures completed with outdated supplies.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement baseline care plans to guide the care provided to two residents (Resident #220 and Resident #221) of 67 residents reviewed for care plans, resulting in the failure to provide instructions to the staff for effective and person-centered care to promote well-being and manage the nutritional status for Resident #220 and provide a plan for showers and bathing for Resident #221. Findings Include: Resident #220: Nutrition: On 4/18/23 during a tour of the facility at 1:10 PM, Resident interviewed in his room, he was eating lunch, chicken potatoes, greens, he said lunch was ok today, but it had not been every day and he was losing weight. Resident #220 said he has been in the facility for about 3 weeks. He said he went from about 140 lbs. to 115 lbs. [...]

Inspectors wroteBased on interview and record review, the facility 1) Failed to assess, monitor, and provide timely interventions for one resident (Resident # 118) reviewed for a change of condition and 2) Failed to ensure that a Boston Heart Monitor was at bedside and in use for one resident (Resident #46) from a census of 117, resulting in unassessed Heart Rhythm and in Resident's #118 developing vomiting and diarrhea without nursing assessments, monitoring or interventions to aid in identifying the cause or relieving discomfort. Findings Include: Resident #118: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #118 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Bipolar disorder, diabetes, arthritis, asthma, dementia, schizophrenia, hypertension, and syncope and collapse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Restorative Nursing services and the management and monitoring of a left arm brace were provided to one resident (Resident #76) of one resident reviewed for range of motion, resulting in Resident #76 lacking consistent placement of the brace and monitoring to determine if it was meeting the resident's needs. Findings Include: Resident #76: Position, Mobility A record review of the Face sheet and MDS assessment indicated Resident #76 was admitted to the facility on [DATE] with diagnoses: history of a stroke, left side weakness, difficulty swallowing, heart disease, and depression. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that appropriate interventions were enacted and supervision was provided to prevent a fall with injury for one resident (Resident #19) and neurological assessments were completed after a fall for one resident (Resident #61) of 4 residents reviewed for falls, resulting in Resident #19 falling out of bed and sustaining a femur fracture and Resident #61 with the potential for serious complications or injury. Findings Include: Resident #19: Accidents: A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #19 indicated she was admitted to the facility on [DATE] with diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, monitor and care for a urinary catheter per standards of practice for one resident (Resident #30) of two residents reviewed for urinary catheters, resulting in no documented assessment or care of the catheter with the likelihood of signs or symptoms of catheter associated infection or problems going unnoticed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 1) Enteral nutrition (tube feeding/nutrition through a feeding tube into the stomach or intestines) formula was provided as ordered for Resident #50, 2) The feeding tube was managed per standards of care and the facility policy for Resident #8 and 3) Dressing changes were performed at the feeding tube insertion site into the abdomen as ordered for Resident #46 of 4 residents reviewed for enteral nutrition, resulting in the potential for Resident #50 to not receive the appropriate amount of Enteral formula and Residents #8 and Resident #46 to experience adverse effects from a lack of management of the feeding tube. Findings Include: Resident #8: [...]

Inspectors wroteThis Citation pertains to Intake Number MI00135512. Based on observation, interview and record review, the facility failed to administer prescribed narcotic medication as ordered by the physician and ensure effective pain management to alleviate pain from an infection of the left hand and lancing of the area, for one resident (Resident #48) of one resident reviewed for pain management, resulting in a lack of pain assessment and administration of narcotic medication with the potential for unrelieved pain and discomfort.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to follow policy on performing/monitoring quality control of glucometers for three glucometers on the 200 Hall, 2) Failed to label glucometer control solutions when opened, failed to dispose of expired glucometer control solutions and 3) Failed to perform glucose monitoring consistent with professional standards of practice that would provide the most accurate results of blood glucose monitoring for Resident #27, affecting residents who reside on the 200 Hall needing glucose monitoring, resulting in the potential for inaccurate test results and inappropriate or lack of treatment governed by the test results.