Deficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
35% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jan 23, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining experiences, incomplete implementation of care plans, inadequate assistance with eating, failure to use gait belts during resident ambulation, inaccurate oxygen administration, and incomplete documentation of meal intake.
Deficiencies (7)
F 0550: The facility failed to provide a dignified dining experience for 2 residents, resulting in potential feelings of diminished self-worth and frustration.
F 0656: The facility failed to implement care plan interventions for 2 residents, including inconsistent use of heel protectors, geri sleeves, and straws, risking skin breakdown and nutritional issues.
F 0657: The facility failed to revise the nutrition care plan for one resident, resulting in confusion regarding diet and fluid restrictions.
F 0677: The facility failed to provide adequate assistance with eating for one resident, resulting in potential avoidable negative physical outcomes.
F 0689: The facility failed to ensure use of gait belts during ambulation for one resident, resulting in a fall and potential injury.
F 0695: The facility failed to ensure accurate oxygen administration for one resident, resulting in inconsistent oxygen delivery at the ordered level.
F 0842: The facility failed to accurately document meal intake for two residents, resulting in inaccurate reflection of nutritional intake and care provided.
Report Facts
Fall Risk Score: 18
Fall Risk Score: 12
BIMS Score: 5
BIMS Score: 1
BIMS Score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LL | Food Service Manager | Reported concerns about staff behavior during dining and care plan confusion |
| E | Health Care Manager | Reported awareness of staff issues and care plan expectations |
| B | Director of Nursing | Reported expectations for care plan adherence and oxygen order compliance |
| Z | Certified Nursing Assistant | Involved in resident fall without gait belt use |
| FF | Licensed Practical Nurse | Reviewed oxygen orders and confirmed inconsistent oxygen settings |
| GG | Registered Nurse | Documented care plan interventions and oxygen administration |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Feb 29, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards in various areas including care planning, medication administration, resident safety, infection control, food safety, staffing data submission, and water management.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for high-risk medications, improper medication administration documentation and handling, unsafe wheelchair transport practices, inadequate feeding tube management, improper food labeling and storage, incomplete staffing data submission, lack of an active water management plan, and failure to consistently implement infection prevention and control measures.
Deficiencies (7)
F 0656: The facility failed to develop and implement a person-centered comprehensive care plan for a high-risk medication (Torsemide) for Resident #32, resulting in incomplete care planning.
F 0658: The facility failed to follow professional standards for medication administration documentation in 3 of 7 residents and medication handling/storage in 1 of 8 residents, resulting in medications being left unsupervised and potential medication errors.
F 0689: The facility failed to ensure safe transport of Resident #6 in a wheelchair without footrests in place, resulting in potential for accident or injury.
F 0693: The facility failed to ensure proper care and services related to feeding tube management for Resident #3, including use of a de-clogger and carbonated beverage without physician orders or care plan interventions.
F 0812: The facility failed to properly label, date, and discard opened food products, increasing the risk of foodborne illness affecting all residents consuming food from the kitchen.
F 0851: The facility failed to submit complete and accurate direct care staffing data for the 4th quarter of 2023, resulting in inaccurate reporting to CMS.
F 0880: The facility failed to implement an effective infection prevention and control program, including lack of a water management plan for legionella, failure to perform hand hygiene, sanitize equipment between residents, wear appropriate PPE, and follow transmission-based precautions for Resident #3.
Report Facts
Residents reviewed for care plans: 13
Residents reviewed for medication administration: 7
Residents reviewed for medication storage: 8
BIMS score: 5
BIMS score: 8
Opened food product discard dates: 2
PBJ staffing data quarters: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in medication administration documentation and feeding tube management findings. |
| RN DD | Registered Nurse | Named in medication administration documentation findings. |
| Nurse Manager E | Nurse Manager | Named in care plan development and wheelchair transport findings. |
| Director of Nursing B | Director of Nursing | Named in medication administration, wheelchair transport, feeding tube management, staffing data, and infection control findings. |
| CENA U | Certified Nurse Assistant | Named in wheelchair transport findings. |
| DCS K | Director of Culinary Services | Named in food labeling and storage findings. |
| Nursing Home Administrator A | Nursing Home Administrator | Named in staffing data submission findings. |
| DPO TT | Director of Plant Operations | Named in water management plan findings. |
| IP/RN H | Infection Preventionist/Registered Nurse | Named in infection prevention and control findings. |
| CENA T | Certified Nurse Aide | Named in infection prevention and control findings. |
| LPN Z | Licensed Practical Nurse | Named in infection prevention and control findings. |
| CENA QQ | Certified Nurse Aide | Named in infection prevention and control findings. |
| CENA SS | Certified Nurse Aide | Named in infection prevention and control findings. |
| RN EE | Registered Nurse | Named in infection prevention and control findings. |
| CENA X | Certified Nurse Assistant | Named in infection prevention and control findings. |
| CENA Y | Certified Nurse Assistant | Named in infection prevention and control findings. |
| LA OO | Laundry Aide | Named in infection prevention and control findings. |
| HK PP | Housekeeper | Named in infection prevention and control findings. |
| ESM NN | Environmental Service Manager | Named in infection prevention and control findings. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 1, 2023
Visit Reason
The inspection was conducted due to a complaint intake MI00135557 regarding a fall incident involving Resident #1 at the facility.
Complaint Details
This citation pertains to intake MI00135557. The complaint was substantiated based on interviews and record review showing failure to follow the care plan leading to Resident #1's fall and injury.
Findings
The facility failed to follow the care plan for Resident #1, resulting in a fall from bed that caused a large laceration and hematoma to her head, transfer to the emergency department, and ongoing pain. The resident's bed was not left in the lowest position as required, contributing to the fall.
Deficiencies (1)
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. Resident #1 fell from bed because the bed was left in a high position contrary to the care plan, resulting in serious injuries.
Report Facts
Hematoma size: 2.5
Oral intake: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Assistant | Assigned to Resident #1 at time of fall; left bed in high position; educated to follow care plan |
| RN C | Registered Nurse Manager | Interviewed regarding Resident #1's bed position at time of fall |
| DON B | Director of Nursing | Interviewed about CNA D's failure to follow care plan and bed position at time of fall |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 15, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident dignity, infection control, Medicaid/Medicare notices, MDS assessment submissions, staff competency, food safety, and infection prevention and control practices at the nursing home.
Complaint Details
The visit was complaint-related, investigating multiple issues including resident dignity, infection control, Medicaid/Medicare notices, MDS assessments, staff training, food safety, and infection prevention. Specific substantiation status is not explicitly stated.
Findings
The facility was found deficient in maintaining resident dignity, providing required Medicaid/Medicare notices, timely submission of MDS discharge assessments, ensuring staff competency training, food safety violations including improper food storage and sanitation, and inadequate infection prevention and control practices including improper PPE use, unclean resident equipment, improper laundry handling, and staff fingernail hygiene.
Deficiencies (6)
F 0550: The facility failed to maintain the dignity of 3 residents during feeding and care, resulting in potential embarrassment and humiliation.
F 0582: The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice to 1 resident, risking inability to appeal discharge timely.
F 0640: The facility failed to submit Minimum Data Set discharge assessments for 4 residents, risking inaccurate tracking of assessments and discharges.
F 0726: Five of 32 Certified Nursing Assistants lacked required annual competency training, risking inadequate resident care.
F 0812: The facility failed to protect food from contamination, maintain proper food dating, repair facility areas, clean equipment, and use proper sanitizer concentration, risking foodborne illness for 41 residents.
F 0880: The facility failed to ensure proper infection control measures including PPE use, hand hygiene, cleaning of resident equipment, laundry handling, and staff fingernail hygiene, increasing risk of cross-contamination among residents.
Report Facts
Certified Nursing Assistants lacking annual training: 5
Residents affected by dignity failure: 3
Residents affected by MDS discharge assessment failure: 4
Residents affected by food safety issues: 41
Residents reviewed for infection control: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager G | Unit Manager | Observed not wearing required eye protection properly and admitted to not being vaccinated. |
| Infection Control Preventionist C | Infection Control Preventionist | Provided statements on PPE use, infection control policies, and staff training. |
| Certified Nursing Assistant O | Certified Nursing Assistant | Observed not performing hand hygiene or PPE use properly and not sanitizing equipment between residents. |
| Infection Assistant EE | Infection Assistant | Provided information on staff education tracking and training. |
| Dietary Manager SS | Dietary Manager | Reported lack of bleach test strips and sanitizer concentration issues. |
| Physical Therapist OO | Physical Therapist | Observed entering resident room without PPE and not performing hand hygiene. |
| Licensed Practical Nurse XX | Licensed Practical Nurse | Reported on enhanced barrier precautions for Resident #44. |
| Unit Clerk PP | Unit Clerk | Entered Resident #9's room without proper PPE. |
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