Alamo Cove Rehab and Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate nurse staffing to promote the physical, mental and psychosocial well-being in 3 residents (Resident #3, Resident #74, Resident #5) of 19 residents reviewed for staffing and 9 of 11 residents as reported during a confidential resident council interview, resulting in unmet care needs and the potential for physical and psychosocial harm for all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to update the facility assessment related to current staffing concerns resulting in the potential for unmet care needs for all residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain proper infection control practices for 1). Transmission based (contact isolation) precautions for 1 (Resident #59) of 1 resident, 2). Enhanced barrier precautions for 1 (Resident #88) of 1 resident, 3). Storage of nebulizer (a medical device that converts liquid medication into a fine mist that can be inhaled directly into the lungs) for 1 (Resident #34) of 1 resident, 4). Use of gloves during insulin administration for 1 (Resident #90) of 1 resident, 5). Cleanliness of shared resident equipment, 6). Proper hand hygiene during medication administration, 7). Storage of oxygen tubing for 1 (Resident #43) of 1 resident, and 8). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain general cleanliness and repair of the facility. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for residents of the facility. Findings Include: On 4/28/26 at 10:05 AM, a window was observed open in Resident #11's room, with no screen was present. Dirt was observed on the over-the-bed table at the foot of the bed, the floor, and on the foot of the bed. Resident #11 was in bed sleeping. In an interview on 4/29/26 at 8:30 AM, Resident #11 reported she was mad and did not understand why she could not have a screen on her window. Resident #11 reported her window was open yesterday when she left the building for an appointment and when she returned, her bed had grass and dirt on it. [...]

Inspectors wroteBased on interview, and record review, the facility failed to take prompt efforts to resolve resident grievances in 1(Resident #5) of 19 residents reviewed for concern resolution, and 9 of 11 residents who attended a confidential meeting, resulting in dissatisfaction with call light response, unresolved concerns related to missing items and the potential for additional care concerns to go unaddressed.

Inspectors wroteBased on interview and record review, the facility failed to sustain a system to ensure corrective measures related to pressure ulcers in 1 of 2 residents (Resident #88) reviewed for pressure ulcers and quality improvement as evidenced by repeated deficiencies on two of the past three surveys and current noncompliance with pressure ulcer concerns, resulting in the potential for continued development or worsening of pressure ulcers for residents with actual skin breakdown or at risk of skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to treat residents with dignity and respect and failed to provide an environment that promoted and enhanced resident quality of life for 3 (Resident #1, #6, and #74) of 4 residents reviewed for dignity, resulting in long call light wait times and the potential for feelings of frustration, depression, and loss of self-worth and an overall deterioration of psychological well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were assess to be appropriate for self-administration of medications for 2 (Resident #5 and Resident #34) of 10 residents reviewed for medication administration resulting in medications being left unsecured in resident rooms, residents self-administering medications without staff assessment, and the potential for negative outcomes from taking/applying too much or too little medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident choice for getting up in the morning by 10 AM for 1 resident (Resident #3), of 19 residents reviewed for choices, resulting in the potential for this resident to not meet her highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to notify a resident responsible party regarding a change in condition for 1 (R303) of 3 residents reviewed for change in condition resulting in the responsible party not receiving x-ray results and knowing extent of injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive resident-specific treatment plan for Enhanced Barrier Precautions (EBP) for 1 resident (Resident #306) of 4 residents reviewed for comprehensive care plans resulting in the potential for unmet care needs and the spread of infection to a vulnerable population.

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise care plan interventions to accurately reflect resident care needs for 1 (Resident #5) of 19 residents reviewed for revision of care planning, resulting in a potential for staff not knowing how to properly care for the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure interventions were implemented to prevent the development of and/or worsening of pressure ulcers in 1 (Resident #88) of 2 residents reviewed for pressure ulcers resulting in the potential for the development of and/or the worsening of an existing pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an environment free from hazards for 2 (Resident #5 and #48) of 5 resident reviewed for accidents, resulting in an increased risk for falls.

Inspectors wroteBased on interview and record review the facility failed to ensure pre and post dialysis treatment assessment and monitoring communication between themselves (the facility) and the dialysis provider (Name Omitted) was maintained for 1 (Resident #11) of 1 resident reviewed for dialysis services resulting in the potential for unrecognized adverse reactions or resident decline due to adverse reactions of dialysis treatments and disruption in the continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to find a pharmacy recommendation for 1 resident (Resident #86) of 5 residents reviewed for medications resulting in the potential for the resident to experience avoidable medication side effects and/or receive unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a medication error rate of less than 5% (total error rate of 10%) in 2 of 8 sampled residents (Resident #48 and Resident #59) reviewed for medication administration, resulting in the potential for reduced medication effectiveness and increased risk of adverse reaction and/or side effects.

Inspectors wroteThis citation pertains to intake #2728846Based on interview and record review, the facility failed to provide adequate care to prevent skin breakdown and the worsening of pressure ulcers in 1 of 3 (Resident #101) residents reviewed for pressure ulcers, resulting in the worsening of a pressure ulcer.

Inspectors wroteThis citation pertains to intake 2748436 and 2728846. Based on interview and record review the facility failed to ensure 2 residents (Resident #112 and Resident #101) were free from significant medication errors when (a) medications were administered outside physician prescribed parameters (b) medications were not administered as ordered without provider notification resulting in Resident #112 being hospitalized for hypoglycemia (low blood sugar) and Resident #101 missing multiple doses of seizure medication, having a seizure and subsequent change in condition resulting in hospitalization.

Inspectors wroteThis citation pertains to intake 2661176, 2728846, 2638850. Based on observation, interview, and record review, the facility failed to provide appropriate Activities of Daily Living (ADL) care for 5 (Resident #101,#103,#110, #113, and #114) of 7 residents reviewed) reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's who are dependent on staff for assistance.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure PASSAR (Preadmission Screening/Annual Resident Review) for a Level I OBRA evaluation and OBRA Level II evaluation were completed timely for 1 resident (Resident #109) of 2 residents reviewed, resulting in the potential for unmet behavioral health needs.

Inspectors wroteThis citation pertains to Intake: 2638850Based on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 3 (Resident #103, #109, and #112) of 13 residents reviewed for care planning implementation, resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to intake #2745481Based on interview and record review, the facility failed to assess the need for an indwelling catheter for 1 (Resident #108) of 5 residents reviewed for incontinence care resulting in pain, frustration, and a delay in the removal of a foley catheter (medical device that helps urine drain from your bladder).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided consistent with professional standards of practice for residents who received enteral nutrition (tube feeding) in 1 (Resident #107) of 2 residents reviewed for tube feeding, resulting in the potential for aspiration pneumonia.

Inspectors wroteThis citation pertains to intake 2728846, 2661176, and 2638850. Based on interview and record review, the facility failed to maintain accurate medical records for 3 residents out of a total of 13 residents (Resident #101, #103 and #112) reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents.

Inspectors wroteThis citation pertains to intake #2595324. Based on observation, interview, and record review the facility failed to provide adequate care to prevent skin breakdown and worsening of pressure ulcers in 1 resident (Resident #108) of 3 residents reviewed for pressure ulcers, resulting in actual skin breakdown and worsening of pressure ulcers due to inadequate treatments, proper repositioning and incontinence care.

Inspectors wroteThis citation pertains to intake: 2612703Based on interview and record review, the facility failed to ensure residents received care in accordance with professional standards upon admission for 1 resident (Resident #106) of 8 residents reviewed for quality of care, when nursing staff failed to implement hospital discharge orders timely for medication administration, resulting in the potential for worsening of health conditions and a delay in treatment.

Inspectors wroteThis citation pertains to intake #1359687. Based on observation, interview and record review the facility failed to implement physician orders for Enhanced Barrier Precautions (EBP: an infection control strategy where gloves and gowns are worn during high-contact resident care to reduce the spread of and/or risk of acquiring drug-resistant bacteria) for 1 resident (Resident #108) of 3 residents reviewed for infection control, resulting in the potential for residents to acquire avoidable drug-resistant infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: (1) effectively clean and maintain food service equipment, (2) label and store food products, (3) date mark all potentially hazardous ready-to-eat food products, and (4) maintain plumbing fixtures effecting 84 residents, resulting in the increased potential for cross-contamination, bacterial harborage, and resident foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively clean and maintain the physical plant effecting 84 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 develop and implement comprehensive care plans in 4 of 19 residents (Resident #13, #38, #44, & #76) reviewed for comprehensive care plans, resulting in the unmet needs related to incontinence care, pressure ulcer prevention, skin integrity, respiratory care, and the potential for an overall decline in physical, mental, and psychosocial wellness.

Inspectors wroteBased on observation, interview, record review the facility failed to provide palatable food products in 2 (#17, #45) of 18 sampled residents, and 11 of 11 residents from the confidential group meeting, effecting 84 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline.

Inspectors wroteBased on observation, interview, record review the facility failed to honor resident food choice preferences in 5 (#63, #44, #73, #17, and #21) of 18 residents and 2 of 11 residents from the confidential group meeting, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper glove use during incontinence care and injection administration, and ensure sanitary storage of respiratory equipment in 3 residents (Resident #13, #44, and #76) of 18 residents reviewed for infection control, resulting in the potential for skin breakdown, UTI (urinary tract infection), bacterial harborage, cross contamination and the spread of disease to a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect in 3 of 3 residents (Resident #13, #44, & #54) reviewed for dignity/respect, and 11 of 11 residents from the confidential group meeting, resulting in unmet care needs and the potential for feelings of diminished self-worth, sadness, and frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure residents did not self-adminster medications that were not assessed as safe to self-administer in 2 of 11 residents (Resident #28, #69) reviewed for self administration, resulting in the potential for mismanagement of medications and worsening medical conditions.

Inspectors wroteThis citation pertains to intake #MI00149980 Based on interview and observation, the facility failed to protect the resident's right to be free from mental, verbal and physical abuse by staff for 1 resident (Resident #49) of 2 residents reviewed for abuse, resulting in verbal intimidation and physical restraint.

Inspectors wroteThis citation pertains to intake #MI00149980 Based on interview and record review, the facility failed to 1. investigate an allegation of abuse for 1 resident (Resident #37) 2. provide an accurate investigation and prevent the potential for further abuse after an allegation of abuse for 1 resident (Resident #49) of 2 total residents reviewed for abuse resulting in the potential for the allegation to not be thoroughly investigated and further abuse to occur.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident/resident representative of the facility bed hold policy and provide a written copy upon hospital transfer for 2 residents (Resident #37, Resident #43) of 3 residents reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the bed hold policy.

Inspectors wroteBased on observation, interview the facility failed follow professional standards for medication administration for 1 out of 11 residents (Resident #332) reviewed for standards of practice, resulting in the potential for cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities of daily living (ADL) to dependent residents, including showers, shaving, nail care, and the application of ted hose (stocking) to 2 (Resident #19 and Resident #76) of 4 residents reviewed for activities of daily living, resulting in an unkempt appearance and the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide preventative care, consistent with professional standards of practice for 2 of 2 residents (Resident #13 & #44) reviewed for at risk to develop pressure injuries, resulting in the potential for the development of an avoidable pressure ulcer, infection, and overall deterioration in health status.

Inspectors wroteBased on observation, interview, and record review the facility failed to 1.) ensure safe transport in a wheelchair with foot pedals in place for 1 resident (Resident #63); 2.) implement gait belt (a device put on a resident who has mobility issues, by a caregiver, prior to that caregiver moving the resident) use for safety during transfers for 2 (Resident #63 and Resident #37) of 3 total residents reviewed for transport safety and transfers resulting in the potential for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care and perform hand hygiene in accordance with standard infection control practices in 2 residents (Resident #13 & #44) of 2 residents reviewed for bowel/bladder incontinence, resulting in the potential for skin breakdown and UTI (urinary tract infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the maintenance, and storage in a sanitary manner of CPAP (continuous positive airway pressure machine increases the air pressure in the throat to prevent airway collapse) machine equipment according to professional standards for 1 of 18 residents (Resident #76) reviewed for respiratory care, resulting in an increased potential for respiratory infection and respiratory distress.

Inspectors wroteBased on interview and record review the facility failed to ensure that PRN (as needed) psychotropic medications were limited to 14 days unless documented rationale by the physician was present in the medical record in 1 (Resident #9) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a double-lock system for a controlled substance in the facility's medication refrigerator resulting in the potential for diversion and/or misappropriation of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow protocol for one resident (R9) of 3 residents reviewed to ensure food brought into the facility was labeled and dated with an expiration date, resulting in the potential for food born illness.

Inspectors wroteThis citation pertains to intake #MI00149360. Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of an allegation of abuse in 1 resident (Resident #114) of 15 residents reviewed for abuse reporting, resulting in the potential for a delayed investigation and further abuse.

Inspectors wroteThis citation pertains to intake #MI00149360. Based on observations, interviews and record review, the facility failed to provide increased supervision for 3 residents (Resident #114, #108, & #106) of 5 residents reviewed for being at risk for falls, resulting in repeated falls for all 4 residents, and Resident #114 sustaining fractured ribs.

Inspectors wroteThis citation pertains to intake # MI00147413 Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet resident needs in 3 residents (Resident #114, #108, & #106) of 15 residents reviewed for sufficient staffing, with the potential for all residents to be affected, resulting in a lack of supervision of residents at risk for falls. For additional information see citations F689.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently offer/provide HS (hour of sleep) snacks to 2 residents (Resident #102 & #113) of 4 residents reviewed for snacks, resulting in resident dissatisfaction.

Inspectors wroteBased on interview and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices in 2 residents (Resident #112 & #115) of 5 residents reviewed for infection control practice, resulting in the potential for transmission of MDRO (multidrug-resistant organisms).

Inspectors wroteThis citation pertains to intakes M100146395 and M100146349. Based on interview and record review, the facility failed to follow their policy and appropriately provide pressure ulcer care as ordered for 1 (Resident #2) of 4 residents reviewed for pressure ulcers, resulting in hospitalization.

Inspectors wroteThis citation pertains to intakes: MI00146486 and 146502 Based on interview and record review the facility failed to provide supervision and assistance in 1 of 4 residents (R1) reviewed for falls/safety, resulting in falls and injuries.

Inspectors wroteThis citation pertains to intake MI00146486. Based on interview and record review, the facility failed to ensure adequate care for a resident who required tube feeding in 1 of 1 resident (R1) reviewed for tube feeding, resulting in an acute change of condition immediate need for ambulance transport to the hospital.

Inspectors wroteThis citation pertains to intakes M100146395 and M100146349. Based on interview and record review, the facility failed to ensure an effective process for receiving and addressing grievances in 1 (Resident #2) of 1 resident reviewed for grievances, resulting in unresolved concerns.

Inspectors wroteThis citation refers to MI0014459 and MI00146322. Based on interview and record review, the facility failed to follow physician orders for 1 of 8 residents ( R4) reviewed, resulting in R4 not receiving medications per the physician's order, and the physician not being notified of R4's high blood sugar readings per the physician's order.

Inspectors wroteThis citation pertains to intake M100146395. Based on interview and record review, the facility failed to ensure there was adequate competencies to provide nursing related services for 1 (Resident #2) of 1 resident reviewed for skilled nursing services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a functional nurse call system at all times resulting in the potential for serious psychosocial or physical harm for vulnerable residents who were often at times without a way to call for routine or emergency assistance.

Inspectors wroteThis citation pertains to Intake # MI00142619. Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet resident needs in 5 of 8 residents (Resident #9, #10, #33, #41, & #55) reviewed for sufficient staffing, resulting in long call light wait times, residents being left wet and/or soiled for extended periods of time, missed showers/baths, late medications, and staff burnout. For additional information see citation F550 and F919.

Inspectors wroteBased on interview, and record review, the facility failed to complete annual performance reviews for 5 Certified Nursing Assistants (CNA's) (CNA's T, U, V, S, and XX) of 5 reviewed for regular in-service training, resulting in the potential for unidentified CNA performance concerns, a lack of training related to staff performance review outcomes, and the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1.) maintain an Infection Prevention and Control Program. 2). follow the standards of infection control for hand hygiene, and glove use during incontinence care for 3 residents (Resident #41, #33 and #9) of 5 reviewed for infection control. 3). to ensure infection control practices were followed for adequate cleanliness of resident shared equipment (including but not limited to: transfer lifts, bath/shower rooms and commonly used surfaces) resulting in the potential for bacterial harborage, cross contamination, and the spread of disease to a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were eligible for recommended vaccines were offered vaccination in a timely manner for 5 residents (Resident #9, #58, #56, #76, ½) out of 5 residents reviewed for immunizations resulting in the potential for developing vaccine preventable disease.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records included documentation that residents/resident representatives were educated, offered and/or received timely, the COVID-19 immunization as recommended by the Centers for Disease Control and Prevention (CDC) for 5 resident (Resident #9, #58, #56, #76, & #189) of 5 residents reviewed for immunizations, resulting in residents not receiving the Covid-19 immunization per CDC guidelines, the potential for incomplete vaccination, and the potential for serious illness and complications from COVID-19 (SARS-CoV-2).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 81 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteBased on observation and interview, the facility failed to maintain a dignified existence for 3 residents (Resident #81, Resident #9, and Resident #10) of 18 residents reviewed for dignity, resulting in long call light wait times, residents being left wet and soiled, and feelings of frustration, anxiety, and embarrassment.

Inspectors wroteBased on interview, and record review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) for Medicare Part A services in 3 of 3 residents (Resident #89, #90, & #91) reviewed for timely provision of notifications, resulting in the potential for the resident or resident representative to be unaware of changes in regard to financial liability, frustration, and a delay in the ability to file an appeal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans in 2 of 18 residents (Resident #11 & #13) reviewed for comprehensive care plans, resulting in the potential for falls/injury for Resident #11 and a lack of resident-centered interventions related to a history of trauma for Resident #13.

Inspectors wroteThis citation pertains to Intake #MI00142619. Based on observation, interview, and record review, the facility failed to maintain professional standards of care and provide adequate incontinence care in 2 of 3 residents (Resident #9 & #41) reviewed for bowel and bladder incontinence, resulting in an increased risk for UTI (urinary tract infection) and the potential for skin breakdown.

Inspectors wroteBased on interview, and record review the facility failed to identify traumatization triggers and implement interventions to mitigate these triggers for 1 (Resident #13) of 18 residents reviewed for trauma informed care, resulting in Resident #13, who had recently survived a life-threatening fire, experiencing fear and anxiety during a fire drill, and a potential for unmet psychosocial needs.

Inspectors wroteBased on interview and record review the facility failed to ensure that monthly medication regimen review (MRR) recommendations were documented in the resident's record and ensure timely physician response to pharmacy recommendations for 1 of 5 residents (Resident #9) reviewed for MRR, resulting in the potential for medication side effects and/or unnecessary medications.

Inspectors wroteThis citation pertains to intake # MI00141109 Based on interview and record review, the facility failed to maintain an environment free from abuse for 2 (Resident #105 and Resident #108) of 8 residents reviewed for abuse, resulting in physical injury, feelings of frustration, mental anguish, and a potential for psychosocial harm.

Inspectors wroteThis citation pertains to intake #MI0014109 and intake #MI0014115 Based on observation, interview, and record review, the facility failed to provide a dignified dining experience for 2 (Resident #107 and Resident #104) of 8 residents reviewed for dignity, resulting feelings of frustration, a potential for decreasing feelings of self-worth, humiliation, and potential for injury related to inattention while physically assisting residents with eating.

Inspectors wroteThis citation pertains to intake MI00140649. Based on observation, interview, and record review, the facility failed to ensure access to a call-light for 1 (R104) of 9 residents reviewed for call-light placement, resulting in the inability to call for assistance and the potential for unmet care needs.

Inspectors wroteThis citation pertains to intake #MI00141109 Based on interview and record review, the facility failed to immediately recognize and report allegations of abuse for 2 (Resident #105 and Resident #108) of 8 residents sampled for abuse, resulting in the potential for abuse to continue and go unreported.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of abuse for 1 (Resident #108) of 8 residents sampled for abuse, resulting in the potential for abuse to continue, for allegations to not be thoroughly investigated to remove the root cause of the problem, and identify interventions to prevent the reoccurrence of the problem.

Inspectors wroteThis citation pertains to intakes MI0014069 and MI00141115. Based on observation, interview and record review, the facility failed to provide care that meets the resident needs for the treatment and/or maintenance of a skin condition in 1 (R104) of 9 residents reviewed for quality of care, resulting in the potential of worsening of skin conditions, lack of monitoring, and effective treatment.

Inspectors wroteThis citation pertains to intakes MI0014069 and MI00141115. Based on observation, interview and record review, the facility failed to float resident heels per the standards of practice to prevent the development of pressure ulcers in 1 (R104) of 9 residents reviewed for pressure ulcers, resulting in the potential for pressure ulcer developement.

Inspectors wroteThis citation pertains to intake MI00141115 Based on observation, interview, and record review the facility failed to ensure that podiatry services were offered to one resident (R104) of 9 reviewed for ancillary services, resulting in dissatisfaction with services.