Cass County Medical Care Facility

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen orders were followed consistently for 3 (Residents #57, #53, and #25) of 3 residents reviewed for respiratory care resulting in residents receiving incorrect oxygen concentrator (a medical device that delivers purified/concentrated oxygen) flow rates (volume of oxygen delivered per minute and often expressed in liters per minute) and the potential for breathing difficulties.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was assessed to be appropriate for self-administration of an inhaler for 1 resident (Resident #34) of 1 resident reviewed for self-administration of medications resulting in the inhaler being left unsecured in resident room, resident self-administering the inhaler without staff assessment, and the potential for negative outcomes from taking too much of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow-up and offer prompt dental services for 1 resident (Resident #6) of 1 resident reviewed for dental care resulting in Resident #6 experiencing bleeding gums, plaque buildup (sticky film of bacteria that causes cavities, gum disease and bad breath if not removed daily) and poor dental hygiene.

Inspectors wroteThis citation pertains to Intake #2641076Based on interview and record review the facility failed to revise a person-centered care plan timely for 1 (Resident #101) of 3 residents reviewed for care plan revisions, resulting in the potential for unmet care needs.

Inspectors wroteThis citation pertains to Intake #2641076Based on observation, interview, and record review the facility failed to maintain adequate supervision to ensure the safety of 1 (Resident #100) of 3 residents reviewed for safety, resulting in Resident #100 experiencing a fall that resulted in a left side pubic rami fracture (a fracture of the pelvis bone).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions and ensure proper labeling and dating of foods in the kitchen and the resident refrigerator in the activity room, resulting in the potential to spread food borne illness to all residents that consume food from the kitchen and residents that store food in the activity room refrigerator.

Inspectors wroteThis citation contains two Deficient Practices Statements, A & B. Deficient Practice Statement A. Based on interview and record review the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted a dignified dining experience for 4 residents (Resident #15, #10, #49, & #40) of 4 residents reviewed for dignity, resulting in feelings of disappointment with the dining experience.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the dignity of one resident (#46) of 18 residents reviewed for dignity, by denying the resident the right to use personal belongings of choice in her room. This deficient practice resulted in decreased ability to pursue an independent activity of choice, and feelings of frustration and disappointment.

Inspectors wroteBased on interview and record review, the facility failed to allow and accommodate resident choice to spend time outdoors by themselves in 1 of 18 residents (Resident #6) reviewed for self-determination, resulting in the potential for residents not meeting their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with getting out of bed for dependent residents in 1 of 3 residents (Resident #8) reviewed for ADL (Activities of Daily Living) care, resulting in the potential for residents to not meet their highest practical level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individualized activities based on resident preferences, needs, and abilities for 3 of 18 Residents (Resident #65, Resident #69, and Resident #63) reviewed for activities, resulting in feelings of boredom, and a potential for loneliness, social withdrawal, and depressed mood.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent skin breakdown for residents at risk for pressure ulcers, for 1 of 5 residents (Resident #69) reviewed for pressure ulcer prevention, 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 properly maintain standard infection control practices during incontinence care for 2 of 18 residents (Resident #55 & #58) reviewed for infection control, resulting in the lack of hand hygiene and improper glove use, and the potential for the development and transmission of communicable diseases and cross-contamination of C. Diff (Clostridioides difficile: a highly contagious bacteria that causes an infection of the bowels).

Inspectors wroteThis citation pertains to intake #MI00143146 Based on interview and record review the facility failed to provide services that meet professional standards of nursing practice related to assessing, monitoring and providing wound care dressing changes for 1 resident (Resident #101) of 3 residents reviewed for professional standards, resulting in ineffective monitoring, dressing changes not completed as ordered, inaccurate documentation, and Resident #101 having a skin tear not cared for for 4 days with signs and symptoms of a wound infection.

Inspectors wroteThis citation pertains to intake #MI00143146 Based on interview and record review the facility failed to assess, monitor, and treat a resident with a skin tear in 1 resident (Resident #101) of 3 residents reviewed for quality of care, resulting in an Resident #101 having a skin tear not cared for for 4 days and signs and symptoms of a wound infection due to lack of care.