Dimondale Nursing Care Center

Inspectors wroteBased on observation, interview, and record review the facility failed to correctly identify, treat, resulting in worsening and non-healing of pressure ulcers for three residents (R29, R32, R81) out of five residents reviewed for pressure ulcers. Findings Include: Resident #29 (R29) Wounds were reviewed for R29. Review of the medical record reflected R29 was admitted to the facility on [DATE], with diagnoses that included chronic pain, delirium, and reduced mobility. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R29 scored 9 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Terminal Kennedy ulcers (KTU) and pressure ulcers are both types of skin breakdown, but they are different in their cause, appearance, and meaning. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively create and maintain the Water Management Plan effecting 144 residents, resulting in the increased likelihood for development of Legionellosis and other opportunistic waterborne pathogens.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 144 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 9 out of 10 resident's (Residents #'s 11, 37, 42, 65, 94, 108, 124, 134, & 242) allegations of abuse were reported to the state agency. Findings Included:Per the facility face sheet R11 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 was cognitively intact. Record review of a concern form dated 5/17/2025, revealed R11 had documented on the concern form that she had run out of oxygen, and Certified Nurse Aid (CNA) JJ told her that she had to wait, and proceeded the leave to attend to another resident leaving R11 with no oxygen. R11 documented on the concern form that CNA JJ made her sit in urine soak brief for over six hours, until a nurse made CNA JJ change her. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure 9 out of 10 residents (Residents #'s 11, 37, 42, 65, 94, 108, 124, 134, & 242) allegations of abuse were thoroughly investigated, assure prevention of further potential abuse, and report the finding within five working days to the state agency. Findings Included:Per the facility face sheet R11 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 was cognitively intact. Record review of a concern form dated 5/17/2025, revealed R11 had documented on the concern form that she had run out of oxygen, and Certified Nurse Aid (CNA) JJ told her that she had to wait, and proceeded the leave to attend to another resident leaving R11 with no oxygen. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure grievances were promptly documented, investigated, tracked and resolved for one resident of one resident reviewed for grievances (Resident #8).

Inspectors wroteBased on interview and record review the facility failed to ensure for two out of two residents (Resident #11 and #242) the right to be free from abuse, and involuntary seclusion. Findings Include: Resident #11 (R11) Per the facility face sheet R11 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 was cognitively intact. Record review of a concern form dated 5/17/2025, revealed R11 had documented on the concern form that she had run out of oxygen, and Certified Nurse Aid (CNA) JJ told her that she had to wait, and proceeded the leave to attend to another resident leaving R11 with no oxygen. R11 documented on the concern form that CNA JJ made her sit in urine soak brief for over six hours, until a nurse made CNA JJ change her. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label and store medication in accordance with accepted professional principles, for one resident (#111) of seven residents during observation of medication administration, one of eight medication carts (to include medication for resident #342), and one medication refrigerator (one east refrigerator) of six refrigerators reviewed. Findings Included:Resident #111 (R111)Review of the medical record revealed R111 was admitted to the facility 02/16/2024 with diagnoses that included type 2 diabetes, congestive heart failure (CHF), atherosclerotic heart disease (build up of substances in artery walls), hypertension, sleep apnea, insomnia, bilateral cataracts, depression, and gastro-esophageal reflux. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and PACE((Program of All-Inclusive Care for the Elderly) of a change in condition for 1 resident (R104) of three residents reviewed for change of condition, resulting in R104 being hospitalized .

Inspectors wroteBased on interview and record review the facility failed prevent a significant medication error as evidenced by administration of Metoprolol (beta-blocker blood pressure medications) without monitoring blood pressure prior to administration for resident (R104), resulting in hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, monitor, document, and provide appropriate and timely treatment per professional standards of practice for one (#9) of one Residents reviewed for management of known Congestive Heart Failure (CHF-inability of the heart to pump blood efficiently, causing shortness of breath, fatigue, leg and foot swelling, and weakness), resulting in a 44 pound weight gain, shortness of breath, acute respiratory failure with hypoxia, acute pulmonary edema and acute re-hospitalization for acute exacerbation of CHF.

Inspectors wroteThis citation refers to intake MI00145124. Based on observation, interview and record review, the facility failed to competently assess and monitor for changes in condition and notify the physician of pertinent findings in a timely manner for 2 residents (Resident #103 and Resident #104) resulting in the potential for and actual harm from unrecognized, clinically significant changes in condition and uncontrolled pain.

Inspectors wroteResident #121(R121) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R121 was a [AGE] year old male admitted to the facility on [DATE], with recent re-admission post new onset diabetes mellitus on 4/4/24 with prior diagnoses that included traumatic brain injury with left craniotomy, pelvic fracture, hypertension (high blood pressure), diabetes insipidus, seizure disorder, hypopituitarism, hypothyroidism, speech and language deficits following brain injury, weakness, difficulties walking and depression. The MDS reflected R121 a BIM (assessment tool) score of 7 which indicated his ability to make daily decisions was severely impaired. The MDS reflected R121 had no behaviors including rejection of care. During a telephone interview on 6/11/24 at 11:59 a.m., R121's father and Durable Power of Attorney (DPOA) Z verified was R121 responsible party. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their rights to self determination were honored for three residents (resident #15, #63 and #97) of six residents reviewed and facility census of 135 for self determination. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to act promptly on grievances and or concern forms reported in resident council meetings and provide responses and resolutions to 52 grievances filed in the last six months, as reported during a confidential resident council interview, in a total sample of 27 residents and a total census of 135 residents, resulting in unresolved resident concerns and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate less than five percent when 8 medication errors were observed from a total of 28 opportunities for one resident (R121) of eight residents observed during medication administration, resulting in a medication error rate of 28.57%.

Inspectors wroteBased on observation, interview, and record review the facility failed to insure that one resident (R121) was free from significant medications errors out of eight residents reviewed during medication pass task, resulting in the potential for adverse physical reactions/outcomes to residents. Findings Included: Resident #121(R121) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R121 was a [AGE] year old male admitted to the facility on [DATE], with recent re-admission post new onset diabetes mellitus on 4/4/24 with prior diagnoses that included traumatic brain injury, pelvic fracture, hypertension (high blood pressure), diabetes insipidus, seizure disorder, hypopituitarism, hypothyroidism, other speech and language deficits following brain injury, weakness, difficulty walking and depression. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage of medications for 1 of 3 medication rooms reviewed, resulting in the increased likelihood for decreased medication efficacy and adverse side effects in a current facility census of 135 residents

Inspectors wroteBased on observation and interview, the facility failed to display current nurse staffing information that was readily accessible for all 135 residents, as well as visitors in the facility, resulting in the likelihood of necessary staffing information not being available to residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store supplies, maintain plumbing in good repair, and prevent plumbing cross connections, resulting in potential contamination of supplies, and the domestic water supply, affecting all residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were within reach for five out of 25 residents (Resident #8, 39, 44, 61, and 64) resulting in the potential for resident needs to go unmet. Findings Included: Resident #8 (R8): In an observation on 3/13/2023 at 9:40 AM, R8 was observed in his room asleep. R8's call light was observed to be hanging over the headboard of his bed not accessible to R8. In another observation on 3/14/2023 at 3:03 PM, R8 was observed to be asleep in his bed, with his call light observed to be on the floor at head of R8's bed, which was not accessible to R8. Record review of a care plan in place for R8 dated 2/24/2021, that addressed falls and safety, revealed an intervention to make sure R8's call light was accessible. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a sanitary and clean environment for one Resident (Resident #4) resulting in a soiled room and dissatisfaction with their living conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints imposed for the purpose of convenience in 1 of 1 resident (Resident #102) reviewed for restraints, resulting in the restriction of mobility and a potential for decline in physical functioning and psychosocial wellbeing. Findings Include: Resident #102 Review of an admission Record revealed Resident #102 (R102) admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction (stroke), aphasia (a comprehension and communication disorder), muscle weakness, dysphagia (a condition with difficulty in swallowing food or liquid), history of falling, vascular dementia, hemiplegia and hemiparalysis following cerebral infarction affecting right dominant side, and unsteadiness on feet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review, revise, and update a comprehensive, individualized plan of care for one of five residents (Resident #23) reviewed for comprehensive care plans, resulting in the potential for impaired physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to monitor and adequately document a skin assessment one of one residents (#74) reviewed for non-pressure skin related conditions. Resulting in the potential for worsening skin condition and continued itch and discomfort.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide podiatry services for 1 of 1 resident reviewed for podiatry care (Resident #4), resulting in painful, thick, and long toenails. Findings Include: Resident #4 Review of an admission Record revealed Resident #4 (R4) admitted to the facility on [DATE] with pertinent diagnoses which included morbid obesity, cellulitis of the right and left leg, generalized anxiety disorder, and type 2 diabetes. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/18/23, reflected R4 scored 15 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R4 did not walk and required extensive to total assistance of one person to toilet. [...]

Inspectors wroteBased on observation, interview and record review failed to prevent falls for one (Resident #102) of four reviewed for falls, resulting Resident #102 sustaining falls and a hospital transfer. Findings Include: Resident #102 Review of an admission Record revealed Resident #102 (R102) admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction (stroke), aphasia (a comprehension and communication disorder), muscle weakness, dysphagia (a condition with difficulty in swallowing food or liquid), history of falling, vascular dementia, hemiplegia and hemiparalysis following cerebral infarction affecting right dominant side, and unsteadiness on feet. [...]

Inspectors wroteBased on interview, and record review the facility failed to provide ongoing communication and collaboration with the contracted dialysis facility regarding dialysis care and continued assessment for one resident (#80) of one resident reviewed resulting in the potential of unmet care needs and possible complications for residents receiving dialysis services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of five residents (Resident #23) was free from unnecessary medications, did not follow the indicated purpose for use without justification of use, resulting in the potential for resident and/or family representatives being ill informed of the purpose. Findings Included: Resident #23 (R23) Review of the medical record reflected R23 was an initial admission to the facility on [DATE] with a re-admission on [DATE] with diagnoses of Crohn's disease, diabetes, unspecified dementia without behaviors, depression, anxiety and weakness. R23 was diagnosis with unspecified psychosis not due to a substance or known physiological condition on 02/23/23. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care planned special eating equipment for one of one Resident (Resident #102) reviewed for assistive devices, resulting in the potential for difficulty with self-feeding and weight loss. Findings Include: Resident #102 (R102) Review of an admission Record revealed Resident #102 (R102) admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction (stroke), aphasia (a comprehension and communication disorder), muscle weakness, dysphagia (a condition with difficulty in swallowing food or liquid), history of falling, vascular dementia, hemiplegia and hemiparalysis following cerebral infarction affecting right dominant side, and unsteadiness on feet. [...]