Durand Senior Care and Rehab Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for two (R5 and R21) of 24 reviewed.

Inspectors wroteBased on interviews and record review the facility failed to conduct the required Monthly Medication Regimen Review on one resident (R11) of the five residents reviewed for Monthly Medication Regimen Review completion. Findings Include:Review of the medical record reflected R11 was an initial admission to the facility on [DATE]. Diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure, Osteoarthritis, low back pain and ankylosing spondylitis lumbar region. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/16/2026 revealed R11 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Based on record reviews, R11 had Monthly Medication Regimen (MMR) for 06/03/26- with no recommendations at this time. Date of 05/05/26- with no recommendations at this time. Date of 04/02/26 with no recommendations at this time. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide one out of one residents (Resident #32) care and services to prevent and promote healing of pressure ulcers resulting in worsening wounds, facility acquired stage 3 pressure wound (full thickness skin loss ), osteomyelitis, and hospitalization. Findings Include: Resident #32(R32) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R32 was a [AGE] year-old female admitted to the facility on [DATE], with most recent re-admission 3/10/25 related to osteomyelitis (wound infection) with other diagnoses that included stage 4 pressure ulcer(full thickness skin and tissue loss, exposing muscle, tendon or bone), diabetes Mellitus, irregular heart rhythm, anxiety and depression. The MDS reflected R32 required substantial/maximal assistance with repositioning in bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label medication in accordance with accepted professional principles, dating of open medication for three out of six medication carts reviewed and failed to ensure proper medication storage of medications for one Resident (#72) out of 112 current residents residing at the facility. Findings Included: During observation of the 200-hall medication cart on 04/29/2025 at 02:06 p.m. it was observed that the following medications did not have a date present when the medication was opened and placed on the container of medications: two inhalers of Symbicort 160/4.5mcg(micrograms), one inhaler of Spiriva 2.5mcg, and one inhaler of Trelegy Ellipta 200mcg/62.5mcg/25mcg. Licensed Practical Nurse (LPN) C explained that it was facility policy that all multidose medication was to be dated at the time that it was opened. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a Preadmission/Annual Resident Review (PAS/ARR) was completed after the 30 day exemption period and failed to notify the State Agency Health Authority for 1 Resident( #98) of 1 reviewed for PAS/ARR from a total sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement comprehensive resident-centered care plans for one out of 19 residents (R32), resulting in worsening of and facility acquired pressure wounds.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control practices for one resident (#111) out of one resident sampled during observation of blood glucose level testing, with a glucometer. Findings Included: Resident #111 (R111) Review of the medical revealed R111 was admitted to the facility 04/10/2025 with diagnoses that included fracture right femur, type 2 diabetes, hypothyroidism (low thyroid hormone), depression, anxiety, hyperlipidemia (high fat content in blood), hypertension, and pain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/16/2025, revealed R111 had a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. During observation and interview on 04/29/2025 at 08:57 a.m. R111 was observed lying down in bed. [...]

Inspectors wroteThis deficiency pertains to Intake MI00150515 Based on interview and record review, the facility failed to provide timely notification to the physician for one Resident (#106) of three residents reviewed for a change in condition. This deficient practice resulted in a delay in medical treatment for a significant change in condition with diabetic ketoacidosis.

Inspectors wroteThis citation refers to intake MI00150353, MI00149992 Based on observation, interview, and record review, the facility failed to provide adequate supervision, conduct timely root cause analysis of fall incidents, implement appropriate interventions to prevent future falls and re-evaluate the effectiveness of interventions for 3 residents (R103, R104, and R105) out of 3 residents reviewed for falls, resulting in R105 falling and re-fracturing recently repaired hip and R103 fall with laceration requiring emergency room treatment and R104 fall with fracture and subdural hematoma and overall decline.

Inspectors wroteThis citation pertains to intakes: MI00149397, MI00150353, Based on observation, interview and record review, the facility failed to ensure sufficient levels of nursing staff to meet resident needs and supervision for three residents (Resident #103, #104, #105) and per resident council with the potential for unmet care needs and facility residents to not attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain dignity for 4 residents (Resident #'s 393, R24, and R13 and one unknown resident) the during the initial dining observation in the 500 hall dining room, using the reasonable person standard this deficient practice resulted in decreased self worth and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 2 (Resident #7 and Resident #10) of 20 residents reviewed resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure antibiotic treatment for Methicillin-resistant Staphylococcus aureus (MRSA/type of bacterial infection that is resistant to many antibiotics) was started timely for one (Resident #6) of one reviewed.

Inspectors wroteBased on observation, interview and record review facility failed to: 1) accurately assess, monitor, treat and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for three Residents (R103, R107 and R109) of four reviewed for pressure ulcers, resulting in R109 facility acquired stage 2 pressure ulcer, and the increased likelihood for delayed wound healing and or worsening of wounds and overall deterioration in health status, and worsening of pressure ulcer wounds with sepsis.

Inspectors wroteThis Citation Pertains To Intake # MI00143774 and MI00143825 Based on observation, interview and record review, the facility failed to respond, assess and render immediate aid in a timely manner for one resident (resident #105) of three reviewed for falls. Findings Include: Review of the clinical record reflected R105 was a [AGE] year-old male admitted to the facility on [DATE]. R105 transferred to another facility on 4/5/24. Review of the Minimum Data Set (MDS) dated [DATE] reflected R105 had a diagnosis of Multiple Sclerosis (MS) and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS reflected assistance was required for all transfers. Review of R105's Social Work progress notes dated 2/7/24 reflected R105 had periods of confusion related to a famous Hollywood actress coming to pick him up and threatening self-harm if she doesn't. [...]