Huron County Medical Care Facility

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a sanitary kitchen, ensure that food items were dated with an opened date, that expired food was removed and/or disposed of, and that food temperatures were monitored prior to serving. This deficient practice had the potential to affect all residents who consume food prepared and served from the facility kitchen and kitchenettes of a census of 72 residents. On 7/15/25 at 10:00 AM, a tour of the kitchen was conducted with Dietary Manager C of the facility kitchen. The following items were observed:-The juice dispenser had juice in boxes that were connected to be dispensed. The boxes had a delivery date but did not have an open date. The DM was asked about facility policy and reported they should be dated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan that provided person-centered care to meet the Resident's needs for one resident (Resident #81) of one resident reviewed for baseline care planning.

Inspectors wroteBased on observation, interview and record review, the facility to ensure that a urinary catheter bag and tubing were secured off of the floor for one resident (Resident #6) of one resident reviewed for urinary catheters, resulting in contamination, an improperly secured catheter bag and tubing with the likelihood of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure accurate physician's orders for oxygen administration for two residents (R38, R81) of two residents sampled for respiratory care, resulting in physician's orders without an oxygen flow rate. Resident #38 R38 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include pulmonary fibrosis, chronic obstructive pulmonary disease, acute respiratory failure and interstitial pulmonary disease. On 07/17/2025 at 11:39 AM, observation revealed an oxygen concentrator in the hall outside of the room of R38 it was administering oxygen at 6 liters per minute. On 07/17/2025 at 12:05 PM, record review of the physician's orders revealed an order for oxygen administration dated 07/03/2025 that read, Treatment Respiratory: [...]

Inspectors wroteThis Citation pertains to Intake Number MI00153947. Based on observation, interview and record review, the facility failed to follow the care plan and treat a resident with dignity for one resident (Resident #1) out of three residents reviewed for dignity, resulting in frustration, arguing and forceful removal from the activity room.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 85 residents who receive meal services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1) Resident and employee illness surveillance and monitoring, 2) Perform hand hygiene and don personal protection equipment (PPE) prior to entering a transmission-based precautions room, 3) Supply the staff with a trash receptacle for a transmission-based precautions room, and 4) Ensure that a urinary catheter bag was off the floor for one resident (Resident #20), resulting in the likelihood of contamination and spread of illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated in a dignified manner for a Confidential Group of residents, from a group of 28 residents reviewed for dignity, resulting in residents having soiled briefs due to call lights not being answered timely, a lack of a functional outdoor patio, and no opportunity to spend their Bingo winnings due to a closed Bingo store. Findings Include: FACILITY On 7/09/24 at 2:03 PM, during a meeting with a Confidential Group of Residents, several residents on the 2nd and 3rd floors said on the 3rd shift (night shift), their call lights were not being answered timely. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to effectively act upon repeated concerns from the facility's Resident Council and one resident (Resident #28) of 28 residents reviewed, resulting in resident frustration and anger that their concerns were not being addressed for 1) Call lights not being answered, 2) Food preferences and cold food, 3) The inability to entertain on the outdoor patio and 4) Removal of the Bingo store. Findings Include: FACILITY Resident Council On 7/09/24 at 2:03 PM, during a meeting with 18 members of the Resident Council, they said they were upset because their concerns were not being addressed. They said they bring their issues and concerns to the Resident Council meetings each month, but they do not feel anyone is listening or trying to resolve their issues. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a baseline care plan for falls for one resident (Resident #24) of 28 residents reviewed for baseline care plans resulting in an incomplete baseline care plan and the resident sustaining falls.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a resident-centered comprehensive care plan for one resident (Resident #134) of 28 residents reviewed for Care Plans, resulting in Resident #134 lacking a Care Plan with resident-specific interventions to address likes and dislikes. Findings Include: Resident #134: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #134 was admitted to the facility on [DATE] with diagnoses: Alzheimer's Dementia, urinary retention, glaucoma, anxiety, depression, pain, restlessness and agitation, constipation kidney cyst, neuralgia and a history of migraines. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to update a care plan timely for one resident (Resident #24) of 28 residents reviewed for care plan updating resulting in late care plan revision after a fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development of a facility-acquired pressure injury and ensure timely nutritional evaluation with the development of the pressure injury for one resident (Resident #46) of three residents reviewed for pressure ulcers, resulting in a deep tissue injury to Resident #46's right heel, and the potential for lack of nutritional intervention to hasten the healing of pressure injury, and the potential of pain and discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Resident #58 had oxygen available in the portable oxygen tank; properly store distilled water for a CPAP machine for a resident in room [ROOM NUMBER]-2; and remove/clean a CPAP machine for Resident #70, of four residents reviewed for respiratory care, resulting in the potential for infection, respiratory illness, low oxygenation, and shortness of breath.

Inspectors wroteBased on interview and record review the facility failed to follow standards of practice for laboratory testing and antibiotic use for one resident (Resident #25) of 4 residents reviewed for antibiotic use, resulting in Resident #25 receiving antibiotic treatment without appropriate laboratory tests to determine if the resident had a urinary tract infection and if the antibiotic was appropriate. Findings Include: Resident #25: Urinary Catheter or UTI A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #25 indicated admission to the facility on 4/24/2020 with diagnoses: Alzheimer's dementia, diabetes, depression, peripheral vascular disease, heart disease, hypertension and a history of urinary tract infection/UTI. The MDS assessment dated [DATE] indicated the resident had severe cognitive loss and needed assistance with all care. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide one resident (Resident #74) their 2023/2024 influenza vaccine, resulting in the likelihood of influenza contraction, hospitalization and/or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to inform and/or educate 6 out of 6 Residents who attended the Confidential Group Meeting about the location of the survey book and ensure that results from the most recent State Survey for complaint investigations and Plans of Correction (POC) for the preceding Standard Recertification Survey were readily accessible, affecting all 78 Residents residing in the facility, resulting in Residents, Residents' Representatives, families and visitors being unable to review the survey results and Plans of Correction.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that neurological assessments (neuro checks) were completed per Standards of Practice, after unwitnessed resident falls and/or witnessed falls with head injury, for 3 residents (Resident #59, Resident #71, Resident #77) of 5 residents reviewed for falls, resulting in the potential for head injury without necessary neurological assessments that could further lead to serious complications and death. Findings Include: A facility policy identified the following: Neurological Assessment, date implemented 02/02/2004 and reviewed/revised 08/2022, . Neurological Assessment is to be performed by the licensed nurse when a resident's condition indicates that neurological changes are probable . Neurological assessment is also mandatory to perform following head trauma sustained during an accident and/or fall . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor a urinary catheter for one resident (Resident #32), resulting in an unsanitary self-emptying urinary drainage bag and unkept urinary output logs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that interventions were enacted to promote nutrition and prevent weight loss for one resident (Resident # 59) of 3 residents reviewed for food or nutrition, resulting in Resident #59 lacking timely assistance with meals, and interventions to prevent weight loss which lead to further weight loss. Findings Include: Resident #59: Nutrition: On 6/27/2023 at 12:25 PM, during lunch observation in the 3rd floor dining room, Resident #59 was observed sitting at a table in the dining room that was not served until last. The residents at the table were watching other residents eat around them. A staff member approached the table and said to the residents that she did not know the meal tickets hadn't been picked up. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses [Registered Nurses (RN) and Licensed Practical Nurses (LPN)] received yearly training competencies to ensure resident care and safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of residents for three nurses of five nurses reviewed for competencies, with the potential to affect all 78 residents residing in the facility, resulting in the potential of nursing staff lacking necessary training and competencies to adequately care for the needs of the residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that drug regimen reviews were completed, dated and in the medical record monthly, for two residents (Resident #8 and Resident #20) of five residents reviewed for medications, resulting in the potential for each resident to receive unnecessary medications and develop adverse effects. Findings Include: Resident #8: A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #8 indicated the resident was admitted to the facility on [DATE] with diagnoses: Alzheimer's, Parkinson's, diabetes, depression, and anemia. The MDS assessment dated [DATE] revealed the resident had mild cognitive decline and needed some help with Activities of Daily Living (ADL). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Infection Preventionist had completed the required training in Infection Prevention and Control. This deficient practice resulted in the potential for a lack of knowledge and appropriate response to aid in the prevention of infections that could lead to resident illnesses, outbreaks and possibly death. Findings Include: Infection Control: On 6/29/23 at 1:54 PM , the Infection Prevention and Control Nurse L was interviewed during a review of the Infection Prevention and Control program. The IPC Nurse was asked how long she had been working in the role of the IPC at the facility and she stated, Since October (2022). The IPC was asked what training she had for the role of IPC and she said she had not yet finished a training program. [...]