Interlochen Health and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 2 of 6 (Resident #1 and Resident #2) residents reviewed for PASARR. The facility failed to complete and accurately request for PASARR specialized services within the 20-day time fame for Resident #1 and Resident #2 after their Interdisciplinary Team meeting on 4/20/26. This failure could place residents at risk of not receiving needed treatment and services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 6 residents (Resident #3) reviewed for ADLs. The facility failed to assist Resident #3 timely with getting out of bed when requested on 7/23/26. This failure could place residents at risk of skin breakdown and affect their dignity and self-esteem. Findings Include:Record review of Resident #3's face sheet, dated 7/23/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had the following pertinent diagnoses: [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 3 shower rooms (Shower room [ROOM NUMBER], Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]), 1 of 4 residents halls (Resident Hall #2), 1 of 3 linen closets (Linen Closet in 200 hall), 1 or 5 resident bed linens (Resident #6) reviewed for clean homelike environment: The facility failed to provide stain free bed linens for Resident #6 on 5/19/26. The facility failed to ensure all shower rooms were visibly clean and free of debris and trash on 5/22/26. The facility failed to ensure Resident Hall 200 was free from urine on the floor on 5/22/26. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to store food in accordance with professional standards for the facility's only kitchen observed for food service safety. The facility failed to ensure food items in the facility refrigerators and dry storage were dated and labeled. These failures could place residents at risk for food borne illnesses and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 resident (Resident #9) of 5 residents reviewed for ADLs. The facility failed to ensure Resident #9 had his fingernails trimmed and cleaned on both hands on 05/19/2026. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and skin breakdown, and a decreased quality of life. Record Review of Resident #9's Quarterly MDS assessment dated [DATE] as a [AGE] year-old male with initial admission date of 05/20/2016 to the facility. His pertinent diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Medication Cart 100) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure LVN E and LVN F responsible for Medication Cart 100, counted controlled drugs every shift change. This failure could place residents at risk of not having the medication available due to possible drug diversion. Record review and observation on 05/19/26 at 10:31 AM of Medication Cart 100, with LVN G revealed missing signatures for Off nurse for 05/09/2026, 05/12/2026, and 05/17/2026 (6:00 AM to 2:00 PM shift) of the narcotic count sheet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received routine and 24-hour emergency dental services for one (Resident #44) of six residents reviewed for the provision of routine/emergency dental services. The facility failed to ensure Resident #44 received routine dental care. This failure could affect residents by placing them at risk of pain, weight loss, infection, difficulty eating and a decline in their quality of life due to unmet dental needs. Record Review of Resident #44's face sheet dated 05/21/26 revealed a [AGE] year-old female with admission date 01/08/26. Her diagnoses included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 resident (Resident #77) of 3 residents observed for infection control. The facility failed to ensure CNA B changed gloves and completed hand hygiene during incontinent care for Resident #77 on 5/20/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness. Record review of Resident #77's Quarterly MDS assessment dated [DATE] reflected Resident #77 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included brain cancer, muscle weakness, and cognitive communication deficit. Resident #77's BIMS score of 6, which indicated Resident #77's cognition was severely impaired. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 2 halls (Hall 200) reviewed for pest control.1. The facility failed to ensure Hall 200 was free of gnats.2. The facility failed to ensure one room at the south end of the hall was free of gnats. These failures could place residents at risk of infestation of pests and compromise resident health.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a baseline care plan for each resident which included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care or ensure a comprehensive care plan was developed in place of the baseline care plan if the comprehensive care plan was developed within 48 hours of a resident's admission for one of three residents (Resident #1) reviewed for baseline care plans. Teh facility failed to develop a baseline care plan within 48 hours of Resident #1's admission. This failure could place residents at risk of not receiving appropriate care upon their admission to the facility.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and interventions to meet a resident's medical and nursing needs that were identified in the comprehensive assessments for 1 of 5 residents (Resident #3) reviewed for care plans. The facility failed to develop a care plan for Resident #3 to address anticoagulant medication use. This failure could place residents at risk for not receiving proper care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #1) reviewed for supervision. CNA A and CNA B failed to safely transfer Resident #1 when they supported the resident under his arm-pits and with a gait belt while lifting him from the floor to his wheelchair, instead of using a mechanical lift. This failure could place residents at risk of injury.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 (Resident #2) residents reviewed for respiratory care. The facility failed to ensure there were cautionary and safety signs indicating the use of oxygen outside Resident #2's room where oxygen was used. These failures placed the residents at increased risk of injury due to fire hazards. [...]

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for pain management. The facility failed to follow their pain management policy when Resident #1's response to pain medication was not monitored and effectiveness was not recorded. This failure could place residents at risk of uncontrolled pain.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to provide or obtain radiology services to meet the need of its residents for 1 of 1 Residents (Resident #1) reviewed for radiology services. The facility failed to correctly order and follow up on stat x-ray. Resident #1 did not get an x-ray for more than 24 hours after a stat x-ray was ordered. The x-ray performed was performed on the leg instead of the wrist. This failure could place residents at risk of delayed treatment, and pain.

Inspectors wroteBased on interview and record review, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 of 3 residents (Resident #1) reviewed for reporting allegations, in that: The facility failed to submit a provider investigation report an injury of unknown origin for Resident #1 to the State Agency within 5 working days of the incident, which occurred on 07/09/25. This failure placed residents at risk for further abuse and neglect due to delayed investigation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 4 (Resident #2) reviewed for misappropriation of property. The facility failed to ensure Resident #2's debit card was secured from unauthorized use of $11,735 when 25 unauthorized withdrawal transactions occurred between 2-12-2025 and 3-13-2025. This failure could place residents at risk for decreased quality of life, misappropriation of property, and financial hardship.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for one (Resident #1) of four residents reviewed for abuse. The facility failed to ensure CNA A, who was suspended on 05/28/2025 due to Resident #1 alleging CNA A verbally abused Resident #1, did not provide care to Resident #1 when CNA A came back to work after being suspended. This failure could place residents at risk for abuse, neglect, and/or exploitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 4 residents reviewed for quality of care. LVN A failed to read an abnormal x-ray result, resulting in Resident #1 experiencing pain with a hip fracture for 2 days before Resident #1 was hospitalized for evaluation. A past noncompliance Immediate Jeopardy was determined to have existed from 4/8/2025 to 4/10/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #1) of 4 residents reviewed for quality of care. LVN A failed to read an abnormal x-ray result, resulting in Resident #1 experiencing pain with a hip fracture for 2 days before Resident #1 was hospitalized for evaluation. A past noncompliance Immediate Jeopardy was determined to have existed from 4/8/2025 to 4/10/2025. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #32) reviewed for infection control. LVN A failed to put on Personal Protective Equipment (PPE) while administering medication via feeding tube to Resident #32, who was on Enhanced Barrier Precaution (EBP). This deficient practice could place residents and nursing staff at risk of transmission of communicable diseases and infections.

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status that was, a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications, for one of three residents (Resident #1) reviewed for notification of changes. 1. The facility failed to immediately notified the physician of a change in condition or decline when Resident #1 experienced shortness of breath and required as needed breathing treatments and oxygen therapy on [DATE] and [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who needed respiratory care, including tracheostomy care and tracheal suctioning, provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #1) reviewed for respiratory care . On [DATE] - [DATE], the facility failed to conduct a respiratory assessment for a potential change in condition or decline when Resident #1 experienced shortness of breath and required as needed breathing treatments and oxygen therapy. On [DATE], Resident #1 was transferred to the ER. Resident #1 was intubated and passed away at the hospital. An Immediate Jeopardy (IJ) situation was identified on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two (Resident #2 and Resident #3) of seven residents reviewed for dignity. The facility failed to ensure Resident #2 was provided with a dignified dining experience, when CNA D stood over her as she was assisting Resident #2 in eating a lunch meal service in the dining room. The facility failed to ensure Resident #3 was provided with a dignified dining experience, when a medical records staff stood over her as she was assisting Resident #3 in eating a lunch meal service in the dining room. This failure could place residents at risk for a loss of dignity, decreased self-worth, and decreased self-esteem.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to develop an individualized comprehensive care plan that addressed how Resident #1's was to be physically transferred. This deficient practice could place residents at risk of receiving inadequate interventions that were not individualized to their care needs and at risk for injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately for 1 of 3 residents (Resident #1) reviewed for neglect, in that: The facility failed to report the allegation of neglect for Resident #1 to the State Agency within required reporting timeframes. This failure placed residents at risk ongoing neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 3 (Residents #1) Residents reviewed for care plans. The facility failed to ensure Resident #1's CNA-J followed care plan interventions for proper supervision and incontinence care. This failure could place resident #1 at risk for injuries.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure resident environment remained as free of accidents hazards as possible: and each resident recieved adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1's CNA-J followed care plan interventions for proper supervision and incontinence care. This failure could place resident #1 at risk for injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 3 resident bathrooms (room [ROOM NUMBER]) and 3 of 4 (Hall 1: shower #1, Hall 2: shower #1 and Hall 2: shower #2) rooms reviewed for environmental concerns. 1. The facility failed to ensure 1 shower room on hall 100 and 2 shower rooms on hall 200 were clean and free of clutter. 2. The facility failed to ensure the light bulb was replaced in bathroom (room [ROOM NUMBER]). This failure could place residents at risk of injury and living in an unsafe and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 4 of 12 (Rooms 222, 223,225, and 226), rooms reviewed for infection control. Facility failed to ensure CNA B sanitized her hands before and after filling residents reused cups with ice and water from different rooms, picking up a call light off the floor with bare hands, and after touching a bed and curtain in Rooms 222, 223,225, and 226. These failures could place residents at risk of infectious disease.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for one (Resident #56) of ten residents reviewed for resident rights. The facility failed to ensure Resident #56 was not left at a physician's office without a facility staff member or family member to supervise her and manage her behaviors for a time period between ten and thirty minutes. These findings could cause the residents unnecessary distress and place the residents at risk of falls and injury due to becoming agitated and combative with people who are not trained in the management of dementia related behaviors.

Inspectors wroteBased on, observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for significant medication error in that: LVN B and LVN D failed to administer insulin to Resident #1 as ordered by physician. LVN B failed to accurately document insulin was not given to Resident #1 as ordered. LVN D failed to document blood sugar before insulin administration. The facility failed to ensure insulin for Resident #1 was not in use 30 days after opening. These failures could cause residents to have uncontrolled high blood or low blood sugar and could lead to hospitalization. Findings Included: [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and failed to provide clean bed linens that were in good conditions for 9 (Residents #1, #2, #3, #4, #5, #6, #9, #10, and #12) of 12 residents reviewed for a safe environment. The facility failed to provide clean and adequate linens for Residents #1, #2, #3, #4, #5, #6, #9, #10, and #12. This failure placed residents at risk of decreased feelings of self-worth, and possible infections.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure that residents who are unable to carry out activities of daily living (ADLs) receive the necessary service to maintain good nutrition, grooming, personal, and oral hygiene for 4 (Resident #1, #4, #12, and #13) of 4 residents reviewed for ADL. The facility failed to provide showers/baths for Residents #1, #4, #12, and #13). These failures could place residents at risk of not receiving personal care services, having decreased quality of life, and skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 2 (Residents #4, and #11) of 12 residents reviewed for receiving daily meals at regular times. The facility failed to serve the 12/06/2023 and the 12/21/2023 lunch meals on time according to schedule for Residents #4 and #11. This failure could place all residents who consume food by mouth at risk for decreased meal satisfaction, decreased intake, loss of appetite, avoidable weight loss, side effects from medications given without food, and diminished quality of life.