Lake Orion Nursing Center

Inspectors wroteThis citation pertains to intake: 3053736. Based on interviews and record reviews the facility failed to promptly implement treatments and interventions as directed by the clinician and failed to ensure ongoing monitoring and evaluation of a resident with an identified change in condition for one (R103) of three residents reviewed for a closed record investigation, resulting in the continued unrecognized decline that required CPR (cardiopulmonary resuscitation) and EMS (emergency medical service) transport to the hospital where the resident subsequently expired, and also failed to ensure medication was available for administration for one resident (R105) of one resident reviewed for medication availability/administration.

Inspectors wroteThis citation relates to Intake 3040613. Based on observation, interview, and record review, the facility failed to complete a full investigation related to an injury of unknown origin for one Resident (R100) of one resident reviewed for abuse.

Inspectors wroteThis citation pertains to intake: 2984138. Based on observations, interviews, and record reviews, the facility failed to ensure care plans and/or fall interventions were timely implemented, reviewed, and/or revised. The facility also failed to follow its fall management policy by ensuring all falls were reviewed by the interdisciplinary team and that fall risk assessments were completed in accordance with the facility policy.

Inspectors wroteThis citation relates to Intake 2645567. Based on observation, interview, and record review, the facility failed to provide adequate staffing for two residents, R403 and R404, which had the potential to affect all facility residents.

Inspectors wroteThis citation pertains to Intake 2546912Based on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced residents' dignity for three (R402, R404 and R405) of three residents reviewed for dignity.

Inspectors wroteThis citation pertains to Complaint #1337621. Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one (R801) of three residents reviewed for accidents and supervision, resulting in the resident being hospitalized for alcoholic ketosis due to alcohol ingestion and lactic acidosis due to walking in 94 degree Fahrenheit (F) temperatures after staff allowed him to go on a leave of absence (LOA) with an unknown individual without consent from the legal guardian and did not identify he had not returned for approximately 30 hours.

Inspectors wroteThis citation pertains to Complaint #1337621. Based on interview and record review, the facility failed to ensure a resident with a substance abuse disorder was assessed and interventions put in place for one (R801) of one resident reviewed for behavioral health services, after it was discovered he went on a leave of absence (LOA), consumed alcohol, and was treated for alcoholic ketosis and withdrawal in the hospital.

Inspectors wroteThis citation pertains to Intake Number(s): MI00153580. Based on interview and record review, the facility failed to provide supervision according to the individualized plan of care for one (R801) of three residents reviewed for falls, resulting in an acute intertrochanteric fracture of the left femur (hip) and an acute subdural hematoma (bleeding between the brain and the skull that ultimately resulted in the resident's death after R801 was left unsupervised on the toilet and sustained a fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop comprehensive care plans per residents' assessed needs for two (R72 and R31) of 18 residents reviewed for care planning.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's physician ordered treatment was dated and timely provided for one (R23) of two residents reviewed for skin care management.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to monitor bowel movement and initiated facilities bowel protocol for one (R19) resident reviewed for bowel and bladder.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure continuous oxygen therapy was accurately documented and administered per physician orders for two (R31 and R4) of two residents reviewed for respiratory care.

Inspectors wroteThis citation pertains to Intake Number(s): MI00150810, MI00150926, MI00151349 Based on interview and record review, the facility failed to ensure one (R801) of three residents reviewed for accidents, was transferred in a safe manner with fully functioning equipment and with the proper level of assistance, resulting in the resident falling out of the mechanical lift sling and sustaining an acute impacted fracture (fracture typically caused by force or trauma) of the right hip, a distal intertrochanteric fracture (fracture between the bony protrusion of the thighbone) of the right hip, an acute intertrochanteric fracture of the left hip, and Focal round hyperdensity (spot brighter than the surrounding brain indicating an abnormality) within the right sylvian fissure (part of the brain) measuring approximately 5 mm (millimeters) .potentially representing aneurysm (bulging blood vessel) or [...]

Inspectors wroteThis citation pertains to Intake MI00148758. Based on observation, interview and record review, the facility failed to safely serve a hot beverage for one Resident (R908) of one reviewed for hot beverages, resulting in first-degree burns (superficial burn or wound that affects the first layer of the skin) on their abdomen and chest.

Inspectors wroteBased on interview and record review the facility failed to ensure a comprehensive infection control program that consistently identified infections based on symptoms and justified the use of antibiotics, (Using McGeer's Criteria for the definition of infections), as well as calculated infection rates, demonstrated on-going tracking, trending, in-services, education, and environmental rounding.

Inspectors wroteThis citation pertains to Intake #MI00139234 Based on observation, interview and record review the facility failed to ensure a resident received their soup in dignified manor for one (R24) of 10 resident's reviewed for accidents.

Inspectors wroteBased on interview and record review the facility failed to ensure consent for vaccines were obtained by the appropriate authority for one resident (R29), of two residents reviewed for choices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the recommendations and physician orders for assistive devices to maintain range of motion and positioning for one (R19) of three residents reviewed for positioning resulting in the potential for a decline in range of motion and worsening of contractures.

Inspectors wroteBased on interview and record review, the facility failed to ensure the offering of pneumococcal (pneumonia) vaccines to one resident (R29), of five residents reviewed for pneumococcal vaccines.

Inspectors wroteBased on interview and record review, the facility failed to implement an active water management 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 of the 63 residents in the facility.

Inspectors wroteBased on interview and record review the facility staff failed to ensure an allegation of abuse was immediately reported to the facility abuse coordinator and to the State Agency for one resident (R14) of two residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to record and administer a controlled medication according to professional standards of practice for one (R25) resident.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from an avoidable fall for one (R4) of three residents reviewed for falls.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a CPAP device (continuous positive airway pressure machine that uses mild air pressure to keep breathing airways open while sleeping) was provided in a timely manner for one resident (R370) of two residents reviewed for respiratory care.