Lansing Care and Rehab

Inspectors wroteThe facility documented a census of 52 residents. The sample included three residents. Based on observation, record review and interview, the facility failed to ensure a safe environment free from preventable accidents when staff turned cognitively impaired Resident (R) 1 and her wheelchair into her bed on 02/01/26, causing R1 to hit her left knee on the bed frame and R1 cried out in pain that staff broke her knee. The direct care staff decided to hug transfer R1 to bed without help from another direct care staff and R1 screamed they broke my [expletive] knee. R1 was dependent on staff for transfers and mobility in her wheelchair. The direct care staff informed the Nurse on 02/01/26 of the increased pain to R1's left lower extremity. [...]

Inspectors wroteThe facility identified a census of 58 residents. The facility identified nine residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) and one resident on contact precautions (safeguards designed to reduce the risk of transmission of microorganisms by direct or indirect contact). [...]

Inspectors wroteThe facility identified a census of 58 residents. The sample included 16 residents, with one medication room, three medication carts, and two treatment carts. Based on observation, interviews, and record review, the facility failed to appropriately store medications and biologicals when staff failed to ensure the medication carts were always locked when the cart was not within the nurses' line of sight.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 16 residents, with three reviewed for dignity and respect. Based on observation, record review, and interviews, the facility failed to provide a dignified care environment for Residents (R) 21 and R18. Findings Included:- R21's Electronic Medical Records (EMR) included diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), type two diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder). [...]

Inspectors wroteThe facility identified a census of 58 residents. The sample included 16 residents, with two reviewed for abuse and neglect. Based on observation, interview, and record review, the facility failed to prevent staff-to-resident verbal and emotional abuse of Resident (R) 44. Findings Included:- R44's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R44's Quarterly Minimum Data Set (MDS) completed 06/14/25 indicated a Brief interview for Mental Status (BIMS) score of zero (severe cognitive impairment). The MDS noted bilateral upper or lower extremity impairments. The MDS noted she used a wheelchair for mobility. [...]

Inspectors wroteThe facility identified a census of 58 residents. The sample included 16 residents, with six residents reviewed for unnecessary medications. Based on observation, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 27, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion).

Inspectors wroteThe facility identified a census of 58 residents. The sample included 16 residents, with three residents reviewed for hospice. Based on observation, interviews, and record review, the facility failed to complete a significant change in the physical condition and complete a comprehensive Significant Change Minimum Data Set (MDS) for Resident (R) 22 with the addition of hospice services.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 16 residents. One resident was sampled for accidents and hazards. Based on observation, interviews, and record review, the facility failed to provide Resident (R) 18's fall interventions as directed by his care plan.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 16 residents, with six residents reviewed for unnecessary medications. Based on observation, interviews, and record review, the facility failed to ensure the Consultant Pharmacist (CP) had identified and reported irregularities for Resident (R) 22.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 16 residents, with six residents reviewed for unnecessary medications. Based on observation, interviews, and record review, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS) test to monitor for adverse effects from the medication Reglan (antiemetic-prevents vomiting) for Resident (R) 22.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 16 residents, with three residents reviewed for hospice services. Based on observation, interviews, and record review, the facility failed to provide a description of the medication and equipment provided to Resident (R) 22 by hospice.

Inspectors wroteThe facility reported a census of 47 residents. The sample included 12 residents with one reviewed for self-determination. Based on record review, interviews, and observations, the facility failed to accommodate Resident (R)28's preferred sleep schedule. This deficient practice placed R28 at risk for decreased psychosocial well-being. Findings Included: [...]

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents with three residents reviewed for Beneficiary Notification. Based on record review and interview the facility failed to ensure a Center for Medicare/Medicaid Services (CMS) form 10055 Advance Beneficiary Notice of Non-coverage (ABN) form was provided to Resident (R) 13. This placed R13 residents at risk of uninformed treatment decisions and unexpected costs.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents with three residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R)43 and R47. This deficient practice placed the resident at risk of delayed care or uncommunicated care needs. Findings Included: [...]

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on record review, interviews, and observations, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported missed medication administrations related to Resident (R)28's prescribed insulin (a hormone that lowers the level of glucose in the blood) and metoprolol (medication used to treat high blood pressure) on the monthly reports. This practice placed R28 at risk for unnecessary medication administration and unwarranted side effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on record review, interviews, and observations, the facility failed to consistently administer Resident (R)28's prescribed insulin (a hormone that lowers the level of glucose in the blood) and metoprolol (a class of medication used to treat high blood pressure) medications This practice placed R28 at risk for unnecessary medication administration and unwarranted side effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents with one resident sampled for food. Based on observation, record review, and interview the facility failed to ensure facility staff accommodated Resident (R) 8's food allergies and food choices. This deficient practice had the potential for adverse food reactions and negative outcomes.

Inspectors wroteThe facility identified a census of 50 residents. Three residents were reviewed for catheter (flexible tubing inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on record review, interview, and observation, the facility failed to provide appropriate catheter cares for Resident (R) 1's indwelling urinary catheter when staff failed to provide flushes as ordered by the physician to prevent urinary tract infections (UTI), failed to ensure catheter cares were provided using acceptable standards of infection control practices, and failed to ensure interventions were consistently and correctly implemented to anchor the catheter to prevent worsening of catheter associated trauma. This deficient practice resulted in catheter related complications including UTI and traumatic injury caused by the indwelling urinary catheter.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 14 residents with five residents reviewed for indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 100, R36, R200 and R30 had a valid, physician ordered indication for the continued use of an indwelling catheter. This deficient practice placed the residents at increased risk for catheter related complications including urinary tract infection and urinary incontinence.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 14 residents with seven residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 100, R200 and R36's urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) drainage bag was placed in a privacy bag. This deficient practice placed the residents at risk for negative psychosocial outcomes, and decreased dignity.

Inspectors wroteThe facility reported a census of 51. The sample included 14 residents with four reviewed for accidents. Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision to prevent accidents or hazard related injuries for Resident (R)200. This deficient practice placed the resident at risk for preventable falls and injuries. Findings Included: [...]

Inspectors wroteThe facility reported a census of 51. The sample included 14 residents with five reviewed for unnecessary medication. Based on observations, interviews, and record reviews, the facility failed to follow the parameters for Resident (R)48's blood pressure medication and failed to follow parameters for 200's insulin (hormone which regulates blood sugar) administration. This deficient practice placed the residents at risk for ineffective treatment and complications related to medication.

Inspectors wroteThe facility reported a census of 51. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observations, interviews, and record reviews, the facility also failed to provide correct diagnosis for antipsychotic medication (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing]) for Resident (R)14. The facility failed to complete abnormal involuntary movement scale (AIMS) testing for R33's psychotropic medication (medication that affects brain activities associated with mental processes and behavior). This deficient practice placed the residents at risk for ineffective treatment and unnecessary side effects related to psychotropic drugs. Findings Included: [...]

Inspectors wroteThe facility identified a census of 51 residents. Based on observation, record review, and interview, the facility failed to ensure that proper hand hygiene was followed during wound care for Resident (R) 19, and catheter care for R100. The facility failed to ensure R200's catheter tubing did not touch communal surfaces. These deficient practices put the affected residents at risk for the spread of infection and/or communicable diseases.