Life Care Center of Plainwell

Inspectors wroteThis citation pertains to intakes #2973222 and #2976634. Based on interview and record review the facility failed to ensure adherence to a Legal Guardian's right to medication treatment choices for 1 resident (Resident #1) of 1 resident reviewed for Legal Guardian's rights, resulting in Resident #1 being treated and prescribed medications against the wishes of the Legal Guardian.

Inspectors wroteBased on interview and record review the facility failed to notify resident's guardians regarding a fall for 1 resident (Resident #1) of 3 residents reviewed for falls resulting in Resident #1's guardians being unaware of the fall and if any injuries occurred.

Inspectors wroteThis citation pertains to intakes #2973222 and #2976634. Based on interview and record review the facility failed to ensure that a resident's behavior was managed and interventions were put in place prior to starting a chemical restraint affecting 1 resident (Resident #1) of 1 resident reviewed for medication management resulting in Resident #1 being prescribed Seroquel {antipsychotic used to balance neurotransmitters (regulates mood, sleep, digestion and movement) in the body and can cause drowsiness and cardiovascular risk (heart risk) in the elderly} upon admission and then adding Klonopin (treats panic disorders by calming the nervous system) to help manage behaviors.

Inspectors wroteThis citation pertains to intake #2960916. Based on interview and record review the facility failed to maintain quality of care by ensuring implementation of skin care treatment and ensure skin care was completed for 1 resident (Resident #2) of 3 residents reviewed for quality of care resulting in dressing changes not being implemented and being monitored causing unmet resident care needs.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to wear appropriate PPE (personal protective equipment) for 1 resident (Resident #5) of 4 residents reviewed for infection control practices resulting in the potential for the spread of disease in a vulnerable population.

Inspectors wroteThis citation is related to intake 2646852Based on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect in 3 (Resident #3, #7, and #18) of 18 residents reviewed for dignity/respect, and 4 of 5 residents from the confidential group meeting, resulting in extended call light wait times, unmet care needs and the potential for feelings of diminished self-worth, sadness, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure clean resident rooms and comfortable temperatures of facility care areas for 9 of 18 residents (Residents #15, 6, 11, 30, 27, 26, 7, 19 and 3) and 3 of 5 residents from a confidential resident council meeting reviewed for clean and comfortable environment, resulting in residents being uncomfortable living in an unclean and cold environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely physician follow up with pharmacy recommendations for 4 residents (Resident #88, Resident #12, Resident #15 and Resident #80) of 5 reviewed for medications resulting in the potential for residents to experience avoidable medication side effects and/or receive unnecessary medications.

Inspectors wroteBased on observation and interview, the facility failed to maintain kitchen plumbing equipment and surfaces in a manner that would allow for safe, clean, and consistent operation.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for ants and winged-insects in five resident rooms (rooms #118, 117, 119, 120, and 106) of 88 resident rooms, and one-resident common area, resulting in the potential for pest transmitted diseases to a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to ensure updated and accurate advanced directive information was in place for 1 of 18 residents (Resident #7) reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure timely provision of podiatry services for 1 (Resident #15) of 1 resident reviewed for foot care resulting in a delay in foot care and potential worsening of conditions of the feet.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure urinary catheters were maintained appropriately for two residents (R8 and R76) of two residents reviewed for urinary catheter care resulting in over-filled indwelling catheter bag and sediment laden catheter tubing and connections, resulting in the potential for urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure pre and post dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) assessments were completed for 2 (Resident #3 and #101) of 2 resident reviewed for dialysis care, resulting in the potential of being unprepared for a potential decline in resident condition, due to the adverse effects from dialysis.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Director fulfilled their responsibility of implementing Medication Regimen Review (MRR) policies/procedures to include coordination of care between the facility and the consulting pharmacist/pharmacy for 4 (Resident #88, 12, #15 and #80) of 5 residents reviewed for medications. This deficient practice has the potential to affect all residents that reside at the facility.

Inspectors wroteBased on interview and record review, the facility failed to: 1) effectively identify quality deficiencies, develop, and implement appropriate action to correct deficiencies; and 2) sustain a system to ensure corrective measures related to resident rights, dialysis, bowel/bladder incontinence/catheter care, and advance directives as evidenced by repeated deficiencies on the past three surveys. This deficient practice has the potential to affect all residents that reside in the facility.

Inspectors wroteThis citation pertains to Intake MI00153382 Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for 1 (Resident #102) of 7 residents reviewed for abuse, resulting in Resident #101 punching Resident #102 in the face.

Inspectors wroteThis citation pertains to intake number MI00151225 Based on interview and record review, the facility failed to ensure nursing staff had appropriate skill sets and completed required annual trainings, resulting in the potential for the delivery of nursing and related services that did not support the attainment or maintenance of the Resident's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to intake number MI00151225 Based interview and record review, the facility failed to ensure individualized approaches were provided to 1 (Resident #103) of 3 residents reviewed for dementia care, resulting in Resident #103 experiencing avoidable stress responses to care interventions.

Inspectors wroteThis citation pertains to MI00149054. Based on interview and record review, the facility failed to thoroughly investigate and resolve grievances for 1 resident (Resident #3) of 3 residents reviewed for missing items, resulting in the resident missing property and the potential for further unresolved grievances to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, or serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective infection control program that included: 1. appropriate hand hygiene and glove use during resident care in 1 of 18 residents (R63), 2. cleaning and disinfecting of resident equipment for 3 of 18 residents (R36, Resident #67, and Resident #11), 3. implementation of Enhanced Barrier Precautions (EBP) per standards of practices for 1 of 18 residents (Resident #11) all reviewed for infection control, and 4. maintain an active and ongoing plan for reducing the risk of opportunistic pathogens of premise plumbing, resulting in the potential for cross-contamination, harborage of bacteria, and increased infections in a vulnerable population.

Inspectors wroteBased on interview and record review the facility failed to ensure accurate documentation of advance directives for 1 (Resident #5) of 18 residents reviewed for advance directive documentation.

Inspectors wroteThis citation pertains to intake#: MI00146614 Based on interviews, and record review, the facility failed to protect the residents right to be free from abuse for 2 (Resident's #61 and #80) of 8 residents reviewed for abuse, resulting in residents experiencing physical restraint, physical and/or verbal aggression, fear, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed-hold to 2 of 3 residents (Resident #41, and #2) reviewed for hospitalization, resulting in the potential for the residents to not return to their same room upon readmission.

Inspectors wroteBased on observation, interview and record review the facility failed to revise a person centered care plan for 1 (Resident #11) of 18 reviewed for person centered care plan revision resulting in an inaccurate reflection of the resident's current care needs.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide restorative exercises per therapy recommendations for 1 (Resident #76) of 1 resident reviewed for position/mobility, resulting in the potential for pain, stiffness, and avoidable decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate care for a resident with an indwelling foley catheter (tube inserted into the bladder to drain urine) in one resident (R63) of 1 residents reviewed for catheter care, resulting in the potential for urinary tract injury and/or infection.

Inspectors wroteBased on interview and record review the facility failed to identify Post Traumatic Stress Disorder (PTSD) triggers and develop and implement care plan interventions to mitigate emotional triggers in 1 (Resident #47) of 5 reviewed for trauma informed care resulting in the potential for re-traumatization due to staff not being informed or knowledgeable of the resident's past trauma and unmet care needs.

Inspectors wroteThis citation pertains to intake #'s MI00145569 & MI00146066 Based on interviews and record review, the facility failed to protect the residents' right to be free from mental and verbal abuse by staff for 3 residents (Resident #102, 103, & 105) of 6 residents reviewed for abuse/neglect, resulting in verbal intimidation, and the potential for psychosocial harm.

Inspectors wroteThis citation pertains to intake #'s MI00145569 & MI00146066. Based on interview and record review, the facility failed to report allegations of abuse to the State Agency in a timely manner for 3 residents (Resident #102, #103, & #105) reviewed for abuse and neglect, resulting in the potential for continued violations involving mistreatment, neglect, or abuse going undetected, unreported, or without thorough investigation.

Inspectors wroteThis citation pertains to intake #'s MI00145569 & MI00146066. Based on interview and record review, the facility failed to thoroughly investigate and protect residents after allegations of abuse were made for 3 residents (Resident #102, #103, and #105) of 6 residents reviewed for abuse, resulting in the alleged perpetrator not being immediately suspended, an incomplete investigation, and the potential for future mistreatment or abuse.

Inspectors wroteThis citation pertains to intake # MI00146066. Based on interview, and record review, the facility failed to ensure care plan interventions were in place per standard of care, to prevent the development of pressure ulcers for 1 resident (Resident #102) of 3 residents reviewed for pressure ulcers, resulting in the development of a Stage 2 pressure ulcer on the right buttock and a deep tissue injury (DTI) on the coccyx.

Inspectors wroteThis citation pertains to intake #MI00146066. Based on interview, and record review, the facility failed to maintain professional standards of care, and provide adequate incontinence care in 2 of 3 residents (Resident #102 and #106) reviewed for incontinence care, resulting in MASD (moisture associated skin disorder).

Inspectors wroteBased on interview, and record review, the facility failed to ensure timely monitoring of weight for a newly admitted resident at risk for malnutrition in 1 resident (Resident #105) of 6 residents reviewed for nutrition, resulting in a delay in identifying significant weight loss, and the potential for alteration in nutrition and hydration status.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a resident care plan in 1 (Resident #102) of 3 residents reviewed for care plan implementation, resulting in the potential for a decline in oral intake of food, a decline in oral intake of fluids, and improper body alignment and/or comfort.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a dependent resident had access to fluids for hydration in 1 (Resident #102) of 3 residents review for hydration status resulting in the potential for dehydration.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistive devices as ordered in 1 (Resident #102) of 3 residents reviewed for assistive devices, resulting in the potential for a decline in oral intake of food and fluids.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that infection control enhanced barrier precautions were implemented in 1 (Resident #102) of 3 residents reviewed for infection control resulting in the potential for the spread of infection, cross contamination, and disease transmission.

Inspectors wroteThis citation pertains to Intake MI0143736. Based on observation, interviews, and record review, the facility failed to protect the resident's right to be free from verbal abuse by another resident in 1 of 3 sampled residents (Resident #103) reviewed for abuse, resulting in Resident #104 cussing and threatening physical violence to Resident #103.

Inspectors wroteThis citation pertains to Intake MI0143736. Based on observation, interviews, and record review, the facility failed to update and revise the person-centered comprehensive care plan in a timely manner for 1 resident (Resident #104) of 5 residents reviewed for care plan revisions, resulting in the potential for physical, mental, and psychosocial unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the further development of pressure ulcers for 1 (Resident 78) of 3 residents reviewed for pressure ulcers, resulting in the development of 7 facility acquired pressure ulcers and worsening of existing pressure ulcers resulting in surgical intervention.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Clean food and non-food contact surfaces to sight and touch; 2. Ensure the installation of an air gap; 3. Properly datemark and discard food product; and 4. Ensure all hand sinks have hot water. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 88 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the facility, at 9:48 AM on 12/4/23, observation of the two door Traulson freezer found accumulation of spotted black debris on the top portion of the door gasket seals. During the initial tour of the facility, at 9:50 AM on 12/4/23, it was observed that the two door true cooler was found with an accumulation of spotted black debris on the top portion of the door gasket seals. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop and implement person centered comprehensive care plans for 5 (Resident #79, #27, #51, #45 and #8) of 5 residents reviewed for care plans, resulting in the potential for residents not being able to achieve their highest practicable level of physical and psychosocial wellbeing.

Inspectors wroteResident #21 Review of an admission Record revealed Resident #21 had pertinent diagnoses which included: major depressive disorder (persistent feelings of sadness), muscle weakness, and dementia (neurocognitive disorder that affects the memory and thinking). During an observation on 12/4/23 at 10:32 AM., Resident #21 was in bed, awake, and counting out loud. No other noise noted in her room. During an observation on 12/4/23 at 1:28 PM., Resident #21 was sitting in her wheelchair in her room in silence. During an observation on 12/5/23 at 10:00 AM., Resident #21 was lying in bed, sleeping. No other noise noted in room. Review of Activity Log (2023) for Resident #21 revealed .recorded entry for one-to-one activities included on 8/13 asked MDS questions . 11/23 attempted to talk to her about what she's thankful for .12/4 checked in and talked to her . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1.)monitor and complete documentation of weights for 1 residents (Resident #8), 2. obtain orders and complete wound dressing changes for 3 residents (Resident #53, Resident #442, and Resident #57) and, 3.) complete neurological checks following a fall for 1 resident (Resident 79) of 6 residents reviewed for quality of care, resulting in potential for negative resident outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 6 (Resident #79, #27, #60, #76, #83, and #54 ) of 8 residents reviewed for behavioral health received behavioral health care services resulting in Resident #79 being hospitalized due to physical aggression and a potential for the other residents to experience a decline in their psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to provide medically related social services to 2 resident (Resident #79, Resident #83) of 18 sampled residents resulting in residents not receiving requested psychological support services and the potential for a decline in psychological well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1.) implement an effective infection control program 2.) don the appropriate Personal Protective Equipment (PPE) when entering resident rooms which required PPE 3.) provide water needed for hand washing and daily hygiene care in 1 of 2 residents (Resident #57), 4. ) follow the infection control protocols when performing resident care in 1 of 2 residents (Resident #78) and, 5.) properly handle storage of open and exposed linens in spa rooms, cleaning products/linens/ and personal hygiene products and 6.) properly clean linen bins in the laundry room per facility infection control protocols, resulting in the potential for further development and transmission of communicable diseases and infections.

Inspectors wroteBased on interview and record review, the facility failed to 1.) Implement and operationalize an antibiotic stewardship program and 2.) failed to ensure appropriate use of an antibiotic for 2 (Resident # 441 and #45) of 5 residents reviewed for antibiotic use, resulting in the potential for inappropriate antibiotic utilization and antibiotic resistance.

Inspectors wroteBased on interview and record review the facility failed to ensure that staff treated residents with dignity and respect in 1(Resident #23) of 7 residents reviewed for dignity, resulting in feelings of frustration and the potential for depression, loss of self-worth and an overall deterioration of psychological well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for 2 (Resident #53, and #78) of 3 residents reviewed for accommodation of needs resulting in resident's inability to call for staff assistance with the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate a resident's right to make choices that were consistent with their assessment and plan of care for 1 of 2 sampled residents (Resident #5) reviewed for resident choices, resulting in the resident not meeting their highest practicable level of well-being.

Inspectors wroteThis citation pertains to intake MI00140935. Based on interview, and record review, the facility failed to notify the responsible party of a change in resident condition in 1 of 19 residents (R45) reviewed for notification of changes, resulting in the resident representative not being made aware immediately of an accident resulting in the lack of ability to participate in timely medical decision-making.

Inspectors wroteBased on interview and record review, the facility failed to ensure that physician orders for immediate care were in place for 1( Resident #442) of 1 resident reviewed for new admission orders, resulting in missed assessments and monitoring for potential side effects related to use of psychotropic and pain medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate in 1 resident (Resident #54) of 18 sampled residents reviewed for Minimum Data Set (MDS) quarterly assessment, resulting in the potential for inaccuracy of treatments, interventions, and cares.

Inspectors wroteBased on observation, interview, and record review, the facility failed to confirm the Pre-admission Screening and Resident Review (PASARR) Level II determination request was sent to the Community Mental Health Services Program (CMHSP) for a Level II OBRA review and/or evaluation for 2 residents (Resident #60 and #45) of 3 residents reviewed, resulting in the potential for the residents to not receive or have delayed mental health services.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received annual Level 1 and follow up Level II PASARR (pre-admission screening/annual resident review) to ensure appropriate mental health services were provided in 1 resident (Resident #71) reviewed for PASARR, resulting in the potential for Resident #71 not being placed in an appropriate setting or receive treatment specific for his mental health needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a baseline care plan was in place for 1 (Resident #442) of 19 sampled residents, resulting in the potential for ineffective care to be provided to the resident.

Inspectors wroteThis citation pertains to intake MI0040935 Based on observation, interview, and record review, the facility failed to follow professional standards of practice by 1.) not following McGeer's criteria for ordering an antibiotic for 1 resident (R45), 2.) documenting completion of wound dressing changes when they were not done for 2 residents (R53 and R57), 3.) not ensuring neurological checks were completed after unwitnessed falls for 1 resident (R79) of 19 residents reviewed for professional standards, resulting in the increase chance of R45 developing medicine-resistant bacteria, potential of R53 and R57 developing infection and R57, R53, and R79 developing worsening conditions and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was consistently provided with showers/bathing for 1 of 4 residents (Resident #78) reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for isolation, psychosocial harm, skin breakdown, harboring infection, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent falls after a fall in 1 (Resident #442 ) of 7 residents reviewed for accidents, resulting in a potential for additional skin tears and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate indwelling catheter care, monitoring the patency of the tubing, and collection bag for 1 (Resident #78) of 3 residents reviewed for indwelling catheter care, resulting in the potential of a urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent availability of hydration and/or nutrition based on resident needs in 3 of 3 residents (Resident #27, #51, and #78) reviewed for nutrition/hydration, resulting in the potential for dehydration.

Inspectors wroteBased on interview, and record review, the facility failed to ensure adequate care for residents who received enteral nutrition (tube feeding) in 1 (Resident #443) of 2 sampled residents reviewed for tube feeding, resulting in the potential for aspiration pneumonia.

Inspectors wroteBased on interview and record review the facility failed to ensure post dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) assessment and monitoring were completed for 1 (Resident #441) of 1 resident reviewed for dialysis care, resulting in the potential of being unprepared for a decline in resident condition, due to adverse effects of dialysis.

Inspectors wroteBased on interview, and record review the facility failed to identify PTSD (Post Traumatic Stress Disorder) triggers and implement interventions to mitigate triggers for 1 of 8 residents (Resident # 76) reviewed for trauma informed care, resulting in the potential risk of re-traumatization and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dementia care treatment that included individualized care interventions that were monitored in 1 of 2 residents (Resident #54) reviewed for dementia care, resulting in facility staff not knowing if interventions were effective and/or appropriate and the potential for residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident remained free from unnecessary mediations in 1 (Resident #45) of 19 residents reviewed for antibiotic use, resulting in the potential of developing a medicine-resistant bacteria.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were screened for eligibility to receive pneumococcal and influenza vaccinations and receive vaccination if eligible for 3 (Resident #19, #53 and #59) of 5 residents reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia and/or influenza.

Inspectors wroteBased on interview and record review, the facility failed to ensure COVID-19 immunization were offered to 2 (Resident #53 and #59) out of 5 residents, reviewed for COVID-19 immunizations, resulting in the increased likelihood of severe infection and complications/death related to COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nurse Aides (CNA's) completed the required 12 hours of training to ensure continued competence in 1 of 5 CNA's reviewed for competency, resulting in the potential for a decrease in resident safety.

Inspectors wroteThis citation has two deficiency practice statements, A & B. Deficiency Practice Statement A This citation pertains to Intake # MI00139066. Based on interview, and record review, the facility failed to provide protection for a resident after an incident of staff to resident abuse in 1 of 1 resident (Resident #114) reviewed for abuse, resulting in an Immediate Jeopardy when on 7/18/23, Certified Nurse Aide (CNA) C restrained Resident #114 to his wheelchair for several hours and other staff and management were aware of the incident, but allowed CNA C continued access to Resident #114 and 57 additional vulnerable residents without any education for the staff or protection for the residents.

Inspectors wroteThis citation pertains to Intake # MI00139098. Based on interview, and record review, the facility failed to ensure residents are free from significant medication errors in 1 of 6 residents (Resident #116) reviewed for medication administration resulting in an Immediate Jeopardy when, beginning on 8/15/23 at approximately 8:00 AM, Resident #116 was identified to have a decreased level of consciousness and was sent to the hospital. [...]

Inspectors wroteThis citation pertains to intake #MI00139066 Based on observation, interview, and record review the facility failed to prevent the use of a physical restraint in 1 (Resident #114) of 1 resident reviewed for restraint use, resulting in potential for injury, seclusion, and/or psychological harm.

Inspectors wroteThis citation pertains to Intake # MI00139073. Based on observation, interview, and record review, the facility failed to ensure timely and appropriate wound care for a laceration obtained during a transfer in 1 of 3 residents (Resident #115) reviewed for accidents/hazards, resulting in delayed wound closure, hospitalization, and a wound infection.

Inspectors wroteThis citation pertains to Intake # MI00139073. Based on observation, interview, and record review, the facility failed to utilize a gait belt to ensure a safe transfer in 1 of 3 residents (Resident #115) reviewed for accidents/hazards, resulting in a leg laceration, hospitalization, and a wound infection.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity and respect in 5 (Resident #108, #118, #119, #121, and #123) of 9 residents reviewed for dignity/respect, resulting in long call light wait times, staff behaviors that did not promote dignity and respect to or in the presence of residents, and feelings of frustration, embarrassment, and loss of self-worth for the residents thus impacting their quality of life.

Inspectors wroteThis citation pertains to intake #MI00136333 and #MI00136123. Based on interview and record review the facility failed to prevent misappropriation of medications and personal funds in 6 residents (Resident #108, #109, #110, #111, #122, and #106) of 6 sampled residents reviewed for misappropriation of personal items, resulting in the potential for ineffective pain management and a loss of financial security.

Inspectors wroteThis citation pertains to Intake # MI00139066, # MI00139073, # MI00136333, & # MI00139098. Based on observation, interview, and record review, the facility failed report timely and accurately to the State Agency required reportable incidents in 8 (Resident #114, #108, #109, #110, #111, #122, #115, & #116) of 10 residents reviewed for reporting, including inappropriate use of a restraint (Resident #114), misappropriation of resident medications (Resident #108, #109, #110, #111, & #122), an improper transfer with major injury/delayed wound care (Resident #115), and a significant medication error resulting in hospitalization (Resident #116), resulting in the potential for additional reportable incidents to go unreported, investigations continuing to be inaccurately reported to the State Agency, and/or cause a delay in the investigative process.

Inspectors wroteThis citation pertains to Intake # MI00139073. Based on interview, and record review, the facility failed to notify the responsible party of a change in resident condition in 1 of 4 residents (Resident #115) reviewed for notification of changes, resulting in the primary physician and representative not being made aware immediately of an accident resulting in a significant wound, and the lack of ability to participate in timely medical decision-making.

Inspectors wroteThis citation pertains to Intake #: MI00136331. Based on interview and record review, the facility failed to protect the resident's right to be free from staff to resident verbal abuse in 1 (Resident #107) of 5 residents reviewed for abuse, resulting in the potential for emotional distress.

Inspectors wroteThis citation pertains to Intake #: MI00136331. Based on interview and record review, the facility failed to implement the abuse policy regarding timely notification of a staff to resident abuse to the abuse coordinator in 1 (Resident #107) of 5 residents reviewed for abuse, resulting in delayed reporting of the incident to the State Agency, delayed initiation of an investigation of the allegation, and allowed the alleged perpetrator to continue to work with Resident #107 and other vulnerable residents.

Inspectors wroteThis citation pertains to Intake # MI00138569. Based on interview, and record review, the facility failed to adhere to professional standards related to accurate transcription of physician orders in 1 (Resident #113) of 23 residents reviewed for professional standards, resulting in missed medication(s) dose(s).

Inspectors wroteThis citation pertains to Intake # MI00138569. Based on interview, and record review, the facility failed to ensure that resident's medical records were accurate in 1 resident (Resident #113) of 23 residents reviewed for accuracy of medical records, resulting in Resident #113 not consistently receiving his medications with the potential for a diminished medical outcome.