Mackinac Straits Long Term Care Unit

Inspectors wroteThis citation pertains to intakes 2638726 and 2641135. Based on observation, interview and record review the facility failed to provide safe transport to an outside appointment for one Resident (#10) of three residents reviewed for accidents/hazards. This deficient practice resulted in harm when R10 sustained a fractured left hip from being improperly secured during transport and fell from her seat when the transport van hit an obstacle in the road.

Inspectors wroteBased on interview and record review, the facility failed to consistently identify targeted behavior and implement non-pharmacological interventions prior to the administration of PRN (as-needed) anti-anxiety medication for one resident (#28) of five resident reviewed for unnecessary psychotropic medication, resulting in the potential for oversedation, dependency on controlled medication and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two Residents (#24 and #46) of twelve Residents reviewed for accuracy of MDS assessments.

Inspectors wroteResident #28 (R28) Review of the MDS assessment, dated 3/19/2025, revealed R28 was admitted to the facility on [DATE] and had diagnoses including anxiety disorder and depression. Further review of the MDS assessment, revealed R28 required substantial/maximal assistance with most Activities of Daily Living (ADLs) and was dependent on staff for transfers. Review of R28's physician orders revealed an order for lorazepam [a controlled anti-anxiety medication] 0.5mg [milligrams] every 8 hours - PRN [as needed] . Special Instructions: May give 0.25, [one-half] 0.5mg tab no closer than [every] 8 hours for increased anxiety . Please monitor [R28] and call [provider] if [R28] shows signs or symptoms of increased confusion or over-sedation. Review of R28's Medication Administration Record (MAR) for 5/01/25 through 5/28/2025 revealed R28 was administered the PRN lorazepam on 32 occasions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed rail assessments were completed to evaluate entrapment risk prior to the use of bed rails, obtain a physician's order for the use of bed rails, attempt alternatives prior to the use of bed rails, provide medical reason for the use of bed rails, and document the risks and benefits of bed rails for one Resident (#46) of one resident reviewed for accident hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide drinks, including water and other liquids consistent with resident needs for one resident requiring thickened liquids (#16) of one resident reviewed for fluid needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control precautions were implemented and hand hygiene and glove changes were performed after touching potentially contaminated items for two Residents (#46 and #29) of six residents reviewed for infection prevention and control.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure timely interventions to prevent facility acquired pressure injuries for one resident (#16) and failed to ensure comprehensive wound documentation for two residents (#16 and #6), per professional standards of practice. This deficient practice resulted in harm when resident #16 developed two Stage 2 pressure injuries and the potential for worsening and delayed healing of Stage 3 pressure injury for resident #6. Resident #16 (R16) A review of the Electronic Medical Record (EMR) for R16 revealed admission to the facility on 8/22/17 with diagnoses of Alzheimer's disease (progressive memory disorder), Down Syndrome (intellectual and developmental delay condition), and seizures. R16's face sheet had a note which read, R16 is unable to answer questions appropriately. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the Minimal Data Set (MDS) assessment was accurate for two residents (Resident #6 and Resident #22) of 12 sampled residents reviewed for comprehensive assessments.

Inspectors wroteBased on interview and record review the facility failed to identify, evaluate, and implement interventions to prevent an avoidable accident when bath aides failed to transport one Resident #3 (R3) of two residents reviewed for safety, safely to the bath via the bath lift in the tub room. This deficient practice resulted in bath lift tipping over while R3 aboard, causing a laceration to his left shin which required sutures. Resident #3 (R3) Review of R3's medical record indicated R3 was admitted to facility on 2/27/24 with diagnoses of age-related osteoporosis (when mineral density and bone mass decreases), Type II diabetes, muscle weakness, and traumatic brain injury. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R3 had a BIMS (Brief Interview for Mental Status) score of 15/15, indicating R3 was cognitively intact. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide preventative care consistent with professional standards of practice, for 1 resident (Resident #5) reviewed for the risk of the development of pressure injuries, resulting in impaired skin integrity, inaccurate/incomplete documentation, and the potential for the delay in treatment, the worsening of a wound, infection, and the overall deterioration in health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual performance reviews were conducted and education based on the outcome of the reviews were completed for two Certified Nurse Aides (CNA's), resulting in the potential for diminished quality and/or inadequate provision of care for all residents living at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one nurse aide completed required in-service training to evaluate nurse aide competence, resulting in the potential for inadequate and substandard quality of care for residents living at the facility.