Macomb Post Acute Care Center

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure a resident with known bowel incontinence was provided dignified incontinence care for one of four residents (R1) reviewed for incontinence care assistance in the sample of seven. This failure resulted in R1 experiencing mental anguish and feeling embarrassed and ashamed of the lack of control of R1 bowels and the need for daily assistance with hygiene.

Inspectors wroteBased on observation, interview and record review, the Facility failed to provide scheduled menu items, palatable food, personal preference food temperature and personal preference portion sizes for dining services. This failure has the potential to affect all 58 Residents residing in the Facility.

Inspectors wroteBased on observation, interview and record review, the Facility failed to maintain clean kitchen floors, clean walk-in cooler, clean walk-in refrigerator units/coolers, clean inside/front/handles of the refrigerators and label/date opened food items in the refrigerator. This failure has the potential to affect all 58 residents residing in the Facility.

Inspectors wroteBased on interview and record review the Facility failed to respond to Resident call lights in a timely manner and comply with Resident requests for assistance, for five of seven Residents (R1, R2, R4, R6 and R7) reviewed for call light response in a sample of sevenFindings include:The Facility Resident Call Bells Policy, dated 11/5/25, documents: will be adequately equipped to allow Residents to call for staff assistance through a communication system which relays the call directly to a staff member or centralized staff work area from each Resident's bedside, toilet and bathing facilities; calls for assistance shall be answered timely; and any staff member that hears or sees an alert from a Resident from the communication system is responsible to answer within reasonable timeframe; non-clinical staff are to answer requests for assistance from the communication system. [...]

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure allegations of resident abuse and neglect were reported to the facility's abuse coordinator and the state agency for three of seven residents (R1, R3, R5) reviewed for Abuse in the sample of seven.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure allegations of resident abuse and neglect were investigated and residents were immediately protected to prevent further potential abuse for three of seven residents (R1, R3, R5) reviewed for Abuse in the sample of seven.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide adequate supervision and prevent a cognitively impaired resident with identified exit seeking behaviors and high risk for elopement from exiting the facility, through alarmed doors and failed to identify the resident's elopement. The resident exited the facility unsupervised and wandered approximately 0.4 miles down a main street which has continuous traffic to the hospital and multiple medical complexes. The police were notified by a community member and upon arrival at 6:43 PM the resident was standing on the corner waving down traffic for help. Due to the resident having an alarm device on her ankle, the police officer called the facility at 7:15 PM, 45 minutes after exiting the facility to confirm the residents' identity. [...]

Inspectors wroteBased on interview and record review the facility failed to have adequate processes in place for acquiring /receiving refill prescriptions for narcotic medications for one (R4) of three residents reviewed for pharmaceutical services in a sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a multidose tuberculin vial was dated when opened. This failure has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to offer food substitutions of similar nutritive value. These failures have the potential to affect all 60 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete and record cool down temperatures for meat that was prepared ahead and stored in the facility's refrigerator for future use, ensure facial hair was appropriately restrained within a hair net while in the kitchen, ensure a gallon of milk's temperature was kept below 41 degrees Fahrenheit, and ensure the sanitation buckets had the appropriate amount of quaternary ammonium. These failures have the potential to affect all 60 residents residing within the facility.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure a resident with a Failure to Thrive diagnosis was provided with Physician ordered double meal portions for one of four residents (R52) reviewed for Nutrition in the sample of 38

Inspectors wroteBased on observation, interview and record review the facility failed to assess, document and provide pain management for one resident (R2) of three residents reviewed for change in condition. This failure resulted in no pain management provided for 7 hours after R2 fell and sustained a left hip fracture

Inspectors wroteBased on observation, interview and record review the facility failed to provide treatment to a scalp laceration post fall and failed to provide post fall neurological monitoring for one resident (R1) of three residents reviewed for change of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure walk-in coolers in the kitchen maintained a temperature of less than 40 degrees Fahrenheit/F and that food in refrigerators were kept at a temperature of 41 degrees Fahrenheit or below. This failure has the potential to affect all 50 residents residing in the facility.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to remove soiled gloves and perform hand hygiene before cleansing a wound, failed to wear gloves while touching wound dressing materials, and failed to wash hands before touching clean items after performing wound care for one of one resident (R1) reviewed for wound care in the sample of seven.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to ensure a resident had physician orders and a diagnosis for use of an indwelling urinary catheter and failed to ensure a resident's indwelling urinary catheter did not come in direct contact with the ground for one of two residents (R4) reviewed for indwelling urinary catheters in the sample of seven.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions for residents with open wounds, indwelling urinary catheters, and peripherally inserted central catheters/PICC for three of six residents (R1, R4 and R6) reviewed for Enhanced Barrier Precautions in the sample of seven.

Inspectors wroteBased on interview and record review the Facility failed to develop a Resident centered Care Plan for three Residents (R6, R9, R17) of 33 reviewed for Care Plans in a sample of 33.

Inspectors wroteBased on observation, interview and record review the Facility failed to follow physician orders for compression stockings for one of 33 Residents (R9) reviewed for quality of care in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a pressure ulcer on re-admission, to administer a physician ordered treatment for a pressure ulcer and provide timely incontinent care and pain management for a resident with a pressure ulcer for one of two residents (R6) reviewed for pressure ulcers in the sample of 33.

Inspectors wroteBased on observation, interview and record review, the Facility failed to implement designated post-fall interventions for one of two Residents (R23) reviewed for Falls in a sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to document the justification for duplicate antipsychotic medication therapy, ensure resident behaviors/symptoms to justify the use of antipsychotic medications, attempt a gradual dose reduction on antipsychotic medications, accurately complete psychotropic medication consents, complete psychotropic assessments prior to the use of antipsychotic medications and document the residents response to non-pharmacological interventions to manage behaviors/symptoms for two of five residents (R6, R17) reviewed for unnecessary medications in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement to the resident, or their representative in a form or manner they could understand. This had the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to establish appropriate fall interventions for one cognitively impaired resident (R2) and failed to prevent falls with injury for two of three residents (R1 and R2) reviewed for fall with injuries in a sample of three. These failures resulted in R1 requiring hospitalization, sustaining scalp lacerations and a cervical fracture, and subsequently resulting in R1's death, and R2 requiring hospitalization and sustaining a scalp laceration.

Inspectors wroteBased on interview and record review the facility failed to respond to resident call lights in a timely manner and comply with resident requests for assistance, for four of four residents (R2, R3, R4, R5 and R6) reviewed for call light response in a sample of four.

Inspectors wroteBased on interview and record review the Facility failed to develop a Care Plan for one (R1) of three Residents reviewed for Care Plans in a sample of three.

Inspectors wroteBased on interview and record review the facility failed to answer resident call lights timely for five (R1, R2, R3, R4 and R5) of seven Residents reviewed for call lights in a sample of seven.

Inspectors wroteBased on observation, interview and record review the facility failed to complete a baseline care plan for one (R91) of two residents reviewed for new admission interim care planning in the sample of 16.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a plan of care for three (R1, R28, and R33) of 16 residents reviewed for care planning in the sample of 16.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise a plan of care for two (R28 and R33) of 16 residents reviewed for care planning in the sample of 16.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff wash hands after removing soiled gloves and before placing clean gloves while performing pressure ulcer wound care and failed to document weekly skin assessments per facility policy for one of two residents (R33) reviewed for pressure ulcers in the sample of 16.

Inspectors wroteBased on observation, interview and record review, the facility failed to change a resident's indwelling urinary catheter bag as ordered by the physician, failed to perform hand hygiene and wear gloves during indwelling urinary catheter care and failed to flush an indwelling urinary catheter as ordered by the physician for one of one resident (R33) reviewed for urinary catheters in the sample of 16.

Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene and maintain glove use during Gastrostomy Tube Care and failed to cleanse a Gastrostomy Tube as ordered by the physician for one of one resident (R33) reviewed for Gastrostomy tubes in the sample of 16.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing and humidifier bottle were dated when initiated and the humidifier bottle contained distilled water for one (R91) of three residents reviewed for respiratory services in the sample of 16.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve a physician ordered diet to one (R28) of two residents reviewed for nutrition in the sample of 16.

Inspectors wroteBased on observation, interview and record review the facility failed to wash hands after removing gloves during incontinence care for one of one resident (R33) reviewed for bowel and bladder in the sample of 16.