Medilodge of Grand Rapids

Inspectors wroteThis citation pertains to intake #3003696 Based on observation, interview and record review the facility failed to recognize a change in condition, ensure residents received care in accordance with professional standards and ensure resident's care choices were followed for 4 Residents (#60, #51, #3, and #30) of 24 reviewed for quality of care, resulting in a delay in treatment for an infection requiring hospitalization and toe amputation for Resident #3, delay in post fall nursing assessment and treatment for a closed nondisplaced oblique fracture of shaft of right femur and closed fracture of proximal end of right fibula for Resident #30, and a delay in treatment for an unrecognized hip fracture requiring surgical repair for Resident #60, and delay in specialized care for Resident #51 who experienced increased pain.

Inspectors wroteThis citation pertains to Intake 2718302. Based on interview and record review the facility failed to honor a residents choice for do not resuscitate (DNR; no CPR to be performed) and ensure cardiopulmonary resuscitation (CPR) was not performed on a resident who was a DNR in 1 (Resident #1) of 8 residents reviewed for CPR, resulting in Resident #1 being subjected to dehumanization and unavoidable pain when facility staff initiated CPR and contacted Emergency Medical Services (EMS) and then performed unwanted life sustaining efforts (cardiopulmonary resuscitation (CPR), automated external defibrillation (AED; [...]

Inspectors wroteThis citation pertains to Intake 2718302. Based on interview and record review the facility failed to obtain and put into place an advance directive (legal documents that provide instructions for medical care to ensure healthcare preferences are honored) in a timely manner and failed to honor the residents do not resuscitate (DNR) order for 1 (Resident #1) of 8 residents reviewed for advanced directives resulting in a resident who did not want life sustaining services to endure painful lifesaving activities that included cardiopulmonary resuscitation (CPR), receiving automated external defibrillation (AED; delivers electric shock to attempt to restore normal heart rhythm), and insertion of an intraosseous venous access (inserting a specialize needle into the bone marrow cavity to provide immediate vascular (bloodstream) access) of the tibia (shinbone).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective system to obtain and use of feedback and input from direct care staff and residents to recognize and monitor for areas of improvement related to resident staffing concerns for 2 residents (Resident #3 and Resident #13) and 4 of 4 residents from a confidential resident council meeting, from a total census of 49 residents reviewed for Quality Assurance and Performance Improvement (QAPI), resulting in the potential for all residents to continue to not receive care to meet their highest practicable level well-being.

Inspectors wroteOn 6/4/25 at 10:16 AM during a confidential group meeting, the group agreed there is not enough staffing on nights and weekend to meet resident needs. They voiced concerns there would be times at nights and on weekends there may be 1 CNA (certified nursing assistant) on each hall and 1 or 2 nurses to run clinical cares in the entire facility. According to the group, this makes longer wait times to get medications and assistance with toileting, The group voiced disheartening concerns when discussing many of the CNAs and nurses they felt were good and caring had left employment while others had put in their notices to leave because of better offers and work conditions. Another concern the group brought to attention was laundry. They stated laundry had one person currently and residents might not get their clothes back until the following week. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration via a feeding (enteral) tube in 1 of 5 residents (Resident #16) reviewed for tube feeding care, resulting in the potential for discomfort and blockage.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate tube feeding care was consistently provided for 2 (Resident #155 and Resident #3) of 4 residents reviewed for tube feeding, resulting in the potential risk for aspiration (something you swallow enters your airway or lungs) for Resident #155 and poor nutritional status for Resident #3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate person-centered and individualized treatment and services were received by 1 resident (R25) of 2 residents reviewed for treatment and services to meet assessed needs, resulting in R25 experiencing psychosocial adjustment difficulty with a suicide plan that included wrapping a call-light cord around her neck threatening to kill herself.

Inspectors wroteThis citation pertains to intake #MI00148777 Based on interview and record review, the facility failed to implement treatment measures when a change in condition was identified (acute stroke) in 1 (Resident #100) of 2 residents reviewed for change in condition, resulting in an Immediate Jeopary when on 1014/24, Resident #100 had sign and symptoms of a stroke and facility staff did not identify them resulting in the diagnosis of a cerebral infarction due to occlusion (Stroke caused by a blockage in a blood vessel) and a 27-day hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls with injury in 1 (Resident #102) of 3 residents reviewed for accident hazards and supervision, resulting in Resident #102 suffering pain, a head laceration which required stitches, and a hematoma on his forehead.

Inspectors wroteThis citation pertains to intake #MI00148997 and MI000149141 Based on observation, interview, and record review the facility failed to 1. ensure proper use of personal protective equipment (PPE) for 2 (Resident #100 and Resident #103) on enhanced barrier precautions and 2. properly clean resident shared equipment, resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staffing to provide adequate care for 2 (Resident #102) of 4 residents reviewed for staffing. This deficient practice resulted in falls and avoidable pain for Resident #102 due to lack of supervision, Resident #100 not receiving proper grooming, and a potential for additional unmet care needs for residents who reside in the building.

Inspectors wroteThis citation pertains to intake #MI00148777 Based on observation, interview, and record review the facility failed to preserve resident dignity during care in 2 (Resident #100 and Resident #103) of 4 residents reviewed for dignity resulting in the potential for a reasonable person to experience feelings of embarrassment, shame and/or a loss of self-esteem.

Inspectors wroteThis citation pertains to intake #MI00148777 Based on interview and record review, the facility failed to notify a resident's responsible party regarding a change in condition for 1 (Resident #100) of 2 residents reviewed for change in condition resulting in a delay in resident transfer to emergency room for evaluation and treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure wound care and compression stocking physician orders were in place for 1of 3 residents (Resident#102) reviewed for professional standards, resulting in the resident receiving care without the direction of a physician, and the potential for worsening of medical conditions.

Inspectors wroteThis citation pertains to Intake: MI00149223 Based on interview and record review, the facility failed to ensure 1 of 1 residents (Resident #100) reviewed for safety, received the correct food tray and assistance with eating on 12/3/24, resulting in an Immediate Jeopardy when Resident #100 choked on a piece of cauliflower and subsequently died.

Inspectors wroteThis citation pertains to intake: MI00149223 Based on interview and record review, the facility failed to implement facility policy and procedure for reporting an incident of neglect (resident choking and subsequent death due to recieving wrong meal tray) to the State Agency in 1 of 1 resident (Resident #100) reviewed for neglect, resulting in the potential for continued violations going unreported or without thorough investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident dignity and rights to privacy were honored as reported by eight of nine residents during a confidential Resident Council meeting resulting in residents feeling frustrated and disrespected.

Inspectors wroteBased on interview and record review, the facility failed to address and resolve concerns/ grievances reported in Resident Council Meetings as reported by seven of nine residents during a confidential Resident Council meeting resulting in unresolved concerns and unmet needs of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide access to bath linens and maintain sanitary conditions for 2 (Resident #13 and Resident #18) of 14 residents sampled for home-like environment, and 7 of 9 residents during a confidential interview, resulting in feelings of frustration, potential delay in care due to limited supplies, and unsanitary conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine showers for 4 (Resident #11, Resident #13, Resident #22, and Resident #35) of 6 residents reviewed for showers, and 7 of 9 residents who attended a confidential meeting, resulting in feelings of frustration, disappointment, and embarrassment about their personal appearance and overall, body cleanliness.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate staff to meet resident needs for 6 (Resident #11, Resident #13, Resident #18, Resident #22, Resident #35 and Resident #12) of 14 residents sampled for sufficient staffing, and 7 of 9 resident who attended a confidential meeting. This deficient practice resulted in long call light wait times, lack of routine showers for dependent residents, limited resident supervision, staff burnout, and the potential for a decline in resident quality of life and/or quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food at a palatable temperature to 9 of 9 residents interviewed during resident council and 2 of 2 resident (Resident #15 and Resident #27) reviewed for food palatability, resulting in the potential for decreased food consumption and potential nutritional decline.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide a nourishing nighttime snack to eight of nine residents who attended a confidential Resident Council meeting resulted in the potential for residents to have more than 14 hours between a substantial evening meal and breakfast the following day, decreased oral intake, and the potential for weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate advanced directive information was in place for 1 of 3 (Resident #21) residents 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 interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for 1 (Resident #20) of 2 residents reviewed for PASARR Screening, resulting in the potential for unmet mental health and psychiatric care needs.

Inspectors wroteResident #27(R27) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R27 admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Type 2 diabetes, and depression. Brief Interview for Mental Status (BIMS) reflected a score of 10 out of 15 which indicated R27 was cognitively impaired (8-12 moderately impaired). During an interview on 7/24/2024 at 8:36 AM, R27 stated that he goes to dialysis 3 days a week and he thinks it is going okay. Review of R27's physician orders revealed the following orders related to his dialysis: hemodialysis 3 days a week on Mondays, Wednesdays, and Fridays, also orders state AV (atrioventricular) shunt site-monitor every shift for signs and symptoms of infection/bleeding, AV shunt site upper arm. Monitor for thrill and bruit every shift, call provider if absent. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received care in accordance with professional standards in 1 (Resident #35) of 1 residents reviewed for quality of care, resulting in Resident #35 having dysuria (pain with urination) for approximately 2 weeks, due to the facility mishandling the lab specimen resulting in a significant delay in the treatment of vulvovaginits (infection or inflammation of the vagina or vulva) and the potential for a decline in overall physical, mental and psychosocial well being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to reassess resident's preference for use of therapy-recommended positioning device for 1 (Resident #12) of 2 residents reviewed for positioning, resulting in the potential for decreased range of motion and related complications, skin breakdown, worsening of contractures (hardening of the muscles, tendons, and other tissues) and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate supra-pubic catheter care for 1of 2 residents (Resident #22) reviewed for catheter care, resulting in the potential for urinary tract infection and complications related to occlusion of catheter tubing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate care for residents who received enteral nutrition (tube feeding) in 1 (Resident #21) of 2 residents reviewed for tube feeding, resulting in the potential for aspiration pneumonia and spoiled tube feeding.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain physician orders for use of oxygen for 1 of 1 resident (Resident #20) reviewed for respiratory care resulting in the potential for improper use, inaccurate settings, irregular cleaning, and respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician ordered laboratory diagnostic services were obtained and completed in a timely manner in 1 (Resident #35) of 1 residents reviewed for laboratory services, resulting in delayed treatment/intervention related to lab results, increased pain/discomfort, and impaired coordination of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices to provide sanitary conditions for resident shared equipment, and implement Enhanced Barrier Precautions (EBP) for a residents with an MDRO (multi drug resistant organism) during care for 3 of 4 residents (Resident #103, #104, & #107) reviewed for infection control, urinary catheter care, wound dressing changes, resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to respect residents private space for 3 of 6 residents (Resident #103, #107 & #111) reviewed for privacy/dignity,resulting in feelings of embarrassment and the potential for resulting in negative psychosocial outcomes.

Inspectors wroteThis citation pertains to intake: MI00143109 Based on observation, interview, and record review, the facility failed to accommodate a resident's right to make choices that were consistent with their plan of care for 3 of 7 residents (Residents #107, #104 & #111) reviewed for resident choices and preferences, resulting in the potential for residents not meeting their highest practicable level of well-being.

Inspectors wroteThis citation pertains to intake: # MI00142857 Based on interview, and record review, the facility failed to prevent misappropriation of a residents' narcotic (controlled substances) medications for 1 of 5 residents (Resident #102) reviewed for misappropriation of property resulting in missing pain medication, and the potential for uncontrolled pain and discomfort.

Inspectors wroteThis citation pertains to intakes: #MI00143109 & MI00143578. Based on observation, interview and record review, the facility failed to provide palatable food for 3 of 5 residents (Resident's #102, #104 & #111) reviewed for food palatability, resulting in residents being dissatisfied with the quality, portion size, taste and temperature of their food and the potential weight loss.

Inspectors wroteThis citation pertains to intake: #MI00143109 & MI00143578. Based on observation, interview, and record review the facility failed to maintain a safe, functional, and sanitary environment by not properly cleaning resident rooms, common areas, and commonly touched items for 2 residents (Resident #102 & #104) of 7 reviewed for homelike environment, resulting in strong odors in the facility, and an increased potential of infection, affecting residents in the facility.

Inspectors wroteThis citation pertains to intake MI00139838 and MI00139892. Based on interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of 12 of 12 residents in the Pinewood unit on the evening of 11/27/2023 and early morning of 11/28/2023, resulting in 12 residents on Pinewood not being checked and changed every two hours, delayed care, and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) ensure proper hand hygiene, glove use, and handling of soiled linens during incontinence care and 2) ensure proper cleaning of shared medical equipment in between resident use for 2 residents (Resident #103 and #105) of 3 residents reviewed for infection control, resulting in the potential for cross-contamination, disease exposure, and the development and spread of infection to a vulnerable population.

Inspectors wroteThis citation pertains to MI00140929. Based on interview and record review, the facility failed to ensure one staff (Former Kitchen Worker LL) received a timely background check and fingerprinting, resulting in the potential for abuse and neglect for all residents.

Inspectors wroteThis citation pertains to intake MI00139838. Based on interview and record review, the facility failed to notify the emergency contact of the transfer of 1 resident (Resident #101) out of 6 residents reviewed for notification of changes, resulting in family not being aware that Resident #101 had transferred to the local hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update a care plan to reflect current interventions for 1 resident, (Resident #109) of 13 residents reviewed for accuracy of care plans, resulting in the potential for staff to provide care that is inconsistent with the needs of the resident.

Inspectors wroteThis citation pertains to intake MI00139838. Based on interview and record review, the facility failed to ensure accurate admission orders were written for one resident (Resident #101) of 13 residents reviewed for accuracy of physician's orders, resulting in the delay of treatment and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to intake MI00139838. Based on interview and record review, the facility failed to 1) provide drain care, 2) administer medications, and 3) perform blood glucose monitoring according to physician's orders for 1 resident (Resident #101) of 4 residents reviewed for quality of care, resulting in lack of treatment, monitoring, and care and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to 1) implement preventative pressure ulcer interventions consistent with professional standards of practice and 2) perform a skin assessment upon readmission from the local hospital for 1 resident (Resident #103) of 3 residents reviewed for pressure ulcer prevention and treatment, resulting in the potential for skin breakdown and overall deterioration in health status.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate health record for 1 resident (Resident #101) of 13 residents reviewed for accuracy of medical records, resulting in unclear documentation and the potential for miscommunication and an unclear picture of the resident's health care status.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper datemarking and discarding of potentially hazardous foods. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 49 residents who consume food from the kitchen. Findings Include: 1. During a tour of the kitchen, starting at 7:34 AM on 6/12/23, it was observed that some items were not dated or were held in the walk-in cooler past their discard dates. These items were a pan of lasagna dated 6/1 to 6/7, a large bowl of lasagna sauce dated 6/1 to 6/7, a container of hot dogs not dated, a container of chicken salad not dated, and a tray of 21 nutritional shakes not dated. A review of the manufacture directions on the shakes state the shakes can be held for up to 14 days from thaw. [...]

Inspectors wroteThis citation pertains to intake #'s MI00136297, MI00135104, MI00135459, and MI00137661. Based on observation, interview and record review, the facility failed to ensure assistance with Activities for Daily Living (ADL) care (showers, incontinence care, eating) was consistently provided for 4 residents (Resident #14, #16, #27 and #44) of 9 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for residents who are dependent on staff for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) secure resident medications and 2) discard expired medication, resulting in unsecured medication and the potential for decreased efficacy of medications and the exacerbation of resident medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) ensure appropriate hand hygiene and glove use during incontinence care for 3 residents (Resident #21, #20, and #2) of 6 residents reviewed for incontinence care, 2) ensure appropriate infection control during tube feeding for 1 resident (Resident #43) of 1 resident reviewed for tube feeding, and 3) ensure appropriate hand hygiene during medication administration, resulting in the increased potential for the development and transmission of communicable diseases and infection in a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) cares were provided per resident preference for 1 (Residents #6) of 19 residents reviewed for resident preferences, resulting in the potential for overall decline in sense of physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to update advance directive status in the electronic health record of one resident (Resident #33) of 3 residents reviewed for advance directives, resulting in the potential for end of life choices not being honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure privacy for 1 resident (Resident #44) of 1 resident reviewed for privacy during bathing care, resulting in frustration and dissatisfaction with care. Resident #44 Review of an admission Record revealed Resident #44, was originally admitted to the facility on [DATE] with pertinent diagnoses which included post-traumatic stress disorder (PTSD), depression, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #44, with a reference date of 3/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #44 was cognitively intact. In a care observation on 6/14/23 at 10:40 AM, Certified Nursing Assistant (CNA) D and CNA K were assisting Resident #44 with a bed bath. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered diabetic care plan for 1 Resident (Resident #4) of 1 Resident reviewed for care planning, resulting in a potential for unmet care needs. Resident #4 Review of Resident #4's admission Record revealed Resident #4, was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 2/10/23 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #4 was severely cognitively impaired. Review of Resident #4's Care Plan did not reveal a care plan focus for Resident #4's diagnosis of diabetes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards for medication administration for 2 (Resident #16, Resident #20) out of 7 residents reviewed for medication administration, from a total sample of 19 residents, resulting in the potential for worsening of health conditions and mismanagement of medications. Findings Include: Resident #16 Review of an admission Record revealed Resident #16 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's disease. Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 6/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #16 was cognitively impaired. [...]

Inspectors wroteThis citation pertains to intake #MI00137590. Based on observation, interview and record review the facility failed to ensure residents received care in accordance with treatment orders for non-pressure wounds for 1 of 19 residents (Resident #20) reviewed for quality of care, resulting in the potential for infection and the worsening of medical conditions. Resident #20 Review of an admission Record revealed Resident #20 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Bullous Pemphigoid (skin blistering condition). Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 3/14/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #20 was cognitively intact. Review of Resident #20's Care Plan revealed, .potential impairment to skin integrity related to Bullous Pemphigoid. [...]

Inspectors wroteThis citation pertains to intake #'s MI00136297 and MI00137590. Based on observation, interviews, and record review, the facility failed to ensure interventions were in place to prevent the development or worsening of pressure ulcers for 3 residents (Resident #14, #20 and #6), of 6 residents reviewed for pressure ulcers, resulting in the potential for development of avoidable and/or worsening pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure range of motion services for 1 resident (Resident #12) of 2 residents reviewed for limited range of motion, resulting in the potential for decreased range of motion and residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate safety measures to ensure resident safety in 2 residents (R150 and R151) of 19 residents reviewed for accidents and hazards, resulting in the potential for accidents and/or injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supplemental oxygen therapy according to physician's orders, the plan of care and professional standards for 1 resident (Resident #6) of 1 resident reviewed for oxygen use, resulting in the potential for hypoxemia (low oxygen in the blood).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a trauma informed care plan for 1 (Resident #44) of 1 resident reviewed for trauma informed care, resulting in the potential for exposure to trauma triggers and re-traumatization.

Inspectors wroteBased on interview and record review, the facility failed to ensure an as needed psychotropic medication was not prescribed for longer than 14 days for one resident (R5) of three residents reviewed for unnecessary medications, resulting in the potential for unnecessary psychotropic medications ad adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to prevent a significant medication error in 1 (Resident #4) of 5 residents reviewed for medication errors, resulting in Resident #4 receiving insulin (medication that controls blood sugar levels) at a greater frequency than ordered.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain accurate medical records for 2 out of 19 residents (Resident #14 and #16) reviewed for medical records, resulting in inaccurate medical records and the potential for facility staff and providers to have inaccurate information related to the resident's nutritional status.