Medilodge of Montrose Inc

Inspectors wroteThis citation pertains to Intake Number 3033898. Based on observation, interview, and record review, the facility failed to 1) Consistently provide the prescribed mechanically altered diet as ordered and 2) Follow the resident's stated dining preferences for one resident (Resident #5) of three residents reviewed for nutrition maintenance and resident preferences.

Inspectors wroteThis citation pertains to intake Numbers 3009454 and 3009709. Based on observation, interview and record review, the facility failed to ensure that Restorative Therapy for range of motion ROM) and splint application were provided, as ordered, for one resident (Resident #105), of three residents reviewed for positioning.

Inspectors wroteThis citation pertains to Intake Numbers 2736807, 2736887, 2736910 and 2742953 Based on observation, interview and record review, the facility failed to ensure that one resident (Resident #2) was free from neglect when staff did not complete a skin assessment after identifying a new area of skin concern, did not ensure appropriate treatment was in place, and did not accurately monitor and document the resident's skin condition, of one resident reviewed for neglect of care, resulting in Resident #2 being admitted to the hospital for 5 days with a diagnosis of cellulitis (bacterial skin infection) and having to receive IV antibiotics.

Inspectors wroteThis citation pertains to Intake Number 2785490. Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Findings Include:Resident #5:On 3/3/2026 at approximately 2:30 PM, Resident #5 reported he loaned CNA S $500 (cash) and they had a verbal agreement that she would pay him back every paycheck. He explained she typically worked weekends, and he gave her $300 cash on a Friday, $100 on Saturday and $100 on Sunday. Resident #5 continued he was upset, as the aide was not abiding by their verbal agreement and had only paid back $30. He stated she eventually came into the facility on a Monday (that she was not scheduled to work) and remitted the remaining $470 that she owed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.

Inspectors wroteThis citation has 2 Deficient Practice Statements (DPS). Based on interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Based on interview and record review, the facility failed to have a comprehensive infection control program for residents residing in the facility

Inspectors wroteBased on interview and record review, the facility to ensure that monthly infection control antibiotic stewardship data collections were completed, 1) antifungal monitoring and stop dates, 2) Resident #6's prophylactic antibiotic line listing, 3) Resident #15's Vancomycin scheduling, dosing and therapeutic level monitoring, and 4) Resident #124 to receive antibiotic with no temperature monitoring, resulting in the high likelihood of increased antibiotic usage and resident infection rates with hospitalizations.

Inspectors wroteBased on interview and record review, the facility failed to ensure that there were adequate staff and/or that staff were utilized appropriately to sufficiently meet the needs of facility residents resulting in increased call light response times, unmet care needs, lack of resident assessment and monitoring. Findings Include:During Resident Council on 1/28/2026, the eight attendees reported the following regarding staffing at the facility:There are not enough staff to meet their needs, and the facility terminates the good staff or forces them out. There is currently a mass exodus of nurses due to how the facility is run and the nurses left do not having enough time to ensure all their needs are met. At times they can have up to three different nurses providing care to them during one shift. Average call light wait time is about 30 minutes and that is across all shifts. On 1/29/2026 at 1: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5% when three medication errors were observed for three residents (Resident #56, Resident. #59, and Resident #111) for a total of 26 observations, resulting in a medication error rate of 11.5%. This deficient practice resulted in the potential for adverse medication effects and decreased medication efficacy related to medications administered late and the lack of implementation of standards of practice for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to operationalize policies and procedures for medication storage in one of one medication rooms and four of five medication carts, resulting in open, undated, expired, and inappropriately stored medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure that residents were treated in a dignified and respectful manner for two residents (Resident #32 and Resident #69) of four residents reviewed, resulting in staff not knocking prior to entering residents' rooms and a lack of timely care resulting in incontinence, and resident's verbalizations of dissatisfaction with care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that physical restraints were not used for one resident (Resident #69) of one resident reviewed, resulting in the use of a seatbelt restraint without an assessment for its use and an evaluation of its appropriateness.

Inspectors wroteBased on observation, interview and record review, the facility failed to update care plan interventions for two residents (Resident #55, Resident #124) of 22 residents reviewed, resulting in the likelihood for missed interventions in treatment and unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the provision of services to maintain grooming and hygiene for one resident (Resident # 1) of two residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed 1) Address a hunger strike for Resident #57, 2) Assess and monitor a new skin alteration for Resident #99, and 3) Ensure a quality of care of assessment and monitoring per professional standards for Resident #124, resulting in a lack of care coordination, documentation and assessments.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of practice by failing to assess and monitor the removal site of a gastrostomy tube (GT) site and monitor pain for one resident (Resident #124) of 3 residents reviewed for tube feeding in a sample of 22 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for storage and cleaning of respiratory equipment for one resident (Resident #1) of three residents reviewed, resulting in a lack of cleaning and appropriate storage of nebulizer (machine which converts liquid into fine mist for administrator of medications directly into the lungs through respiration) equipment.

Inspectors wroteThis citation pertains to Intake Numbers 2688354 and 2689940. Based on observation, interview and record review the facility failed to ensure timely reporting, notification, comprehensive assessment and continued post-fall monitoring for one resident (Resident #2) following an unwitnessed fall of one resident reviewed for safety and accidents.

Inspectors wroteThis Citation Pertains to Intake Numbers 2614165, 2646780, 2646846, and 2674790. Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from sexual abuse and physical abuse by other residents for three residents.

Inspectors wroteThis Citation Pertains to Intake Number 2648479. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure comprehensive discharge planning and a safe discharge home for one resident (Resident #110) of three residents reviewed for transfer/discharge.

Inspectors wroteThis citation pertains to intake Numbers 2591663, 2612086, and 2665756. Based on observation, interview and record review, the facility failed to provide urinary incontinence care per professional standards of practice for two residents (#102, #112)

Inspectors wroteThis citation pertains to Intake Number 2580183. Based on interview and record review the facility failed to have diabetic supplies available to facility staff when Resident #108 had a hypoglycemic episode, resulting in a blood sugar of 52 and being placed on ventilator upon arrival to the Emergency Room. Findings Include: Resident #108:On [DATE] at approximately 11:00 AM, a review was conducted of Resident #108'S medical record and it revealed he admitted to the facility on [DATE] with diagnoses that included, Peripheral Vascular Disease, Heart Disease, Atrial Fibrillation, Diabetes Mellitus, Chronic Kidney Disease and Hypertension. Resident #108 was his own person and able to make his needs known to staff. Further review of his chart yielded the following: Progress Notes:[DATE] at 17:01: Resident in room comfortable in bed with call light in reach. [...]

Inspectors wroteThis Citation pertains to intake Number 2585749. Based on interview and record review, the facility failed to obtain a physician's order for urinary catheter per professional standards of practice for one resident (Resident #106), resulting in the potential for bladder injury, prolonged illness, and an indwelling catheter being left in place with no physician's order.

Inspectors wroteThis Citation Pertains to Intake#: 2569658Based on observation, interview and record review, the facility failed to develop and implement interventions, including monitoring and supervision, to prevent resident-to-resident abuse involving 2 residents of 4 residents reviewed for abuse, including Resident #1 who grabbed Resident #2's hand and placed it on his pants over his genitals, resulting in the potential for additional instances of abusive behavior towards other residents. A review of the Face Sheet indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: History of a stroke, difficulty talking, COPD, history of falls, depression, hypertension, Dementia, arthritis, and GERD.A review of the Face Sheet indicated Resident #2 was admitted to the facility on [DATE] an readmitted on [DATE] with diagnoses: [...]

Inspectors wroteThis Citation Pertains to Intake#: 2566178Based on observation, interview and record review, the facility failed to provide medications, and a right knee X-ray as ordered for one resident (#3) of three reviewed for medications and treatments, resulting in Resident #3 experiencing pain, nausea and delayed treatment. A record review of the Face sheet indicated Resident #3 was admitted to the facility on [DATE] with diagnoses: recent back surgery, neuropathy, anxiety, GERD, hypotension, history of a stroke, weakness, anemia, chronic kidney disease, and depression. On 7/31/2025 at 10: 37 AM, Resident #3 was observed lying in bed awake and alert. He said he had not received his medications for a couple of days after admission and was having pain and nausea. He said he was now receiving his medications but was upset that it took so long. [...]

Inspectors wroteThis citation pertains to Intake #2577143. Based on observation, interview and record review, the facility failed to obtain timely dental services for one resident (Resident #4), who fell and injured their mouth area of one resident reviewed for dental care. A review of Resident #4 medical record revealed an admission into the facility on 6/26/25 with diagnoses that included diabetes, end stage renal disease, difficulty in walking and muscle weakness. A review of the Resident's Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 15/15 that indicated the Resident was cognitively intact and the Resident needed setup or clean-up assistance with oral hygiene and substantial/maximal assistance with toileting hygiene, bathing, lower body dressing and needed partial/moderate assistance with transfers. [...]

Inspectors wroteThis citation pertains to intake 1205083 and 1205084. Based on interview and record review, the facility failed to Prevent 2 facility acquired stage II pressure ulcers/PU, for 1 resident (Resident #15) of 3 resident's reviewed for PU's, resulting in 2 facility acquired stage II pressure ulcers, pain, increased risk for infection, antibiotic usage and hospitalization. Findings Include:Review of the Face Sheet, Resident #15's facility care plans dated 3/24/25 through 4/1/25, Physician, Nurse Practitioner and nursing notes dated 3/24/25 through 3/27/25, revealed Resident #15 was [AGE] years old, unable to make own healthcare decisions, admitted to the facility on [DATE], after a severe car accident, had a tracheostomy, feeding tube (G-tube), urinary catheter, dependent on staff for all Activities of Daily Living/ADL's and was a full code. [...]

Inspectors wroteThis citation pertains to intake Numbers 1205063 and 1205084. Based on observations, interview and record review, the facility failed to ensure that call lights were answered timely and assist with care needs, snacks, and incontinence care in a timely manner for four residents (6, 7, 14, and 18) of eight residents reviewed for call light responses, a Confidential Resident and a Confidential Group of Residents.

Inspectors wroteThis citation pertains to intake numbers: 1205082 and 1205084. Based on interview and record review, the facility failed to provide prompt efforts to resolve complaints pertaining to prolonged call light response time, food palatability, bedtime (HS) snack distribution, Weekend Manager on Duty (MOD) availability and accessibility for residents, staff attitude in providing quality of care, availability and assistance and to ensure the process to address grievances was understood for confidential group of 15 residents, resulting in unresolved grievances and potential for further frustration.

Inspectors wroteThis citation pertains to Intake Numbers 1205063, 1205080 and 1205084. Based on observation, interview and record review, the facility failed to provide necessary assistance to honor residents' preferences, choices, or requests to maintain bathing, grooming, nail care and personal hygiene for 6 residents (Resident's #1, #3, #6, #7 #18 and #22) of 7 residents reviewed for Activities of Daily Living/ADL care, resulting in the loss of personal dignity and individuality.

Inspectors wroteThis citation pertains to intake #1205063. Based on observation, interview and record review, the facility failed to maintain a consistently operational and accessible call light system affecting 5 residents (R7, R10, R11, R18 and R22), Residents residing in the100 hall, 200 hall, 300 hall, 400 and 500 halls, resulting in extended call light times and unmet needs.

Inspectors wroteThis citation pertains to intake #1205082. Based on interview and record review, the facility failed to protect a resident from abuse and neglect for one resident (R#14) when a nurse on midnight shift neglected to respond to the call light promptly, and did not provide nursing care during IV infusion while the resident's PICC (Peripherally Inserted Central Catheter) machine alarm was sounding for prolonged periods and wound care as needed of a total sample of 3 residents reviewed for abuse and neglect.

Inspectors wroteThis Citation pertains to Intake Number MI00153369. Based on observation, interview and record review, the facility falsified the completion of staffs' online education, which had the potential to affect a census of 112 residents residing in the facility. Findings Include: On 6/10/25 at 8:50 AM, an interview was conducted with Nurse B. When asked about education, the Nurse reported that they started a new education (online education) but could not get into the program and had not completed the education though the facility wanted to have it done. The Nurse reported having issues with getting in the system and had not completed the education. On 6/10/25 at 12:45 PM, an interview was conducted with CNA (Certified Nursing Assistant) I. When asked if they have had their education completed with the new online education, the CNA indicated she had not completed it. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00153563. Based on observation, interview and record review, the facility failed to ensure infection control practices were followed and emergency equipment was available for residents with tracheostomy status for four residents (#14, #15, #16 and #17) of four residents reviewed for tracheostomy and oxygen care.

Inspectors wroteThis Citation pertains to Intake Numbers MI00153369 and MI00153563. Based on observation, interview and record review, the facility failed to ensure resident safety with a lack of timely documentation of Resident #13 exiting the building unattended by staff. The facility also failed to update and/or revise care planning to include exit-seeking behavior and ensure that staff signed out pagers that notify staff of the resident call system and door activation for one resident (Resident #13) of three residents reviewed for elopement.

Inspectors wroteThis Citation pertains to Intake Numbers MI00151406 and MI00151580. Based on observation, interview and record review, the facility failed to ensure that residents' rights and/or dignity were maintained by failing to answer residents' call lights in a timely manner, ensure that call lights were in reach, ensure that meals and/or snacks were provided and followed the residents' preferences, and provide adequate lighting in a resident's room for five residents (#2, #3, #6, #8, and #9) of five residents reviewed for food and call lights, resulting in long call light wait times, incontinence, and frustration.

Inspectors wroteThis Citation pertains to Intake Number MI00151746. Past Non-Compliance (PNC) was identified at the facility during investigation of the allegation and was accepted by the survey team upon exit from the facility for this citation. Following discussion with the State Manager, Past Non-Compliance was accepted with a Compliance Date of 3/24/2025. Based on interview and record review, the facility failed to immediately report to the Abuse Coordinator allegations of sexual abuse and report timely to the State Agency abuse allegations for one resident (#1) of four residents reviewed for abuse, resulting in a delay in the investigation and the potential lack of resident safety to go undetected and abuse to continue to occur.

Inspectors wroteThis Citation pertains to Intake Number MI00151580. Based on interview and record review, the facility failed to ensure that the required posting of daily nursing staff was accurate and updated, resulting in a lack of accurate documentation of daily staffing available to all 112 residents residing in the facility, the residents' representatives, staff and visitors.

Inspectors wroteThis Citation Pertains to Intake Number MI00150467. Based on observation, interview and record review, the facility failed to ensure the provision and documentation of Activities of Daily Living (ADL) and hygiene care for five residents (701, 702, 703, 704, and 705) of five residents reviewed.

Inspectors wroteThis Citation Pertains to Intake Number MI00150264. Based on observation interview and record review the facility failed to ensure an operational call light system in the short-term units of the facility (100, 200, 300, and 400 hallways).

Inspectors wroteThis Citation Pertains to Intake Number MI00150264. Based on interview and record review, the facility failed to ensure timely nursing assessment, response, and documentation for a change in condition for one resident (#705) three residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure tube feeding equipment was maintained, tube feeding supplies were labeled and dated, and enteral nutrition and care per physicians' orders were provided for four residents (#34, #35, #53, #90) out of five residents reviewed for enteral nutrition, resulting in undated solutions, unassessed skin, inaccurate volumes infused and dirty equipment.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1) Ensure that residents received oxygen as ordered for 4 residents (#'s 21, 24, 30 and 83) of 6 residents reviewed for oxygen use and; 2) Ensure proper management of oxygen and trach supplies for 2 residents (#'s 24 and 83) of 5 residents reviewed for Trachs, resulting in the potential for the lack of necessary oxygen therapy and contamination of supplies. Findings Include: Resident #21: On 12/05/2204 at 9:54 AM, Resident #21 was observed wheeling herself rapidly in her wheelchair past the nurses table near the 300 hall. Her face was red and she was breathing heavily. A staff member was walking with her and said she was looking for a nurse, because the resident's oxygen tank was empty. The resident was asked if she was having difficulty breathing and she shook her head Yes and stated, I need a new oxygen tank. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that Licensed Nurses (RNs-Registered Nurses and LPNs-Licensed Practical Nurses) and Certified Nursing Assistants (CNA) received yearly competency evaluations to ensure competent and trained nursing staff to perform their duties to attain or maintain the wellbeing of residents, for six Nurses and CNAs of seven staff reviewed for evaluations, education and competencies, resulting in the potential nursing staff lacking necessary training and skills to adequately care for the needs of the residents residing in the facility of a census of 105.

Inspectors wroteBased on observation, interview and record review, the facility failed to post required, accurate, updated nurse staffing records and retain accurate data of the nurse staffing hours, resulting in the potential to affect all Residents residing in the facility of a census of 105, Resident representatives and visitors to be unable to determine nursing staff on duty.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage of medications in 4 of 4 medication carts reviewed, and ensure appropriate narcotic reconciliation, resulting in opened and undated multi-dose medications, the potential for unaccounted controlled substances and altered medication efficiency.

Inspectors wroteBased on observation, interview and record review, the facility failed to update care plan interventions for 2 residents (#74, #75) of 22 sampled residents, resulting in the potential for resident care needs being not met/missed, prolonged illness or injury.

Inspectors wroteBased on record review and interview, the facility failed to follow physician's orders for monitoring blood pressure and heart rate parameters with administration of the medication Metoprolol (used to treat chest pain and hypertension (high blood pressure)) for one Resident (#34), of six reviewed for medication review, resulting in the potential for adverse drug consequences, lack of medication treatment effectiveness and medical conditions left untreated.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist with denture care and nail care for two Residents (#11 and 51) of seven residents reviewed for activities of daily living, resulting in fingernails long and jagged, denture cup with debris inside and the potential for embarrassment, skin injury and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to 1. Coordinate and collaborate hospice service for Resident #83 to ensure comprehensive care and 2. Complete timely assessment and monitoring of skin and change bandages and sheets when visibly soiled for Resident #403. Findings Include: Resident #403: On 12/3/2024 during initial tour, Resident #403 was observed in bed resting, she stated she recently admitted to the facility after being septic and coding. She reported her fingers are black which is why they are bandaged and were last changed last night by facility staff. Resident #403's bilateral hands were bandaged but were completely saturated with brown colored drainage. There was a dressing on the right side of her neck dated 11/25 11:00 and another dressing on her right arm with no date. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure thorough initial therapy assessment documentation, prevent a reduction in range of motion and the development of contracture for one resident (Resident #10) of one resident reviewed for limited range of motion. Findings Include: Resident #10: On 12/4/2024 at 11:05 AM, Resident #10 was observed resting in this in his room. He reported he has been at the facility for one year and therapy has not attempted to stand him up. He stated they informed him he would not be able to stand due to the outwardness of his feet. He reported he was walking at one point with a cane and now is not able too. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary management and care of an indwelling urinary catheter for 2 residents (Resident #24, and Resident #74) and management of recurrent Urinary tract infection/UTI for one resident (Resident # 73) of 3 residents reviewed for urinary catheters, resulting in the potential for complications including infection and a decline in condition. Findings Include: Resident #24: Urinary Catheter or UTI On 12/03/2024 at 10:23 AM, Resident #24 was observed sleeping in bed. An indwelling urinary catheter (Foley catheter) bag was sitting on the floor bent over, not hanging freely; the catheter tubing had thick yellow urine with sediment and biofilm (a sticky grouping of bacteria) on the inside of the catheter walls. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to respond to pharmacy recommendations for two (#8 and #9) residents of five residents reviewed for unnecessary medications. Findings Include: Resident #8: On 12/4/2024 at 10:45 AM, a review was completed of Resident #8's medical records and it revealed he admitted to the facility on [DATE] with diagnoses that included, Traumatic Brain Injury, Depression, Insomnia and Adjustment Disorder. On 12/05/24 at 12:15 PM, review was conducted of Resident #8's Medication Regime Review's (MRR) from November 2023- November 2024. It was found there were three recommendations from the pharmacist that the facility failed to respond too. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide risk versus benefits and/or medication education to one resident (Resident #75) or resident/responsible party, resulting in Resident #75 to be administered a benzodiazepine medication without appropriate risk versus benefit analysis of the medication explained to the resident/responsible party and the increased potential for serious side effects and adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food preferences for a lunch for one resident (Resident #22) of fifteen residents reviewed during the dining task, resulting in consumption of food not liked with the likelihood of decreased nutritional intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper medication administration and clean reusable medical equipment for one resident (Resident #10) of six residents reviewed for medication administration task, resulting in the use of unsanitary equipment and the administration of dirty pills.

Inspectors wroteBased on interview and record review the facility failed to: 1.) obtain laboratory results for the use of antibiotics prior to starting antibiotic therapy for two residents (#6 and #73); of three residents reviewed for antibiotic stewardship and initiate interventions to reduce antibiotic use, potentially effecting all residents, resulting in the potential for unnecessary medications, additional infections and resistant organisms. Findings Include: Resident #6: On 12/4/2024 at 11:00 AM, review was completed of Resident #6's medical record and it revealed he admitted to the facility on [DATE] with diagnoses that included, Parkinson's, Atrial Fibrillation, Major Depression and Kidney Disease. Further review of Resident #6's record revealed the following: November 2024 MAR (Medication Administration Record): [...]

Inspectors wroteThis Citation pertains to Intake Number MI00147080. Based on interview and record review, the facility failed to ensure one resident's (Resident #106) care plan (Impaired Hepatic Status) was implemented of 3 residents reviewed for care plans, resulting in the likelihood for exacerbated hepatic systems (increased abdominal girth, abdominal pain, fullness/discomfort, jaundice), pancreatic involvement (inflammation of pancreas) and hospitalization. Findings Include: Resident #106: Review of the Face Sheet, care plans dated 9/6/24, nursing and physician notes dated 9/5/24 through 9/13/24, revealed Resident #106 was [AGE] years old, alert, admitted to the facility on [DATE], and required assistance with activities of daily living (ADL's). [...]

Inspectors wroteThis Citation pertains to Intake Number MI00146098. Based on interviews and record review, the facility failed to ensure that one resident (Resident #101), who had a long history of mental illness (Bipolar Disorder, anxiety, attention deficit, and Borderline Personality with harm threats and physical aggression), of 3 residents reviewed for mental health services, obtained mental health services (including mental health medication review) while at the facility, resulting in a major psychotic episode with violent and aggressive behaviors towards staff, threats of harm to staff, with hospitalization. Findings Include: Resident #101: Review of the Face Sheet, behavioral charting, Minimum Data Set (MDS, resident assessment) dated 7/24, and progress notes, revealed Resident #101 was 30 years-old, admitted to the facility on [DATE] and discharged to the hospital on 8/2/24. [...]

Inspectors wroteDuring an interview on 7/24/24 at 10:56 AM, Maintenance Director B was queried on the investigative legionella water sampling on 6/3/24 for room [ROOM NUMBER]. When asked what water fixture the sample came from, Maintenance Director B stated they probably tested the sink of the room [ROOM NUMBER] bathroom. When queried why the shower fixture wasn't tested in addition to the sink, Maintenance Director B stated, Didn't think about it, I guess. When queried about the sampling method, Maintenance Director B stated that they don't have sampling instructions from the lab and that they let the water run for a few minutes, then draw the sample. According to the facility's Water Management Program, it notes on page 26, Informative Annex C - Guidance Legionella Testing is Utilized . Sample Collection Hot Water Systems - Obtain two samples pre flush & post flush: - Pre Flush: [...]

Inspectors wroteThis Citation Pertains to Intake Number MI00145431. Based on interview and record review, the facility failed to implement policies and procedures to ensure a comprehensive and accurate assessment and documentation for one resident (Resident #205) of one resident reviewed, resulting in a lack of accurate, complete, and concise documentation and nursing assessment for a change in condition.

Inspectors wroteThis Citation pertains to Intake Number MI00145431. Based on observation, interview and record review, the facility failed to ensure medications were given timely and as ordered for one resident (Resident #201) of 3 residents reviewed for medications, from a census of 111 residents, resulting in Resident #201 receiving doses of medication too close together and too far apart, which could lead to adverse effects and decreased effectiveness of the medications. Findings Include: Resident #201 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #201 was admitted to the facility on [DATE] with diagnoses: hydrocephalus, bipolar disorder, rheumatoid arthritis, anxiety, chronic pain syndrome, history of pulmonary embolism. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00142716. Based on interview and record review the facility failed to provide adequate supervision and assistance for one resident (Resident #113) of 3 residents reviewed for falls resulting in Resident #113 falling and sustaining a serious laceration requiring hospitalization.

Inspectors wroteThis Citation pertains to Intake Number MI00136915. Based on interview and record review, the facility failed to ensure an environment free of abuse (verbal and physical) for four residents (Resident #117, Resident #118, Resident #119 and Resident #120), of 8 residents reviewed for abuse, resulting in verbalizations of anger, hostility, threats of violence, and physical and verbal abuse from Resident #102. Findings Include: Review of the facility admission packet given to all residents and/or Power of Attorneys at the time of admission (un-dated), stated Federal and/or State law gives you the right to remain at the center (the facility) once admitted , and not be transferred or discharged against your will, except for the following: The health and/or safety if the resident or other individuals in the center are endangered. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00143098 Based on interview and record review the facility failed to treat one resident (Resident #111) of 3 residents reviewed for residents' rights with dignity resulting in Resident #111 having feelings of frustration and mental anguish.

Inspectors wroteThis Citation pertains to Intake Number MI00141964. Based on observations, interviews and record review the facility failed to implement standards of care and care planning for pressure relief and implement interventions to keep a pressure ulcer free from contamination for one resident (Resident #115) of 3 residents reviewed for pressure ulcers, resulting in Resident #115 having chronic wound contamination (urine and feces) and a lack of consistent pressure relief for 3 unstageable pressures and pressure ulcers worsening.

Inspectors wroteThis Citation pertains to Intake Number MI00143607. A complaint was filed with the State Agency that alleged the facility was not providing adequate tracheostomy (surgical opening into the windpipe to allow air to flow in and out) care. Based on observation, interview, and record review, the facility failed to assure that staff maintained infection control prevention ((sterile technique), while performing tracheostomy suctioning for one resident (Resident #122) of one resident reviewed for tracheostomy care, leading to the likelihood for increased risk of respiratory infection.

Inspectors wroteThis Citation Pertains to Intake Number MI00142145 Based on observation, interview and record the facility failed to ensure that nurses were competent to administer medications for 1 resident (Resident #1) of 5 residents reviewed for medication administration resulting in medication errors, adverse effects from medications, and transfer to the hospital. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #1 indicated the resident was admitted to the facility on [DATE] with diagnoses: history of a stroke, arthritis, hypertension atrial fibrillation, weakness, anemia, anxiety, and depression. The MDS assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating full cognitive abilities. On 1/24/2024 at 11:00 AM, Resident #1 was interviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent skin injury and pressure ulcer development for two residents (Residents #23, Resident #239), resulting in the development of new skin injuries for Resident #23, and the development of a Stage III pressure ulcer after admission to the facility and failed to use positioning devices.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent repeated urinary tract infections (UTI's) for one resident (Resident #78), resulting in hospitalization and a prolonged illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) maintain equipment and properly use single-service items, 2) provide date labels, 3) ensure equipment was clean and dried properly, and 4) properly use gloves, resulting in the potential contmination of food product, increasing the risk of foodborne illness, affecting all residents that consume food from the kitchen.

Inspectors wroteResident #77: A review of Resident #77's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included stroke, dysphagia, diabetes, seizures, anxiety, muscle weakness, and dementia. A review of the Minimum Data Set assessment, dated 10//11/23, revealed the moderately impaired cognition and needed setup assistance with eating, moderate assistance with shower/bathing, and lower body dressing. On 11/7/23 at 1:42 PM, an observation was made of Resident #77 sitting in her wheelchair, dressed. Prior to entering the room, a sign on the door indicated that a Resident was on transmission-based precaution (TBP) for contact precautions. There were two residents that resided in the room, the sign did not indicate which resident was in TBP. The sign indicated that prior to entering the room, gown and gloves were to be put on. On 11/8/23 at 11: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity by failing to answer residents' call lights in a timely manner and ensure an adequate supply of linen for two residents (Resident #31, Resident #47) of 10 residents from the confidential Resident Group meeting, and residents observed during initial tour of the facility, of 23 residents reviewed for dignity and respect, resulting in frustration, anger and the potential of unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise care plans with resident changes to ensure that interventions necessary for care and services were provided for 5 residents (Resident #16, Resident # 31, Resident #41, Resident #43, and Resident #239) of 27 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #16: Care Planning On 11/07/23 at 2:56 PM, Resident #16 was observed lying in bed in her room, visiting with her son. She said she was at the facility for antibiotic treatment for an ongoing infection related to prior back surgery. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #16 was admitted to the facility on [DATE] with diagnoses: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to 1.) Ensure sanitary storage of respiratory equipment for 4 residents (#23, #41, #43, and #47)), 2.) Ensure humidification for Resident #43's CPAP machine and 3.) Ensure appropriate assessment, monitoring and management of a tracheostomy tube for one resident (#41) of 4 residents reviewed for respiratory care, resulting in the potential for exposure to infectious organisms for residents (#23, #41, #43 and #47), the potential for a dry airway during CPAP treatment for Resident #43, and the potential for the lack of ability to safely maintain the airway for Resident #41. Findings Include: Resident #41: Respiratory Care A record review of the MDS assessment and Face sheet for Resident #41 indicated admission to the facility on 6/13/2023 and readmission on [DATE] with diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication was not left in a resident's room or on the floor, properly label open containers of medication and treatments, dispose of expired medical supplies, maintain a clean medication cart from loose tablets for three of four medication carts, one treatment cart and one medication room reviewed for storage and labeling of medication and supplies, resulting in the lack of a clean space to store and prepare medications, and the potential for drug diversion, residents to receive medication with altered potency and efficacy and medical procedures completed with outdated supplies.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Code Status was assessed, documented and accessible in the medical record prior to obtaining a physician's order for Code Status for 2 residents (Resident #288 and Resident #289) of 3 residents reviewed for Advance Directives, resulting in the potential for the resident's lack of informed knowledge related to options for code status and miscommunication of code status which could lead to a lack of appropriate interventions for care. Findings Include: Resident #288: Advance Directives A record review of the Face sheet indicated that Resident #288 was admitted to the facility on [DATE] with diagnoses: Fracture left femur, arthritis, hypertension, atrial fibrillation, cardiac pacemaker, GERD, and anxiety. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a person-centered baseline care plan to guide the care provided to one resident (Resident #288) of 27 residents reviewed for care plans, resulting in the failure to provide instructions to the staff for effective and person -centered care to promote well-being and provide pain management for Resident #288. Findings Include: Resident #288: Pain Management A record review of the Face sheet indicated that Resident #288 was admitted to the facility on [DATE] with diagnoses: Fracture left femur, arthritis, hypertension, atrial fibrillation, cardiac pacemaker, GERD, and anxiety. On 11/07/23 at 11:26 AM, Resident #288 was moaning and stated, Pain is my main problem. She said she cries from the pain and was very frustrated. Resident #288 said she was new to the facility and it was her 3rd day there. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with grooming/removal of facial hair for one resident (Resident #43) and ensure preference of showering with assistance of bathing activity for two residents (Resident #31 and Resident #339) of three residents reviewed for Activities of Daily Living (ADL) care, resulting in unmet care needs, mustache hair with food debris while eating, and the potential for body odor, embarrassment and diminished feeling of self-worth and dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent cross contamination of pests (flies) on an open foot wound and food for one resident (Resident #74), resulting in cross contamination of food items and wounds, frustration and with the likelihood of infection or maggot infestation.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor, ensure that the head of bed was elevated and provide Percutaneous Gastrostomy (PEG) tube feeding timely for one resident (Resident #438), resulting in the head of bed below 30 degrees, undated dressing to the PEG site, with the likelihood of complications such as aspiration and a clogged PEG tube.

Inspectors wroteBased on interview and record review, the facility failed to provide five medications timely for one resident (Resident #438), resulting in five missed evening medications with the likelihood of an increase or relapse in symptoms.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%, when 3 medication errors were observed from a total of 26 opportunities, for one resident (Resident #44) of 5 residents observed for medication administration, resulting in an error rate of 11.54%. Findings Include: FACILITY Medication Administration Resident #44: On 11/7/2023 at 9:25 AM during the Entrance Conference with the Director of Nursing/DON, she said the Medication Administration times for residents was divided into morning/AM (6:00 AM to 10:00 AM) and evening/HS 6:00 PM to 10:00 PM or at specific times if the medication was ordered with specific administration instructions. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #44 was admitted to the facility on [DATE] with diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent significant medication errors for 1 resident (Resident #44) of 6 residents reviewed for medication errors, resulting in medications being administered to the resident's hours after they were due for Resident #44 leading to the potential for mistreatment of the resident's medical conditions, serious side effects, adverse effects and a decline in condition. Findings Include: FACILITY Medication Administration Resident #44: On 11/7/2023 at 9:25 AM during the Entrance Conference with the Director of Nursing/DON, she said the Medication Administration times for residents was divided into morning/AM (6:00 AM to 10:00 AM) and evening/HS 6:00 PM to 10:00 PM or at specific times if the medication had specific administration instructions. [...]