Medilodge of Southfield

Inspectors wroteThis citation pertains to Intake Number(s): 2974196 and 2794550. Based on observation, interview and record review, the facility failed to protect the residents right to be free from physical abuse by staff and residents for four (R801, R805, R809, and R810) out of six reviewed for abuse resulting in R808 punching R801 in the jaw causing fear, pain and discoloration, attempting to choke R809, and hitting R810 in the face; and a staff member pushing R805 causing a fall.

Inspectors wroteThis citation pertains to Intake Number 2794550. Based on interview and record review, the facility failed to report witnessed resident to resident physical abuse to the State Agency for two (R809 and R810) of six resident reviewed for abuse who were physically abused by R808.

Inspectors wroteBased on observation, interview and record reviews the facility failed to adequately assess/monitor residents experiencing identified changes of condition, notify the Physicians of their continued decline and transfer the residents to higher levels of care in a timely manner, for four residents (R7, R97, R168 and R175) of four residents reviewed for changes in condition, resulting in R7 not being transferred to a higher level of care and expiring, R97 having a critically low hemoglobin level and expiring, R168 having to be transferred to the hospital and subsequently intubated and R175 contracting sepsis resulting in shock. These deficient practices resulted in the increased likelihood of serious harm, serious injury and/or death to occur.

Inspectors wroteThis citation pertains to intake #1194668. Based on record review and interview, the facility failed to purchase a surety bond in an amount equal to the current balance of personal funds held in the resident trust fund. This deficient practice has the potential to affect 82 resident's that have funds managed by the facility.

Inspectors wroteBased on observation, interview, and record review facility failed to maintain food service equipment based on professional standards for food service safety resulting in the potential to result in food borne illness among all residents who consume food/drinks from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to identify area of deficiency and maintain an effective quality assurance and performance improvement program (QAPI) for respiratory care, catheter care and residents experiencing changes in condition. This practice has the potential to affect all residents that reside in the facility.

Inspectors wroteThis citation pertains to intake #'s 1194664 and 1194670. Based on observation, interview and record review the facility failed to ensure residents received assistance with oral hygiene, incontinence care, bathing, and nail care for three (R8, R138, and R152) of seven residents reviewed for Activities of Daily Living (ADL).

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store and secure medications and biologicals in one of eight medication carts and one of four medication rooms observed for medication storage.

Inspectors wroteBased on observation, interview and record reviews the facility failed to ensure meals were maintained and served at a palatable temperature affecting multiple residents, including multiple residents from the confidential group interview, resulting in dissatisfaction with meals and the potential for nutritional decline.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were treated with dignity during nursing care for one resident (R59) out of two residents reviewed for dignity/respect.

Inspectors wroteBased on observation, interview, and record review facility failed to provide appropriate equipment (in a timely manner) for two residents (R176 & R177) of two residents reviewed for reasonable accommodation of needs. This deficient practice has the potential for accidents and improper care with feelings of frustration and dissatisfaction.

Inspectors wroteBased on interview and record review facility failed to follow up timely about the grievances expressed by the resident and follow their grievance process for one (R177) of one resident reviewed for grievances. This deficient practice has the potential for dissatisfaction and frustration with the care/services received during their stay at the facility.

Inspectors wroteThis citation pertains to intake #2572077Based on interview and record review the facility failed to thoroughly complete a discharge summary for two residents (R172 and R173) of five residents reviewed for discharges.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure timely interventions were implemented to prevent the development of two facility acquired pressure ulcers for one (R21) out of three residents reviewed for pressure sores/wounds.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that catheter orders and monitoring were in place for one resident (R174) of one resident reviewed for catheter care resulting in the potential for infection and other complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for two residents (R176 & R95) of three residents reviewed for respiratory care resulting in the potential for respiratory difficulties related to no orders for R176's Bi-level Positive Airway Pressure (BiPAP - a breathing aid/machine that helps people with breathing difficulties) and no orders for R95's tracheostomy care/speaking valve (a surgical procedure that creates an opening in the trachea/windpipe to allow for breathing and/or to remove secretions).

Inspectors wroteThis citation pertains to intake #1194668. Based on observation, interview, and record review, the facility failed to provide medically related social services related to discharge planning for one (R138) of one resident reviewed for social services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure routine dental services were provided for one resident (R18) of one resident reviewed for ancillary services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper infection control protocols and practices for implementation of enhanced barrier precautions (EBP) and transmission-based precautions (TBP) for two (R5 and R10) of three residents reviewed for infection control. This deficient practice has the likelihood to result in cross-contamination and the spread of infection and disease.

Inspectors wroteThis citation pertains to Intake Number(s): MI00152656 Based on interview and record review, the facility failed to report an allegation of misappropriation of resident property and the facility's investigation into the allegation to the State Agency within the required time frame for one (R802) of three residents reviewed for misappropriation of property.

Inspectors wroteThis citation pertains to Intake Number(s): MI00152656 Based on interview and record review, the facility failed to thoroughly investigate an allegation of misappropriation of resident property for one (R802) of three residents reviewed for misappropriation of property.

Inspectors wroteThis citation pertains to intake# MI00151103. Based on interview and record review, the facility failed to ensure incontinence care was provided in a timely manner for one resident (R905) of two residents reviewed for Bowel and Bladder.

Inspectors wroteThis citation pertains to Intake Number(s): MI00150901, MI00151135, MI00151140, MI00151161. Based on interview and record review, the facility failed to report multiple allegations of sexual abuse by a staff member to the Abuse Coordinator and/or State Survey Agency in a timely manner for one (R801) of four residents reviewed for abuse, and one unidentified resident, resulting in a delay in investigation and R801 exhibiting signs of fear and distress when a male Certified Nursing Assistant (CNA) regularly assigned to the unit continued working after the allegations were made.

Inspectors wroteThis citation pertains to intake: MI00147960 & MI00147915. Based on observation, interview and record reviews the facility failed to notify the family of R707 of a fall and notify both legal guardians for R706 of an accident that resulted in an injury, for two of three residents reviewed for an injury of unknown origin.

Inspectors wroteThis citation pertains to intake: MI00147960. Based on interview and record reviews the facility failed to coordinate effective discharge planning that met the needs and provided care giver support for one (R707) of two residents reviewed for discharges.

Inspectors wroteThis citation pertains to intake: MI00147759. Based on observation, interview and record reviews the facility failed to ensure staff consistently provided assistance with brief changes/toileting needs for one (R705) of three residents reviewed for Assistance of Daily Living.

Inspectors wroteThis citation has two deficient practices. Deficient Practice #1 This citation pertains to intake #MI00147354. Based on observation, interview, and record review, the facility failed to ensure resident's rights related to the appropriateness of placement on a locked, secured unit for one resident (R702) of three residents reviewed for resident's rights, resulting in feelings of frustration after being moved to a locked, secured unit.

Inspectors wroteThis citation has two deficient practices. Deficient practice #1 This citation pertains to Intake #MI00147275 Based on interview and record review the facility failed to ensure adequate staffing and proper bed mobility were provided to prevent a fall for one (R701) of four residents reviewed for falls.

Inspectors wroteThis citation pertains to Intake Number(s): MI00146327 and MI00146090. Based on interview and record review, the facility failed to report an allegation of neglect and multiple resident to resident abuse incidents to the Administrator and the State Agency for two (R507 and R501) of five residents reviewed for abuse and three unknown residents, resulting in the allegations not being investigated and the potential for unidentified and continued abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to interact with a resident in a dignified and respectful manner for one (R505) of two residents reviewed for dignity and respect.

Inspectors wroteThis citation pertains to Intake Number(s): MI00146090. Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse by staff and verbal abuse (as witnessed by R514) by a resident for two (R501 and R502) of five residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate multiple incidents of resident to resident abuse perpetrated by one (R501) of five residents reviewed for abuse, resulting in the potential for continued and unidentified abuse and the lack of identifying three victims to ensure their safety and well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program, resulting in the presence of gnats and flies (R26 and R102) throughout the facility and resident complaints. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteThis citation pertains to intake #MI00145602. Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment, affecting multiple residents throughout the facility.

Inspectors wroteThis citation has three deficient practices (DPS). DPS#1 Based on observation, interview and record review the facility failed to ensure a resident transfer was completed per the plan of care for one resident (R93) of six residents reviewed for accidents/hazards/supervision.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents were free of any significant medication errors for one (R70) of one resident reviewed for medication errors.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one (R395) of one resident reviewed for abuse, was free from misappropriation of their social security money when the money was rerouted to the facility without consent of the resident.

Inspectors wroteBased on interview, and record review, the facility failed to develop resident-specific comprehensive care plans for two (R137 and R246) of 29 residents reviewed for care plans, resulting in lack of identified mood, behavior, targeted symptoms and use of psychotropic medication for R137, and lack of hospice needs for (R246).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plan reviews were completed with the required interdisciplinary (IDT) team for two (R246 and R137) residents, and ensure the care plan was revised to reflect the current status of the resident's post-fall interventions for one (R26) of 29 residents reviewed for care plan revisions, resulting in the lack of opportunity for the Residents, their legal representatives, and/or family members to participate in the discussion of treatment options and decisions which pertained to their care, and direct care staff being unaware of changes in the resident's care needs following a fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activity of daily living care including timely brief change, associated peri-care and linen change for one (R29) resident of two residents reviewed for Activities of Daily Living (ADLs).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure narcotic medication for discharged resident (R445) was disposed of in a timely manner.

Inspectors wroteBased on interview and record review the facility failed to ensure a Physician ordered diagnostic (duplex scan) was obtained per the physician's order for one resident (R46) of one residents reviewed for radiology diagnostics.

Inspectors wroteBased on observation, interview and record review the facility failed to follow core infection control procedures for enhanced barrier precautions (EBP) for two residents (R93 and R297) of three residents reviewed for transmission based precautions.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective immunization program (for influenza and pneumonia) for two (R77 and R82) of five residents reviewed for vaccinations resulting in the potential for influenza and pneumonia infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure functional furniture (bed with working remote) was provided for one (R16) of 14 residents reviewed for the environment task, resulting in the potential loss of independence, dignity, and well-being due to poor positioning during meals.

Inspectors wroteThis citation pertains to Intake Number(s): MI00145377. Based on interview and record review, the facility failed to ensure two (R806 and R812) of three residents reviewed for abuse, were free from misappropriation of their money and property, resulting in a staff member electronically transferring $13.00 of R806's money to himself and $142.00 to an unknown person using a mobile payment service application, and the same staff member stealing R812's cellular phone.

Inspectors wroteThis citation pertains to Intake(s): MI00144759 & MI00144593. Based on observations, interviews, and record reviews the facility failed to implement measures/restrictions implemented by the County's health department after the identification of a facility resident diagnosed with presumptive healthcare associated Legionella (a type of bacteria that causes pneumonia), failed to timely and accurately conduct surveillance of the facility's infections, and failed to ensure water management meetings were being conducted as documented in the facility's policy for three residents (R705, R706 and R708) of six reviewed for infection control. This had the ability to also affect 140 of 140 residents that resided in the facility at the time of the survey, resulting in non-compliance with the local Health Department/County's Epidemiologist restrictions and the risk of growth and spread of Legionella. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain general repair and cleanliness of resident rooms, bathrooms, and common areas for all residents residing on 1st floor South unit, and 2nd floor North and South units, resulting in the potential for avoidable contamination and decrease in satisfaction of living.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure physician notification and follow-up for a resident with a change of condition for one (R701) of four residents reviewed for quality of care.

Inspectors wroteThis citation pertains to intake #MI00144187. Based on observation, interview, and record review, the facility failed to ensure treatment in a dignified manner for two residents (R#'s 506 and 510) of three residents reviewed for dignity, resulting in verbalized feelings of anger, embarrassment and disgust.

Inspectors wroteThis Citation is based on intake MI00143989. Based on interview and record review, the facility failed to (1) obtain authorization to manage personal funds, (2) properly manage a trust account, and (3) follow the policy provided by facility on personal funds and trust accounts for one resident(R500) reviewed for misappropriation of funds resulting in resident alleging stolen money.

Inspectors wroteThis citation pertains to intake #MI00144015. Based on observation, interview, and record review, the facility failed to properly care for percutaneous endoscopic gastrostomy (PEG) tubes (feeding tubes) for one resident (R#505), of two residents reviewed for PEG tubes.

Inspectors wroteThis citation pertains to intake #MI00144187. Based on observation, interview, and record review, the facility failed to appropriately implement enhanced barrier precautions (EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) and wear the required personal protective equipment (PPE) for resident's on EBP for two residents, (R#'s 505 and 509) of three residents reviewed for enhanced barrier precautions, resulting in the potential for the transmission of multidrug-resistant organisms.

Inspectors wroteThis citation pertains to intake # MI00143211. Based on interview and record review, the facility failed to notify and discuss a room change with a resident and their responsible party for one resident (R901) of one residents reviewed for room changes, resulting in R901 being moved to a new room without approval of the responsible party and the increased potential for transfer trauma.

Inspectors wroteThis citation pertains to intake # MI00143211. Based on interview and record review, the facility failed to provide a written copy of the bed-hold notification upon transfer to the hospital for one resident (R901) of one residents reviewed for transfers, resulting in R901 being discharged to the hospital without written notification of the bed-hold instructions and the potential for them to save their bed for return to the facility.

Inspectors wroteThis citation pertains to Intake MI00143384. Based on interview, and record review, the facility failed to ensure physician ordered diagnostic laboratory testing was completed for one resident (R902) of one resident reviewed for change of condition, resulting potential for unidentified infection.

Inspectors wroteThis citation pertains to intake #MI00142805. Based on interview and record review, the facility failed to ensure ongoing assessment and monitoring for one resident (R701) with a tracheostomy and a diagnoses of diabetes, of three residents reviewed for assessment and monitoring, resulting in the delay of identification of a change of condition including respiratory distress, decreased blood oxygen saturation levels, elevated blood pressure, and hyperglycemia requiring a transfer to the emergency room and placement in the intensive care unit.

Inspectors wroteThis citation pertains to intake #MI00141573. Based on observation, interview and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteThis citation pertains to intake #MI00140589. Based on observation and interview, the facility failed to provide a clean, comfortable, safe, and home-like environment for four residents (R601, R603, R607 and R618), in addition to multiple residents throughout the facility, resulting in unsanitary/unsafe conditions and lingering urine odors.

Inspectors wroteThis citation pertains to MI00139360 and MI00140459. Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one (R601) of 11 residents reviewed for abuse, resulting in multiple instances of misappropriation not being reported to the local police.

Inspectors wroteThis citation pertains to MI00139360 and MI00140459. Based on interview and record review, the facility failed to ensure the protection of residents and thoroughly investigate allegations of misappropriation for one (R601) of 11 residents reviewed for abuse, resulting in the potential for further misappropriation to occur and allegations not being thoroughly investigated.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents and visitors had access to previous survey results, resulting in residents and visitors being uninformed of deficiencies identified in the facility. This had the potential to affect all residents who resided in the facility.

Inspectors wroteR109 On 8/8/23 at 10:43 AM, R109 was observed asleep, laying in bed with a tube feeding pump that was next to the bed that was on and set to a rate of 76 Milliliters (ML) an hour. There was approximately 800 ML of the jevity tube feeding formula that remained in the container. Additionally, there was a suction machine stored on the bedside dresser. On 8/8/23 at 2:35 PM, R109 remained laying in bed in the same manner as observed earlier, with the same amount of tube feeding formula that remained in the container. The tube feeding pump was turned off. On 8/8/23 at 2:37 PM, R109's family (introduced as the resident's daughter, granddaughter and great-granddaughter) entered the room and woke the resident up. When asked about the resident's use of a tube feeding, the granddaughter reported R109 had some recent weight gain and further reported the resident was now on a pleasure tray. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and implement interventions to address changes in range in motion (ROM) for one (R42) of three residents reviewed for limited ROM, resulting in R42 developing contractures of the lower extremities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the exterior dumpster area in a sanitary manner. This deficient practice had the potential to affect all residents, staff and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an effective Quality Assurance & Performance Improvement (QAPI) program that identified systemic quality issues and implemented appropriate plans of action to correct quality deficiencies (R294) and maintain sustained compliance resulting in the potential to affect all residents that resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to eliminate harborage conditions to maintain an environment free from pests. This deficient practice had the potential to affect all residents, staff and visitors.

Inspectors wroteThis citation pertains to intake #s: MI00138275, MI00136994 and MI00138484. Based on observation, interview and record review, the facility failed to ensure multiple residents were treated in a dignified manner including two (R57 and R131) of four residents reviewed for dignity and failed to provide dignified dining (R9, R10, R58, R16, R72, R37, R51, R137 R60, R44, R84), resulting in the expressions of frustration, and the potential for decreased feelings of self-worth.

Inspectors wroteThis citation pertains to Intakes: MI00135989, MI00136742, and MI00138275. Based on observation, interview and record review, the facility failed to provide a clean, comfortable, safe and home-like environment to ensure that hallways, resident rooms, floors and other facility areas and equipment were clean and in good repair affecting multiple residents (Rs: 2,8, 27, 32, 34, 38, 48, 61, 64, 66, 80, 86, 101, 116, 121, and 341) throughout the facility, resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness and upkeep. This deficient practice had the potential to affect all residents that reside within the facility.

Inspectors wroteThis citation pertains to intake: MI00138275 This citation has two deficient practices. Deficient Practice #1: Based on observation, interview and record review the facility failed to ensure Physician orders for oxygen therapy were followed for one residents (R56) of three residents reviewed for respiratory care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident diagnosed with Post Traumatic Stress Disorder (PTSD) received care and services that accounted for experiences and identified and implemented interventions to mitigate triggers for one (R73) of one 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 the provider documented a rationale in the medication record for continuing a medication dosage identified as an irregularity by the consultant pharmacist and failed to address pharmacy recommendations for two (R78 and R166) of five residents reviewed for medication regimen reviews, resulting in the potential for adverse reactions and ineffective medications.

Inspectors wroteThis citation pertains to intake #MI00138215. Based on interview and record review, the facility failed to ensure antipsychotic medication orders were implemented as intended for one (R58) of five residents reviewed for unnecessary medications, resulting in the resident receiving an additional 1 Milligram (MG) of antipsychotic medication for over three months and the increased likelihood for serious adverse side-effects.

Inspectors wroteThis citation pertains to intake # MI00138275 Based on observation interview and record review, the facility failed to ensure a medication room was maintained in a safe/sanitary manner in one of two medication rooms reviewed.

Inspectors wroteBased on observation, interview, and record reviews the facility failed to consistently provide therapy services for one (R102) of three residents reviewed for rehab services.

Inspectors wroteBased on interview and record review the facility failed to ensure all evaluations/consultations were available for review in the medical record for one resident (R56) of one residents reviewed for medical records.

Inspectors wroteThis citation pertains to intake #s: MI00135989 and MI00136742. Based on observation, interview and record review, the facility failed to maintain ventilation exhaust systems on the first floor and second floor south units (including the rooms of R27,34,48,73,64,101 and141), resulting in strong, unpleasant fecal and urine odors affecting all residents and/or visitors that reside within those units, extending to the facility's front hallway and lobby area.

Inspectors wroteThis citation pertains to Intake #: MI00136638 Based on observation, interview, and record review, the facility failed to ensure a bed of appropriate length was provided for one resident (R56) of one residents reviewed for accommodation of needs.

Inspectors wroteThis citation pertains to intake: MI00136994. Based on observation, interview, and record review the facility failed to document care concerns and follow the facility's policy for concerns for one (R131) of one resident reviewed for grievances.

Inspectors wroteThis citation pertains to intake: MI00136994 and MI00138275. Based on observation, interview, and record review the facility failed to prevent verbal aggression and mistreatment for one (R131) of five residents reviewed for abuse.

Inspectors wroteThis citation pertains to Intake(s) MI00136561 and MI00136742 Based on observation, interview and record review the facility failed to timely report to the State Agency (SA) allegations of staff to resident physical abuse for one (R91) of nine residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed accurately and sent to local community mental health for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for one (R75) of three residents reviewed for PASARR assessments, resulting in the potential for unmet mental health treatment and services, and a decline in psychosocial well-being. Findings Include: R75 R75 was admitted to the facility on [DATE] after hospitalization. R75 was living in the community with their family prior to hospitalization. R75's admitting diagnoses included Chronic Obstructive Pulmonary Disease (COPD), diabetes, seizures, Dementia, and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan which addressed behaviors for one (R444) of 38 residents reviewed for care planning.

Inspectors wroteThis citation has two deficient practices Deficient Practice #1 Based on observation, interview and record review, the facility failed to ensure medications were available for administration and medications were prepared appropriately for three residents (R56, R6 and R107) of three residents reviewed for Nursing standards of practice.

Inspectors wroteThis citation pertains to intake #'s MI00135989, MI00138215, MI00138275, and MI00136638. Based on observation, interview and record review, the facility failed to ensure dependent residents were consistently provided with nail care for one (R42) of seven residents reviewed for Activities of Daily Living (ADL's). Findings Include: On 8/8/23 at 9:51 AM, R42 was observed lying in bed, her fingernails were noted to be approximately 3/4-1 inch in length. When asked if she wanted her nails that long, R42 explained she would like them shorter, but no one cut them for her. Review of the clinical record revealed R42 was admitted into the facility on 1/19/23 with diagnoses that included: dementia, rheumatoid arthritis and osteoarthritis. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure treatments for pressure ulcers were completed per Physicians orders for one resident (R93) of six residents reviewed for pressure ulcers.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop person-centered dementia care for one (R37) of four residents reviewed for dementia care, resulting in the potential for increased behaviors and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent when medication errors were observed from a total of 30 opportunities for two (R's 6 & 107) of five resident's observed for the medication administration task, resulting in a medication error rate of 50%.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent significant medication errors for two (R's 6 and 107) of five residents reviewed for the medication administration task.