Memory Lane of Dexter

Inspectors wroteBased on interview and record review, the facility failed to notify three residents (Residents #25, #34, and #36) out of 16 sampled residents and/or the responsible parties of the resident fund balances remaining above $6,068.80 (the limit which should trigger a notification when the amount in the resident's account reached $200 of the Supplemental Security Income (SSI) resource limit) for the months of February 2026 through April 2026. The facility census was 63. Review of the facility's policy titled, Deposit of Resident Funds, revised 2021, showed:- Resident personal funds that are held and managed by the facility will be safeguarded;- Should the resident permit the facility to hold, safeguard, and manage his/her personal funds, the facility will:a. deposit funds in excess of 50 dollars into an interest bearing account separate from facility operating funds;b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate incontinent care for two residents (Residents #48 and #58) out of three sampled residents. The facility census was 63. Review of the facility's policy titled, Perineal Care, dated February 2018, showed:- Wash the perineal area, wiping from front to back. Continue to wash the perineummoving from inside outwards to the thighs; - Wash the rectal area thoroughly, wiping from the base of the perineum andextending over the buttocks. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 63. Review of the facility's policy titled, Sanitation, revised November 2022, showed:- The food service area is maintained in a clean and sanitary manner;- All kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects;- All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning;- Ice machines and ice storage containers are drained, cleaned and sanitized per manufacturer's instructions. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents (Residents #7 and #19) out of five sampled residents received the pneumococcal (an infection caused by a common type of bacteria) immunization after the resident and/or the resident's representative received the education and signed the consent form for the pneumococcal immunization administration. The facility census was 63. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility's census was 64. Review of the facility's policy titled, Refrigerators and Freezers, revised November 2022, showed: - This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines; - Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes on packaging. [...]

Inspectors wroteBased on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for four residents (Residents #2, #3, #30, and #33) out of five sampled residents. The facility's census was 64. Review of the facility's policy titled, Tapering Medications and Gradual Dose Reduction, revised July 2022, showed: - After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences; - Residents who use psychotropic (medications that affect the mind, emotions, and behavior) medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 29 opportunities with two errors made, for an error rate of 6.9%, which affected two residents (Resident #30 and #267) out of two sampled residents. The facility's census was 64. Review of the facility's policy titled, Insulin Administration, revised September 2014, showed: - The type of insulin, dosage requirements, strength, and method of administration must be verified before administration; - The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery systems prior to their use. Review of the lispro KwikPen (insulin in a pen-type device) manufacturer instructions for use, revised July 2023, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program. This had the potential to affect all residents in the facility. The facility's census was 64. Review of the facility's policy titled, Pest Control, revised May 2008, showed: - Our facility shall maintain an effective pest control program; - This facility maintains an on-going pest control program to ensure that the building is kept free of insects. Observation on 01/15/25 at 9:15 A.M. of the dry goods storage room showed: - Multiple gnats crawling on the floor between the kitchen and dry goods storage room; - Numerous gnats flying around the dry goods storage room and crawling on the floor; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 47. Review of the facility's policy titled, Deep Cleaning Schedule, undated, showed: - Deep clean the stove/oven including grease trap on Monday; - Deep clean the convection oven on Tuesday; - Deep clean the refrigerator/freezers, wipe out/ throw expired food out on Wednesday; - Deep clean the toaster on Thursday; - Deep clean the counters (all counters need to be cleared wipe down and cookware replaced inverted) on Friday; - Deep clean the coffee maker on Saturday; - Deep clean the sinks and throw expired food out Sunday; - The policy did not address cleaning of the floors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in nine occupied resident room sinks which put 19 residents on the male memory care unit at an increased risk of injuries from exposure to the hot water. The facility census was 47. Review of the facility's, Safety of Water Temperature Policy, dated 2009, showed: - Tap water in the facility shall be kept within a temperature range to prevent scalding of residents; - Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than blank degrees F, or the maximum allowable temperature per state regulation; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident and/or representative received a written summary of the baseline care plan for three sampled residents (Resident #47, #100, and #201) out of three sampled residents. The facility census was 47. Review of the facility's policy titled, Baseline Care Plan, dated March 2022, showed: - A baseline plan of care is to meet the resident's immediate health and safety needs and is developed for each resident within 48 hours of admission; - The baseline care plan includes instructions needed to provide effective, person-centered care of the resident; - The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control practices during medication administration for one resident (Resident #3) out of six sampled residents, while passing cups during the meal time, and during incontinent care for one resident (Resident #29) out of three sampled residents. The facility failed to implement a risk management process specific to Legionella disease (a serious type of pneumonia caused by Legionella bacteria) which had the potential to affect all residents, staff, and the public. The facility's census was 47. Review of the facility's policy titled, Administering Medication, dated April 2019, showed: - Medications are administered in a safe and timely manner, and as prescribed; - Staff follows established facility infection control procedures for the administration of medications, as applicable. 1. [...]