Michaelsen Health Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's arms were positioned safely outside the sling during a transfer using a sit-to-stand mechanical lift. This failure resulted in the resident falling through the sling, sustaining a head injury that required five staples. This applies to 1 of 4 residents (R2) reviewed for mechanical lift transfer safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow policy on Contact Isolation on a resident with known history of Clostridium Difficile. The facility also failed to follow policy on EBP (Enhanced Barrier Protection). This applies to 16 of 16 residents (R4, R5, R8, R9, R16, R21, R39, R43, R48, R59, R64, R72, R73, R82, R95, R96) reviewed for Infection Control in the sample size of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medication regimens remain free from unnecessary medications. This applies to 1 resident (R81) reviewed for medication regimen in a sample of 20 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide timely and comprehensive pain and physical assessment after a fall. This delay resulted in R1 experiencing untreated prolonged pain for five hours from a fracture after a fall and a delay in treatment. This applies to 1 of 3 residents (R1) reviewed for fall-related incidents.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's emergency contact representative regarding a fall incident. The failure to notify placed the resident at risk for compromised advocacy and potentially delayed medical decision making. This applies to 1 of 3 (R1) residents reviewed for notification of significant medical change.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was rolled in a safe manner by two staff persons during incontinence care for 1 of 3 residents (R1) in the sample of 3 reviewed for safety and supervision. This failure resulted in R1 falling out of bed and sustaining fractures of her right and left femurs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for residents who require assistance from staff for ADLs. This applies to 4 of 4 residents (R11, R46, R52, R60) reviewed for ADLs in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were safely and securely stored. This applies to 4 of 4 residents (R61, R68, R137, R139) reviewed for medications in a sample size of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygeine and handled and transported soiled linen in a sanitary manner, and ensure visitors were educated on isolation practices. This applies to 6 of 6 residents (R50, R21, R56, R52, R58, R188) reviewed for infection control in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care with dignity to 3 of 3 residents (R21, R56, and R50) reviewed for resident rights in a sample of 23.

Inspectors wroteBased on observation and interview the facility failed to ensure a resident's mattress fit the bedframe to prevent injury. This applies to 1 of 6 residents (R334) reviewed for accidents in a sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly pharmacy recommendations were addressed. This applies to 2 of 5 residents (R21 and R51) reviewed for medication review in a sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to transcribe physician medication orders upon admission, which caused a resident to miss her significant medications for four days. This applies to 1 of 3 residents (R135) reviewed for significant medication errors in a sample of 23. Findings Include: On 12/17/2024 at 5:53 PM, V20 (R135's family member) said Eliquis (a blood thinner) and Atorvastatin medications were on R135's admission/transfer form and didn't know why it was not prescribed. V20 said R135 missed a total of eight doses, and the doctor should have been notified. V20 said R135 is [AGE] years old and has atrial fibrillation, mitral valve prolapse, and heart conditions with a pacemaker, and the missing Eliquis could have caused severe conditions. On 12/19/24 11:40 AM, R135 said the faicility failed to give her the Eliquis and cholesterol medication. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a resident's blood glucose level for sliding scale insulin administration prior to that resident eating a meal. This applies to 1 of 2 residents (R20) reviewed for glucose monitoring.

Inspectors wroteBased on interview and record review, the facility failed to administer intravenous (IV) antibiotics according to physician orders. This applies to 1 of 8 residents (R2) reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to perform monthly Medication Regimen Reviews (MRR) for residents residing in the facility. This applies to 4 of 7 (R2, R21, R34, and R42) reviewed for medication regimen review.

Inspectors wroteBased on observation and interview the facility failed to ensure a wound remained covered by a dressing as ordered by the physician. This applies to 1 of 3 (R1) residents reviewed for pressure ulcers in a sample of 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to monitor and document urine output for residents with an indwelling urinary catheter. This applies to 2 of 3 residents (R11 and R15) reviewed for indwelling urinary catheters in the sample of 22.

Inspectors wroteBased on Observation, Interview, and Record Review the Facility failed to have a Physician's order for oxygen administration in accordance with their policy. This applies to 1 of 1 (R1) resident reviewed for oxygen administration in a sample of 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify person-centered, non-pharmacological approaches for residents receiving psychotropic medications. The facility also failed to identify resident specific behaviors to monitor the response/effectiveness/side effects of psychotropic medications. This applies to 1 of 5 residents (R49) reviewed for psychotropic medications in the total sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a therapeutic diet as ordered by the physician. This applies to 3 of 3 (R5, R14, R45) residents reviewed for therapeutic diets in a sample of 22.