Mymichigan Medical Center Sault

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively monitor for progression of a Stage IV pressure injury (full-thickness tissue loss with exposed muscle, bone, tendon or cartilage exposed) for one Resident (#21) of two residents reviewed for pressure injuries. This deficient practice resulted in unidentified worsening of the wound with infection requiring debridement and intravenous (IV) drug therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by:Failing to ensure labeling of food. Failing to ensure expired food was discarded. Failing to ensure proper hand sanitization when preparing food. This deficient practice had the potential to result in food borne illness among any or all 35 residents in the facility who receive meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure COVID 19 vaccinations were offered to five Residents (#1, #3, #7, #21, & #25) of five residents reviewed for COVID 19 vaccinations resulting in the potential for serious respiratory illness. Resident #1 (R1)Review of the Minimum Data Set (MDS) assessment, dated 12/10/2025, revealed R1 was admitted to the facility on [DATE]. Review of R1's electronic medical record (EMR) revealed no documentation indicating the Resident was offered and/or received/declined the current 2025-26 Covid-19 vaccination. Further review of the EMR revealed the most recent documentation was a signed declination for the 2024-25 Covid-19 vaccination, dated 10/10/2024. Resident #3 (R3)Review of the MDS assessment, dated 12/02/2025, revealed R3 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform an assessment for self-administration of medication for one Resident (#5) of one resident reviewed for self-administration of medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents or resident's representatives were provided with written notification of transfer and/or the facility's bed hold policy at the time of transfer out of the facility or anytime thereafter for two Residents (#1 and #3) of three residents reviewed for hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the needs of a resident coping with verbal and physical abuse, provide emotional support from social services, obtain outside referral services, and develop and implement a comprehensive care plan for one Resident #5 (R5) of one resident reviewed for social services and referral services. This deficient practice resulted in harm which affected R5's psychosocial wellbeing with statements of physical and verbal abuse from her son and a verbalization of feeling scared. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely review and follow-up for pharmacy recommendations for two Residents (#1 and #2) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective antibiotic stewardship program affecting one Resident (#29) of one resident reviewed for antibiotic use. This deficient practice resulted in the potential for the administration of unnecessary medication and antibiotic resistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents right to be free from abuse for two Residents (R10 and R11) of four residents reviewed for sexual abuse, resulting in the potential for psychosocial harm including feelings of humiliation and fear based on a reasonable person standard.

Inspectors wroteThis citation pertains to intake MI00150095. Based on observation, interview and record review, the facility failed to follow care planned interventions to ensure staff performed safe transfers for two Residents (#1 and #3) of four residents reviewed. This deficient practice resulted in actual harm when Resident #1 experienced a fall resulting in a right femur fracture and subsequently required surgical intervention and pain.

Inspectors wroteThis citation pertains to MI00149861 Based on interview and record review, the facility failed to notify the state agency of a resident-to-resident sexual abuse allegation to the state agency for two Residents (#1 and #3) of four Residents reviewed for abuse. This deficient practice resulted in the potential for sexual abuse abuse.

Inspectors wroteThis citation pertains to MI00149861 Based on interview and record review, the facility failed to ensure care plans were updated promptly and revised appropriately for two Residents (#1 and #3) of four residents reviewed for care plans. This deficient practice resulted in care plans which did not reflect resident needs.

Inspectors wroteThis Citation Pertains to Intake Number MI00149462. Based on interview and record review the facility failed to ensure a complete and thorough investigation was completed on an incident of potential abuse involving two Residents (#30 and #31) out of three Residents reviewed for abuse. This deficient practice resulted in the potential for undetected abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failing to ensure that food items were kept free from contamination due to improper storage or due to potential thawing and refreezing. B. Failing to properly clean and sanitize dishes and utensils. C. Failing to ensure food preparation surfaces in the dietary department were properly sanitized. D. Failing to ensure that food items were dated and discarded on or before the expiration date. This deficient practice had the potential to result in food borne illness among any or all 35 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Quality Assurance and Performance Improvement (QAPI) program committee was composed of the required committee members. This deficient practice resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues placing all 35 residents of the facility at risk for quality care concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dining adaptive equipment for four Residents (#26, #23, #3, and #24) of 6 residents reviewed for dining assistive devices. This deficient practice resulted in increased difficulty with food consumption and independent eating, as well as the potential for decreased food/fluid intake and risk for weight loss.

Inspectors wroteResident #1 (R1) Review of R1's EMR progress notes revealed R1 was transferred to the emergency department on 7/29/2024 and admitted to the hospital with discharge back to the facility on 8/01/2024. Further review of R1's EMR revealed no documentation of notification of transfer or discharge was provided to R1 or their representative. Review of the July 2024 transfer and discharge list provided to the Long-Term Care Ombudsman revealed R1's transfer and hospitalization was not included on the list. Review of the facility policy titled, Transfer (Internal and External) and Discharge, last revised 9/2023, revealed the following: Purpose: To ensure residents are appropriately transferred or discharged from the LTC [Long Term Care] . [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the bed-hold policy to residents or their representatives prior to a hospital transfer for two Residents (#16 and #1) of two residents reviewed for hospital transfers.

Inspectors wroteBased on observation, interview and record review, the facility failed to physically assess an acute change in condition and failed to timely identify and treat constipation for one Resident (#18) of one resident reviewed for change in condition, resulting in abdominal discomfort, nausea, and the potential for worsening of medical condition and complications of constipation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate feeding assistance for one Resident (#20) of one resident reviewed for nutrition, resulting in the potential for decreased intake and weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a medication error rate less than five percent for 1 Resident of 4 residents reviewed for medication administration, resulting in 2 observed medication errors out of 25 opportunities, and a medication error rate of eight percent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure therapeutic diets were served as prescribed for three Residents (#14, #26, and #34) of six residents reviewed for therapeutic diets. This deficient practice resulted in the potential for health complications and contributed to an inability for residents to meet their goals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the use of enhanced barrier precautions (EBP) during wound care according to the physician's order and current standards of practice for one Resident (#15) of two residents reviewed for wound care, resulting in the potential for the spread of multidrug-resistant organisms (MDROs).

Inspectors wroteDuring an interview on 10/17/23 at 4:10 PM, R33 stated he got a cold but I'm almost over it. R33 remarked his roommate also was sick and was sleeping during the day which was unusual. R33 stated many residents seemed to be sick. This Citation will have two deficient practice statements: A and B. A. Based on observation, interview, and record review, the facility failed to establish and maintain a complete infection control program to prevent, identify, report, investigate, and control the spread of infections and communicable diseases based on accepted national standards. This deficient practice resulted in an unidentified facility-wide outbreak of COVID-19 that affected 25 of 34 facility residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently employ the services of an Infection Preventionist (IP) who completed specialized training in infection prevention and control and was responsible for the facility's infection control program. This deficient practice resulted in an unidentified outbreak of COVID-19 with the potential to affect all 34 vulnerable residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to honor resident food preferences for 5 of 6 residents (R6, R13, R15, R18 and R26) reviewed for nutritional services. This deficient practice resulted in decreased meal enjoyment and the potential for weight loss and nutritional decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate catheter care to prevent urinary tract infections for two Residents (R12 and R27) out of two residents reviewed for catheter care. This deficient practice resulted in the potential for urinary tract infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to recognize, address, and evaluate the fluid needs of one resident (R15) out of six residents reviewed for nutritional status. This deficient practice resulted in the potential for fluid overload and medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dining adaptive equipment for two Residents (R15 and R17) of three residents reviewed for dining assistive devices. This deficient practice resulted in increased difficulty with food consumption and independent eating, as well as the potential for decreased food/fluid intake and risk for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete and post the daily nurse staffing information at the beginning of each shift. This deficient practice resulted in the inability of residents and visitors to determine the number of staff available to provide resident care and had the potential to affect all 34 residents in the facility.