Mymichigan Skilled Nursing Facility

Inspectors wroteBased on observation, 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 existing and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate indications for use of chemical restraints for 5 residents (Residents #4, #11, #12, #17 and #23), of 12 residents reviewed for chemical restraints, resulting in, decreased communication between professional staff, the protentional for unmet resident needs, care not tailored toward residents' needs, and sedation with falls. Findings Include: Review of the facility Behavior Management Monitoring Policy and Procedure last reviewed on 4/2025, stated The Behavioral Management Committee (BMC) shall monitor weekly and more frequently as needed: use of psychoactive medications and for potential to reduce/eliminate psychoactive medications. The BMC will seek to determine if there is justification for the initiation of psychoactive medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure that informed consent was obtained prior to initiation of psychotropic medications for one resident (Resident #2) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a restorative nursing program and ensure coordination with therapy services for one resident (Resident #6) of one resident reviewed for limited Range of Motion (ROM).

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring for the presence of potential adverse consequences of anticoagulation medication therapy for one resident (Resident #6) of two residents reviewed for anticoagulation medication therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication administration error rate of less than 5% when two medication errors were observed for two residents (Resident #7 and Resident #16) from a total of 32 observations, resulting in a medication error rate of 6.25%.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a call bell communication device was responded to for two residents (#9, #72), of 22 sampled residents, resulting in Resident #9 and #72 being seated in the dining room with a silver metal service bell which was rung with no response from facility staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide for safe wheelchair transport for two residents (#7 and 17) of two residents reviewed, resulting in residents being pushed in wheelchairs without footrests and the potential for injury.

Inspectors wroteBased on interview and record review, the facility failed to implement and operationalize policies and procedures for psychotropic medication use for one resident (Resident # 7) of five residents reviewed resulting in a lack of appropriate diagnoses and indications for treatment, a lack of Gradual Dose Reductions (GDR), and the potential for ineffective and inappropriate treatment.

Inspectors wroteBased on observation, interview and record review, the facility Failed to 1) Ensure that kitchen food items are dated with received by dates and use by dates and 2) Ensure that foods brought into the facility from family are dated, resulting in an increased likelihood for food borne illness with the potential to affect 22 Residents residing at the facility who consumed oral nutrition from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development of facility-acquired pressure ulcer injuries for one resident (Resident #8), resulting in facility-acquired (in-house) development of pressure ulcers, pain, discomfort, and the likelihood for prolonged illness or hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for fall prevention for one resident (Resident #6) of five residents reviewed, resulting in a lack of implementation of Physical Therapy recommendations, lack of enactment and reevaluation of planned care plan interventions, and Resident #6 experiencing a fall with a head laceration necessitating emergency medical treatment, staples, unnecessary pain, and the likelihood for additional falls with injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to label food items with Use by dates, resulting in an increased likelihood for food borne illness with hospitalization and potentially affecting all 24 residents who consume oral nutrition from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to operationalize policies and procedures to ensure that appropriate notification of a resident's condition, per the resident's request, for one resident (Resident #6) of one resident reviewed, resulting in the potential for inappropriate and undesired communication of private healthcare information and a breach in confidentiality.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure sanitary storage of respiratory and oxygen equipment, oxygen administration per Health Care Provider (HCP) order, and comprehensive respiratory care planning for two residents (Resident #12 and Resident #16) of two residents reviewed, resulting in the likelihood for unmet respiratory needs, illness, and a decline in overall health status.

Inspectors wroteBased on interview and record review, the facility failed to implement and operationalize policies and procedures for psychotropic medication management for two residents (Resident #6 and Resident #16) of five residents reviewed, resulting in a lack of a 14-day evaluation and stop date for as needed (PRN) psychotropic medications, lack of documentation of consent for use, and the potential for unnecessary psychoactive medication utilization and adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure clinical staff posting of licensed and un-licensed staff was completed daily and posted with accurate and complete data, resulting in the inability for residents and visitors to know what clinical staff were working on those days.

Inspectors wroteThis Citation pertains to Intake Number MI00140583. Based on observation, interview and record review, the facility failed to ensure necessary supervision for one resident (Resident #101), who was left in the dining room unsupervised with a hot cup of coffee, which did not have a lid on it. The resident spilled the hot coffee on her lower abdomen and upper thigh area, resulting in first and second degree burns, pain, wound care and prolonged healing time. Findings Include: Resident #101: [...]