Qualicare Nursing Home

Inspectors wroteThis citation pertains to Intake 3065458. Based on observation, interview and record review, the facility failed to ensure podiatry care was provided to one (R101) of three residents reviewed for foot care.

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 to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 02/24/2026 at 10:02 AM, observation of the kitchen found a faucet on the back wall of the cookline. When the cold and hot handles were turned no water came out, Certified Dietary Manager (CDM) B stated it is not used by kitchen staff. On 02/24/2026 at 10:45 AM, observation of the first-floor tub room revealed a domestic water fixture above the tub faucet. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living, affecting all residents. Findings Include:On 02/24/2026 at 10:35 AM, the Kitchen Supervisor (KS) C was observed draining sanitizer from the three-compartment sink. As the sink drained, the discharge pipe began dripping onto the floor. At this time an interview conducted with Certified Dietary Manager (CDM) B revealed that they were aware of the problem and had entered it into the maintenance repair system. When asked how long the issue had been documented in the system, no answer was provided. On 02/24/2026 at 10:53 AM, observation of the first-floor biohazard room found that the foot pedals that activate the sink faucet leaked when engaged. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure timely follow-up of a PASSAR referral and level II evaluation for one resident (R13) of two residents reviewed for PASSAR requirements. This failure placed (R13) at risk for not receiving specialized services and supports recommended for individuals with serious mental illness or cognitive impairment.

Inspectors wroteThis citation pertains to intake 2561232. Based on interview and record review the facility failed to timely and appropriately assess a new onset leg pain for one Resident (R901) of three residents reviewed for quality of care, resulting in R901 experiencing prolonged signs and symptoms of severe pain with subsequent hospitalization to address the pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (R12) of two residents reviewed for dignity were aided with eating in a dignified manner, resulting in the potential for feelings of discomfort while eating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident and/or legal representative formulated an Advance Directive to grant and/or withhold life sustaining treatment (Cardiopulmonary Resuscitation/CPR, Artificial Nutrition/Peg Tube, Artificial Hydration/ IV, and Diagnostic Testing) according to their wishes upon admission for two residents (R45 and R55) of four residents reviewed for advance directives, potentially resulting in inaccurate life sustaining or life withholding medical treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that one resident's (R73) medications were properly stored during medication administration of three residents reviewed for medication pass.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that one resident (R73) of reviewed during medication administration medications were properly stored.

Inspectors wroteThis citation pertains to intake MI00145673. Based on interview and record review the facility failed to provide adequate supervision for one resident (R903) out one resident reviewed for elopement, resulting in the resident leaving the facility, unbeknownst to staff, for six and a half hours. Findings Include: Record review of R903's electronic medical records (EMR) revealed admission into the facility on 7/2/24 with a diagnosis of a pneumothorax (collapsed lung). According to the Brief Interview for Mental Status (BIMS) dated 7/9/24, R903 had intact cognition with a score of 15 out of 15. Record review of R903's Progress Notes dated 7/13/24 at 10:05 AM, Note Text: this writer was approached by physical therapist stating he was unable to locate resident to perform therapy services. writer checked room and resident was not in his room. [...]

Inspectors wroteThis citation pertains to intakes MI00143423 and MI00144201. Based on observation, interview, and record review, the facility failed to prevent verbal abuse for one (R801) of four residents reviewed for abuse resulting in feelings of anger.

Inspectors wroteBased on interview and record review the facility failed to update a PASSAR (Preadmission Screening/ Annal Resident Review) Level 1 Screening form for one resident (R7) of two residents reviewed for PASSARs, resulting in the potential for the resident to not be screened for the need of mental health services.

Inspectors wroteThis citation pertains to Intake MI00138460. Based on interview and record review, the facility failed to provide showers for one resident (R101) out of 4 residents reviewed for ADL (Activities of Daily Living) care.

Inspectors wroteThis citation pertains to Intake MI00138460. Based on interview and record review, the facility failed initiate a wound consult order in a timely manner for one resident (R101) out of five residents reviewed for pressure ulcers, resulting in the potential in delayed treatment of a pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative services as ordered to maintain range of motion (ROM), and mobility for one resident (R22) of nine residents reviewed for range of motion, resulting in the potential for a decline in range of motion, and mobility.

Inspectors wroteThis citation pertains to Intake MI00142235. Based on interview and record review, the facility failed to provide indwelling catheter (tube inserted into the bladder to assist with urination) care and document urine out put for one resident (R100) out of three people reviewed for catheters.

Inspectors wroteBased on interview and record review, the facility failed to consistently weigh and document weights for four consecutive weeks for one resident (R95) of three residents reviewed for nutrition/weights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage of nasal cannula tubing for one resident (R8) out of two residents reviewed for respiratory care, and cover a linen cart during transport resulting in the potential for cross-contamination.