The Lodge at Taylor

Inspectors wroteThis citation pertains to intake 2602236. Based on observation, interview and record review the facility failed to ensure safe maintenance of shower gurneys, as four out five were observed to be missing safety pins required to secure the side rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call button was within reach for one resident (R102) reviewed for call light access.

Inspectors wroteBased on observation, interview, and record review, the facility failed to demonstrate professional standards of practice by not securing a physician's order and properly documenting wound care for one resident (R102) out of three residents reviewed for wound care.

Inspectors wroteThis citation pertains to MI000151505. Based on observation, interview, and record review the facility failed to implement adequate interventions and supervision to prevent multiple falls for one (R103) of three residents reviewed for accidents, resulting in injuries and hospital visits.

Inspectors wroteBased on observation, interview and record review, the facility failed to act promptly on a consistent grievance received from residents at ten consecutive monthly Resident Council Meetings resulting in residents not having water passed to them on a regular basis and feelings of frustration due to not having their needs met.

Inspectors wroteBased on observation and interview, the facility failed to maintain the over-bed tables in 7 resident rooms (#'s B4, C2, E4, G2, I11, I12, and J9).

Inspectors wroteBased on interview and record review the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms DCH-3877 and/or DCH-3878 documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for mental illness needs upon admission for two (R44 and R86) of four residents reviewed for PAS/ARRs, resulting in the potential for residents not to receive care and services appropriate to their mental health needs.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered and failed to notify the physician of missed doses for one resident (R250) out of five residents reviewed for medications.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate foot care for one resident (R32) out of four residents reviewed for Activities of Daily Living (ADLS).

Inspectors wroteBased on interview and record review the facility failed to effectively communicate with a dialysis provider for one resident (R250) out of three residents requiring dialysis services, resulting in seven doses of antibiotics that were not administered as ordered by a physician.

Inspectors wroteBased on observation, interview and record review the facility failed to apply a barrier while administering medications for one resident (R15) out of four residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a bathroom call light was in working order for one (R1) of two residents reviewed for environment resulting in call light not answered in a timely manner, unmet care needs, and the potential delay in responding to emergency situations.

Inspectors wroteBased on observation, interview and record review the facility failed to perform proper hand hygiene and gloving during wound care for one resident (R205) out of three residents reviewed for infection control practices.

Inspectors wroteThis citation pertains to intake number MI00145631. Based on observation, interview, and record review the facility failed to include one resident (R501) on the podiatrist list out of three residents reviewed for Activities of Daily Living (ADLS), resulting in R501 having overgrown toenails and resident dissatisfaction with foot care.

Inspectors wroteThis citation pertains to intake MI00145907 and MI00146790. Based on observation, interview, and record review, the facility failed to ensure tube feeding (liquid nutrition) was administered in accordance to physician's orders for one (R510) of four residents reviewed for tube feeding resulting in R510's tube feeding being on hold for an undetermined amount of time, the amount of tube feeding administered being less than prescribed, and the potential for the resident to have insufficient nutrition, hydration, and weight loss.

Inspectors wroteThis citation pertains to intake MI00146210. Based on observation, interview, and record review, the facility failed to ensure appropriate tracheostomy (surgical opening created in the front of the neck into the trachea to help oxygen reach the lungs) care was provided to one of three residents (R510) reviewed for tracheostomy care resulting in R510 not receiving the prescribed amount of humidified oxygen due to unaddressed malfunctioning humidification equipment with the potential for respiratory complications.

Inspectors wroteThis citation pertains to Intake number MI00145631. Based on interview and record review the facility failed to provide Occupational Therapy (OT) sessions as ordered for one (R501) of three residents reviewed for physical rehab, resulting in missed therapy sessions and resident dissatisfaction.

Inspectors wroteThis citation pertains to intake MI00145597. Based on interview and record review, the facility failed to implement interventions for a hypoglycemia (blood glucose/sugar) for one resident (R103) out of three residents reviewed for change in condition, resulting in R103 being hospitalized for hypoglycemia.

Inspectors wroteThis citation pertains to intake MI00145283. Based on interview and record review, the facility failed to provide accurate resident identifying documents and medical records upon emergent transfer to the hospital for one resident (R101) of three residents reviewed for emergency transfer, resulting in resident identification and medical information not being sent with EMS (Emergency Medical Service) personnel to the hospital and the potential for unmet care needs upon transfer.

Inspectors wroteThis citation pertains to intake number MI00144256. Based on interview and record review, the facility failed to immediately report an allegation of sexual abuse for two residents (R601and R603) of three residents reviewed for abuse, resulting in unreported allegations of abuse and the potential for further allegations of abuse to go unreported.

Inspectors wroteThis citation pertains to Intake MI00143341. Based on interview and record review, the facility failed to implement adequate interventions in a timely manner for one resident (R103) deemed to be at very high risk for pressure ulcers out of five residents reviewed for wound care, resulting in the worsening of an existing stage 4 pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and report abnormally elevated blood sugar levels as ordered for one resident (R103) out of three residents reviewed for diabetes mellitus management, resulting in the physician not having the opportunity to timely participate in medical decisions regarding care and treatment.

Inspectors wroteThis citation pertains to Intake MI00143095. Based on interview and record review, the facility failed to ensure a physician's assessment accurately reflected current diabetes mellitus status for one resident (R102) out of three residents reviewed for blood sugar management, resulting in the potential for delayed execution of appropriate medical treatments and medical needs.

Inspectors wroteThis citation pertains to intake MI00142154. Based on observation, interview, and record review the facility failed to transcribe an order for oxygen administration and pulse oximeter monitoring (measures the saturation of oxygen carried in red blood cells- 90% -100% is considered normal) for one resident (R102) reviewed for oxygen.

Inspectors wroteThis citation pertains to intake MI00142154. Based on observation, interview, and record review the facility failed to store prescription medications in a safe, secure manner for two (R102 and R103) of four residents reviewed for medication administration when medications were left at the resident's bedside.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow professional standards of practice for medication administration through a PEG tube (flexible tube surgically inserted through the abdomen into the stomach for nutrition/medication administration) for one of one resident (R8) when PEG tube placement/Residual was not verified prior to medication administration resulting in the potential for medications not properly administered and medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to correctly identify or assess and monitor a biliary tube (a flexible tube surgically inserted into the gallbladder through the abdomen) for one resident (R86) resulting in discomfort and the potential for dislodgement, blockage, or backflow of drainage into the gallbladder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently monitor the Suprapubic (S/P) catheter (catheter inserted into the bladder through a small incision in the abdomen) and accurately document output for one resident (R15) out of five reviewed for catheter care, resulting in a potential delay in the detection of a urinary tract infection and other unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper storage of insulin, date medications as recommended and dispose of expired medications in three of five medication carts reviewed during inspection of medication carts, resulting in the potential for residents to receive expired medications with altered potency and efficacy.