Inspection Reports for
The Cortland Wyoming

MCL 333.20178 Nursing home, home for the aged, or county medical care facility; description of services to patients or residents with Alzheimer's disease; staff training and continuing education practices: review of staff person’s employee records revealed there was no evidence of staff training on Alzheimer’s disease or related conditions.

R 325.1921 Governing bodies, administrators, and supervisors; protection: a staff member administered an insulin injection without washing hands or wearing gloves, not following facility policy.

R 325.1921 Governing bodies, administrators, and supervisors; protection: Resident D had a halo assistive device without a physician order or adequate service plan information as required by facility policy.

R 325.1932 Resident’s medications; service plan: Resident C’s service plan lacked detailed information on anxiety/agitation behaviors requiring medication administration and use of nonpharmaceutical interventions.

R 325.1931 Employees; general provisions: Resident I’s and Resident H’s service plans lacked clear direction on the type and schedule of promptings/reminders required.

R 325.1932 Resident’s medications; service plan: multiple residents’ service plans lacked information on who is responsible for medication administration.

R 325.1932 Resident’s medications; medication administration: Resident C was prescribed two pain medications with no instructions on administration priority or combination, risking harm due to staff discretion.

R 325.1932 Resident’s medications; medication availability: Resident H, J, and K did not receive prescribed Lorazepam on 03/03-03/04 due to medication unavailability.

R 325.1970 Water supply systems; hot water temperature: multiple resident rooms had water temperatures below 105 degrees or above 120 degrees Fahrenheit.

R 325.1976 Kitchen and dietary; food safety: the walk-in freezer contained opened, unsealed, and undated food items including chicken nuggets, corn bread, and pepperoni.

R 325.1932 Resident medications: staff did not notify Resident A’s physician when prescribed medications were refused.

R 325.1932 Resident medications: staff did not initial the medication administration log for Levothyroxine on 04/23 and 04/27.

R 325.1935 Bedding, linens, and clothing: Resident B was observed lying in bed with no clean linens, only a blanket, and the facility did not ensure linens were washed and the bed was appropriately changed.

R 325.1931 Employees; general provisions: Resident B is resistant to care and requires increased time of two staff members to provide care, but the service plan did not specify these care needs or frequency of checks.

R 325.1931 Employees; general provisions: the facility allowed Resident A to be left outside unattended without staff assistance, inconsistent with his service plan which did not outline the required supervision and assistance.

R 325.1975 Laundry and linen requirements: clean linen cart was stored next to a garbage can in the common area and clean linen storage contained items other than clean linens, posing a risk for cross contamination.

R 325.1976 Kitchen and dietary: work surfaces in the memory care unit kitchen were dirty, unclean, and not in good sanitary condition.

R 325.1976 Kitchen and dietary: incomplete and/or missing dishwasher sanitization records from February 2024 to June 2024 prevented determination if multi-use utensils were properly cleaned and sanitized.

R 325.1976 Kitchen and dietary: multiple food items in various kitchen areas were not dated and/or labeled with the open date, making it unclear if they were safe for consumption.

R 325.1979 General maintenance and storage: industrial cleaning materials, sodium chloride wound irrigation solution, and sharps were found unsecured and easily accessible in multiple common areas, posing a risk to residents with impaired cognition.

R 325.1931 Employees; general provisions: the facility did not provide appropriate care, supervision, or safety for Resident A in March 2023 resulting in Resident A eating dry hot chocolate mix causing a cough, and in April 2023 hospice documentation revealed Resident A’s heels were not floated consistently by facility staff.

R 325.1922 Admission and retention of residents: the facility was unable to provide a current and up to date service plan for Resident A when requested.

R 325.1921 Governing bodies, administrators, and supervisors: the facility failed to maintain an organized program to provide supervision, assistance, and supervised personal care for Resident A upon return from hospital and prior to being found unresponsive.

R 325.1931 Employees; general provisions: care staff did not provide appropriate assistance or supervision during Resident A's transfer, resulting in a fall and injury.

R 325.1913 Licenses and permits; general provisions: the facility did not notify the department within 5 business days of the administrator vacancy and role change.

R 325.1921 Governing bodies, administrators, and supervisors: the facility failed to appoint a competent administrator responsible for operating the home.

R 325.1942 Resident Records: the facility did not maintain current resident records with all entries dated and signed; records were incomplete and limited.

R 325.1921 Governing bodies, administrators, and supervisors: the home failed to maintain an organized program of protection as Resident A had her blood drawn on 5/15/23 without a physician’s order and in a common area where others could observe.