7 Reports
Inspection Report — Jul 13, 2026
Complaint Investigation
Date: Jul 13, 2026
Visit Reason
Investigation of a complaint received on 2026-07-09 about wound care.
Complaint Details
Wound care was not provided: established. Additional findings: not established.
Findings
One rule violation was established related to failure to provide and document wound care for Resident C.
Deficiencies (1)
R 325.1921 Governing bodies, administrators, and supervisors: the facility failed to ensure protection and safety of Resident C by not providing and documenting wound care as prescribed.
Report Facts
Corrective action plan due: 15
Inspection Report — Jul 9, 2026
Complaint Investigation
Date: Jul 9, 2026
Visit Reason
Investigation of a complaint received on 07/09/2026 about Resident A not being cared for.
Complaint Details
Resident A is not cared for: not established. Additional findings: service plan omitted specific care needs — established.
Findings
One rule violation was established related to the omission of specific care needs in Resident A's service plan. The allegation that Resident A was not cared for was not established.
Deficiencies (1)
R 325.1931 Employees; general provisions: review of Resident A’s service plan revealed the service plan omitted specific care needs that Resident A required.
Report Facts
Corrective action plan due: 15
Inspection Report — Dec 23, 2024
Complaint Investigation
Date: Dec 23, 2024
Visit Reason
Investigation of a complaint received on 2024-12-23 about Resident A being left unattended and having bed sores due to staff not assisting.
Complaint Details
Resident A left unattended in dining room: not established. Additional findings: not established.
Findings
No violations were found; the allegation that Resident A was left unattended and had bed sores was not established.
Inspection Report — Sep 16, 2024
Complaint Investigation
Date: Sep 16, 2024
Visit Reason
Investigation of a complaint received on 2024-09-11 about resident neglect, soiled linen storage, and shower leaks.
Complaint Details
Resident A neglected: not established. Resident B neglected: not established. Soiled linen and trash are kept in shower room: established. Shower leaks and floor is wet: not established. Additional findings: service plan not updated — established.
Findings
Two rule violations were established related to storage of soiled linen and trash in the shower room and failure to update a resident's service plan. Three allegations of resident neglect and shower leaks were not established.
Deficiencies (2)
R 325.1968 Toilet and bathing facilities: the shower room was used for storage and housekeeping functions, including a trash bin and a clean linen cart blocking the shower.
R 325.1922 Admission and retention of residents: Resident B’s service plan was not updated to correctly reflect his care needs, including feeding and repositioning requirements.
Report Facts
Corrective action plan due: 15
Inspection Report — Feb 28, 2024
Renewal
Date: Feb 28, 2024
Visit Reason
License renewal notice; no inspection report attached. Administrative review without an on-site visit.
Findings
The license was renewed following an administrative review that revealed substantial compliance with applicable rules.
Report Facts
License length: 12
Inspection Report — Sep 22, 2023
Complaint Investigation
Date: Sep 22, 2023
Visit Reason
Investigation of a complaint received on 2023-09-21 about medication administration and meal service.
Complaint Details
Residents have not been getting their prescribed medications: not established. Residents are served meals that are cold and late: established.
Findings
One rule violation was established regarding meals being served cold and late. The medication administration allegation was not substantiated.
Deficiencies (1)
R 325.1952 Meals and special diets: meals were delivered to resident rooms on unheated, open carts causing the meals to lose temperature and be served cold and late.
Report Facts
Corrective action plan due: 15
Inspection Report — Aug 30, 2022
Original Licensing
Date: Aug 30, 2022
Visit Reason
Original license application for a home for the aged.
Findings
Medilodge of Grand Rapids home for the aged is in full compliance with applicable licensing act and administrative rules.
Report Facts
License term length: 6
12 CMS Surveys
Inspection Report — Jun 4, 2025
Complaint Investigation
Date: Jun 4, 2025
Visit Reason
Investigation of a complaint received on 2025-06-02 about medication administration, feeding tube care, staffing, mental health treatment, food safety, and quality assurance.
Complaint Details
Medication administration via feeding tube: violation established. Feeding tube care and head of bed elevation: violation established. Staffing insufficiency and delayed call light response: violation established. Mental health treatment and suicide prevention for resident #25: violation established. Food safety and sanitation violations: violation established. Quality assurance failures related to staffing concerns: violation established.
Findings
Multiple deficiencies were found including improper medication administration via feeding tube, inadequate feeding tube care, insufficient nursing staffing leading to delayed resident care, failure to provide appropriate mental health treatment and suicide prevention, food safety violations in storage and sanitation, and ineffective quality assurance processes related to staffing concerns.
Deficiencies (6)
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: facility staff administered medications via feeding tube using a syringe plunger method instead of the gravity method as required by facility policy.
F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube: the facility failed to maintain proper head of bed elevation during tube feeding and failed to prevent feeding tube clogging, resulting in risk of aspiration and poor nutrition for residents #155 and #3.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: staffing was insufficient on nights and weekends, causing long delays in call light response and unmet resident care needs for multiple residents including #3 and #13.
F 0742 Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty: the facility failed to provide adequate suicide prevention and individualized mental health care for resident #25, who made a suicide attempt by wrapping a call light cord around her neck.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: raw chicken was stored above ready-to-eat salads, kitchen pans had encrusted grease, utensils were dirty, and dish machine temperatures frequently failed to meet required sanitizing levels.
F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action: the facility failed to maintain an effective system to obtain and use feedback from staff and residents to address ongoing staffing concerns, resulting in unresolved issues with call light response times and resident care.
Report Facts
Call light response time: 50
Feeding pump rate: 85
Feeding pump volume remaining: 350
Dish machine wash temperature: 160
Dish machine rinse temperature: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN D | Registered Nurse | Named in medication administration and mental health findings |
| UM/LPN K | Unit Manager/Licensed Practical Nurse | Named in feeding tube care and feeding pump clogging findings |
| LPN C | Licensed Practical Nurse | Named in staffing and feeding pump findings |
| DON B | Director of Nursing | Named in feeding tube care and mental health findings |
| DM V | Dietary Manager | Named in food safety and sanitation findings |
| CNA L | Certified Nurse Aide | Named in call light response findings |
| SS E | Social Worker | Named in mental health and quality assurance findings |
| NHA A | Nursing Home Administrator | Named in staffing and mental health findings |
Inspection Report — Jun 4, 2025
Complaint Investigation
Date: Jun 4, 2025
Visit Reason
Investigation of a complaint received on 2025-06-04 about insufficient nursing staff and delayed call light responses.
Findings
The facility failed to have sufficient staffing to ensure resident care needs were responded to timely for 4 of 5 residents reviewed and 4 of 4 residents from a confidential resident council group meeting, affecting the entire facility census of 49.
Deficiencies (1)
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility had insufficient nursing staff on nights and weekends, resulting in delayed call light responses up to 50 minutes and unmet resident care needs.
Inspection Report — Jan 10, 2025
Complaint Investigation
Date: Jan 10, 2025
Visit Reason
Investigation of a complaint received on 2024-10-14 about failure to implement treatment measures, failure to notify family of change in condition, inadequate supervision to prevent falls, insufficient staffing, and infection control violations.
Complaint Details
Failure to implement treatment measures for stroke: violation established. Failure to notify family of change in condition: violation established. Inadequate supervision causing falls and injuries: violation established. Insufficient staffing impacting care: violation established. Improper use of PPE on enhanced barrier precautions: violation established. Failure to clean shared equipment: violation established.
Findings
Multiple deficiencies were found including failure to implement treatment measures for a stroke resulting in immediate jeopardy, failure to notify family of change in condition, inadequate supervision leading to falls and injuries, insufficient staffing impacting resident care, and failure to follow infection prevention and control protocols including improper use of PPE and unclean shared equipment.
Deficiencies (6)
Failure to implement treatment measures when a change in condition was identified (acute stroke) in Resident #100, resulting in immediate jeopardy and a 27-day hospitalization.
Failure to notify Resident #100's responsible party regarding a change in condition on 10/14/24 and 10/15/24, resulting in delayed transfer to emergency room.
Failure to provide adequate supervision to prevent falls with injury for Resident #102, resulting in pain, head laceration requiring stitches, and hematoma.
Failure to ensure sufficient staffing to provide adequate care for residents, resulting in falls, delayed care, and unmet resident needs.
Failure to properly use personal protective equipment for Residents #100 and #103 on enhanced barrier precautions, including not wearing gowns and gloves during care and transfers.
Failure to properly clean shared resident equipment, including mechanical lifts and shower chairs, increasing risk of infection transmission.
Report Facts
Hospitalization duration: 27
Pain level: 5
Staffing levels: 2
Staffing levels: 3
Staffing levels deemed necessary: 3
Staffing levels deemed necessary: 6
Number of residents requiring 2 staff assistance: 21
BIMS score: 12
Pain level: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Named in findings related to failure to implement treatment, staffing shortages, improper PPE use, and supervision |
| RN N | Registered Nurse | Named in findings related to failure to notify family, failure to implement treatment, and staffing shortages |
| RN J | Registered Nurse | Named in findings related to failure to notify family and monitoring Resident #100 |
| LPN R | Licensed Practical Nurse | Named in findings related to transfer of Resident #100 to emergency room |
| CNA E | Certified Nurse Assistant | Named in findings related to repositioning Resident #100 without PPE and staffing shortages |
| CNA H | Certified Nurse Assistant | Named in findings related to failure to wear PPE during transfer of Resident #103 and staffing shortages |
| RN W | Registered Nurse | Named in findings related to staffing shortages and supervision of Resident #102 |
| CNA V | Certified Nurse Assistant | Named in findings related to staffing shortages, supervision of Resident #102, and failure to clean lifts |
| CNA G | Certified Nurse Assistant | Named in findings related to failure to clean lifts and PPE use |
Inspection Report — Jan 6, 2025
Complaint Investigation
Date: Jan 6, 2025
Visit Reason
Investigation of a complaint received on 2024-12-03 about failure to provide correct diet and feeding assistance resulting in choking and death.
Complaint Details
Failure to provide correct diet and feeding assistance resulting in choking and death: established. Failure to timely report the incident to the State Agency: established.
Findings
The facility failed to ensure Resident #100 received the correct pureed diet and assistance with eating on 12/3/24, resulting in choking on a piece of cauliflower and subsequent death. Immediate jeopardy was identified and removed after staff education and policy implementation.
Deficiencies (2)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to ensure Resident #100 received the correct diet tray and assistance with eating on 12/3/24, resulting in choking and death.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report the choking incident and subsequent death of Resident #100 to the State Agency.
Report Facts
Number of Licensed Nurses: 15
Number of C.E.N.A.s: 27
Number of Licensed Nurses educated: 6
Number of C.E.N.A.s educated: 14
Inspection Report — Jul 25, 2024
Renewal
Date: Jul 25, 2024
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The facility was found to have multiple deficiencies including failure to provide adequate staffing, failure to provide routine showers, failure to maintain sanitary kitchen conditions, failure to provide food at palatable temperatures, failure to provide timely laboratory services, failure to provide appropriate care for residents with medical devices, and failure to ensure residents received care according to professional standards.
Deficiencies (17)
F 0561 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice: facility failed to ensure resident dignity and rights to privacy were honored as reported by eight of nine residents during a confidential Resident Council meeting.
F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility: facility failed to address and resolve concerns/grievances reported in Resident Council Meetings as reported by seven of nine residents resulting in unresolved concerns and unmet needs.
F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: facility failed to ensure accurate advanced directive information was in place for 1 of 3 residents reviewed.
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely: facility failed to provide access to bath linens and maintain sanitary conditions for 2 of 14 residents sampled and 7 of 9 residents interviewed, resulting in frustration, potential delay in care, and unsanitary conditions.
F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed: facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for 1 of 2 residents reviewed for PASARR Screening, resulting in potential for unmet mental health and psychiatric care needs.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: facility failed to develop and implement a comprehensive, person-centered care plan for 2 of 14 residents reviewed, resulting in incomplete reflection of residents' status and potential for unmet care needs.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: facility failed to provide routine showers for 4 of 6 residents reviewed and 7 of 9 residents interviewed, resulting in frustration, disappointment, and embarrassment about personal appearance and cleanliness.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: facility failed to ensure residents received care in accordance with professional standards in 1 resident reviewed for quality of care, resulting in delayed treatment of vulvovaginitis due to mishandling of lab specimen.
F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason: facility failed to reassess resident's preference for use of therapy-recommended positioning device for 1 of 2 residents reviewed for positioning, resulting in potential for decreased range of motion and related complications.
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: facility failed to ensure appropriate supra-pubic catheter care for 1 of 2 residents reviewed for catheter care, resulting in potential for urinary tract infection and complications related to occlusion of catheter tubing.
F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube: facility failed to ensure adequate care for 1 of 2 residents reviewed for tube feeding, resulting in potential for aspiration pneumonia and spoiled tube feeding due to improper positioning and unlabeled feeding formula.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: facility failed to obtain physician orders for use of oxygen for 1 resident reviewed for respiratory care, resulting in potential for improper use, inaccurate settings, irregular cleaning, and respiratory infection.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: facility failed to provide adequate staffing to meet resident needs for 6 of 14 residents sampled and 7 of 9 residents interviewed, resulting in long call light wait times, lack of routine showers, limited supervision, staff burnout, and potential decline in resident quality of life and care.
F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents: facility failed to ensure physician ordered laboratory diagnostic services were obtained and completed in a timely manner in 1 resident reviewed for laboratory services, resulting in delayed treatment/intervention, increased pain/discomfort, and impaired coordination of care.
F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: facility failed to provide food at a palatable temperature to 9 residents interviewed and 2 residents reviewed for food palatability, resulting in potential for decreased food consumption and nutritional decline.
F 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests: facility failed to consistently provide a nourishing nighttime snack to 8 of 9 residents interviewed during resident council, resulting in potential for residents to have more than 14 hours between evening meal and breakfast, decreased oral intake, and potential weight loss.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: facility failed to maintain sanitary conditions in the kitchen including improper cooling of food, open and exposed raw meat, unclean cookware, leaking dish machine drain, dish machine wash temperatures below required minimum, and expired or undated food items, resulting in potential to spread food borne illness.
Inspection Report — Apr 23, 2024
Complaint Investigation
Date: Apr 23, 2024
Visit Reason
Investigation of complaints received about resident rights, self-determination, misappropriation of medications, food palatability, infection control, and environment cleanliness.
Complaint Details
Resident privacy violations: established. Failure to accommodate resident choices: established. Misappropriation of narcotics: not established. Food palatability issues: established. Infection control failures including enhanced barrier precautions and equipment sanitation: established. Environmental cleanliness failures: established.
Findings
The facility was found to have multiple deficiencies including failure to respect resident privacy, failure to accommodate resident choices, failure to prevent misappropriation of controlled substances, failure to provide palatable and adequate food, failure to implement infection prevention and control practices including enhanced barrier precautions, and failure to maintain a safe, clean, and sanitary environment.
Deficiencies (6)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: staff failed to respect residents' privacy by entering rooms without knocking and exposing residents during care.
F 0561 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice: residents were not assisted timely or properly with toileting and hygiene, and their preferences were not accommodated.
F 0602 Protect each resident from the wrongful use of the resident's belongings or money: facility failed to prevent misappropriation of controlled substances due to improper narcotic destruction and documentation practices.
F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: residents reported food was cold, repetitive, unpalatable, and portions inadequate; many trays returned uneaten.
F 0880 Provide and implement an infection prevention and control program: staff failed to use enhanced barrier precautions for residents with MDROs, failed to sanitize shared equipment and lifts, and resident rooms and equipment were visibly soiled.
F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: facility failed to maintain clean resident rooms and common areas, with strong odors, soiled furniture, and accumulation of dust and debris under beds and in rooms.
Inspection Report — Dec 18, 2023
Complaint Investigation
Date: Dec 18, 2023
Visit Reason
Investigation of complaints MI00139838 and MI00139892 regarding quality of care, staffing, and infection control.
Complaint Details
Failure to timely fingerprint and background check staff: established. Failure to notify emergency contact of resident transfer: established. Failure to update care plan for resident interventions: established. Delayed and inaccurate physician orders and treatments: established. Inadequate pressure ulcer prevention and skin assessment: established. Insufficient nursing staff on night shift causing neglect: established. Failure to maintain accurate medical records and document physician notifications: established. Inadequate infection prevention and control practices including hand hygiene and equipment cleaning: established.
Findings
Multiple deficiencies were found including failure to ensure timely background checks, failure to notify emergency contacts, inaccurate care plans, delayed and inaccurate physician orders and treatments, inadequate pressure ulcer prevention, insufficient nursing staff on night shift, failure to maintain accurate medical records, and inadequate infection prevention and control practices.
Deficiencies (9)
F 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft: facility failed to ensure one staff (Former Kitchen Worker LL) received a timely background check and fingerprinting, resulting in potential for abuse and neglect.
F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge: facility failed to notify the emergency contact of the transfer of Resident #101 to the hospital.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: facility failed to update Resident #109's care plan to reflect current interventions, resulting in potential for inconsistent care.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: facility failed to ensure accurate admission orders and timely treatment for Resident #101, resulting in delayed medication administration, drain care, and blood glucose monitoring.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: facility failed to provide drain care, administer medications, and perform blood glucose monitoring according to physician's orders for Resident #101.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: facility failed to implement preventative pressure ulcer interventions and perform a timely skin assessment upon readmission for Resident #103.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: facility failed to provide sufficient nursing staff on night shift of 11/27/2023, resulting in 12 residents not being checked and changed every two hours and delayed care.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: facility failed to maintain accurate health record for Resident #101, including failure to document notification of high blood sugar to physician.
F 0880 Provide and implement an infection prevention and control program: facility failed to ensure proper hand hygiene, glove use, and handling of soiled linens during incontinence care for Resident #103 and failed to ensure proper cleaning of shared medical equipment between resident use for Residents #103 and #105.
Inspection Report — Aug 29, 2023
Complaint Investigation
Date: Aug 29, 2023
Visit Reason
Investigation of a complaint received on 2023-07-24 about elopement risk and safety hazards.
Complaint Details
Failure to prevent elopement of Resident #100: violation established.
Findings
An Immediate Jeopardy was found due to failure to prevent elopement of Resident #100 who exited the facility unnoticed. Multiple interventions were implemented to remove the Immediate Jeopardy and prevent recurrence.
Deficiencies (1)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to prevent elopement of Resident #100 who was at high risk and exited the building unnoticed, resulting in Immediate Jeopardy to resident health and safety.
Inspection Report — Jun 14, 2023
Complaint Investigation
Date: Jun 14, 2023
Visit Reason
Investigation of a complaint received on 2023-06-12 about multiple care and safety concerns including resident care, medication errors, infection control, and facility safety.
Complaint Details
Failure to provide showers and pressure ulcer care: established. Medication errors including insulin and wound care: established. Inadequate trauma-informed care for PTSD: established. Unsafe resident transfers: established. Improper food storage and labeling: established. Inaccurate medical records and meal documentation: established. Infection control breaches: established.
Findings
Multiple deficiencies were found including failure to provide adequate assistance with activities of daily living, medication errors, failure to maintain accurate medical records, inadequate infection control practices, unsafe resident transfers, and improper food storage and labeling.
Deficiencies (13)
The facility failed to ensure Resident #6 received showers as requested and proper pressure ulcer care; oxygen therapy was not consistently provided as ordered.
Resident #14 did not consistently receive scheduled showers and incontinence care; pressure ulcer prevention interventions were not fully implemented.
Resident #16 was found soaked with urine and feces multiple times; medication administration errors occurred including insulin given daily instead of weekly.
Resident #20 had multiple medication administration errors including missed wound care treatments and improper insulin and powder use; pressure ulcers worsened due to inadequate care.
Resident #27 reported missing scheduled showers and inadequate bathing assistance; hair was tangled and greasy.
Resident #44 was not provided trauma-informed care for PTSD; bathing care was inconsistent and privacy was not maintained during care.
Resident #12 did not consistently receive ordered active and passive range of motion therapy, risking decreased mobility.
Residents R150 and R151 were not safely transferred; R150 transferred herself without assistance or gait belt, and R151 was pushed in a wheelchair without foot pedals, risking falls.
Resident #4 received Trulicity insulin daily instead of weekly due to medication order error; the error was not properly reported or corrected.
Medications were not secured properly; expired medications and improperly dated food items were found in storage, risking resident safety.
Food items in the kitchen and pantry were held beyond discard dates or were not properly dated, increasing risk of foodborne illness.
Resident #14 and #16 had inaccurate meal intake documentation, risking improper nutritional assessment.
Infection control practices were inadequate: staff failed to perform hand hygiene and glove changes during incontinence care and medication administration; tube feeding equipment was dirty.
Report Facts
Medication error duration: 14
Medication missed treatments: 2
Medication missed treatments: 3
Medication administration frequency error: 4
Range of motion attempts: 1
Range of motion attempts: 1
Food discard date exceeded: 3
Food discard date exceeded: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Documented insulin not given on incorrect daily order; did not recall reporting medication error |
| CNA K | Certified Nursing Assistant | Failed to change gloves and perform hand hygiene during incontinence care for multiple residents |
| RN I | Registered Nurse | Failed to perform hand hygiene between resident contacts and before medication administration |
| Corporate Consultant C | Corporate Consultant | Entered incorrect Trulicity order and observed expired insulin; instructed staff to discard |
| Director of Nursing B | Director of Nursing | Reconnected oxygen tubing for Resident #6; acknowledged medication error and infection control issues |
| Social Worker BB | Social Worker | Reported lack of trauma-informed care plan for Resident #44 and PRN medication reorder issues for R5 |
| Dietician P | Dietician | Reported importance of accurate meal intake documentation |
Inspection Report — Jun 14, 2023
Complaint Investigation
Date: Jun 14, 2023
Visit Reason
Investigation of a complaint received on 2023-06-12 about inadequate care and treatment for residents.
Complaint Details
Inadequate assistance with activities of daily living for Residents #14, #16, #27, and #44: established. Failure to provide ordered wound care for Resident #20: established. Failure to prevent development or worsening of pressure ulcers for Residents #14, #20, and #6: established. Failure to provide ordered range of motion services for Resident #12: established.
Findings
The facility was found to have multiple deficiencies related to inadequate assistance with activities of daily living, failure to provide appropriate wound care and pressure ulcer prevention, and failure to provide ordered range of motion services.
Deficiencies (4)
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to ensure assistance with ADL care (showers, incontinence care, eating) was consistently provided for 4 residents (#14, #16, #27, #44), resulting in potential for avoidable negative outcomes.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to ensure residents received care in accordance with treatment orders for non-pressure wounds for Resident #20, resulting in potential for infection and worsening conditions.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to ensure interventions were in place to prevent development or worsening of pressure ulcers for Residents #14, #20, and #6, resulting in potential for avoidable and/or worsening pressure ulcers.
F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility: the facility failed to ensure range of motion services for Resident #12, resulting in potential for decreased range of motion and residents not meeting their highest practicable well-being.
Inspection Report — Mar 1, 2023
Complaint Investigation
Date: Mar 1, 2023
Visit Reason
Investigation of a complaint received regarding nephrostomy tube care and medication administration.
Complaint Details
Failure to dispense pain medication timely for Resident #16: established. Failure to monitor and care for nephrostomy tubes for Resident #10: established.
Findings
The facility failed to monitor and care for nephrostomy tubes consistent with professional standards of practice, resulting in an Immediate Jeopardy due to the likelihood for serious harm or death. Resident #10 required emergency transfer to the hospital for appropriate care including intravenous fluids, replacement of nephrostomy tubes, and antibiotic treatment for a serious infection.
Deficiencies (1)
F 0691 Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services: the facility failed to monitor and care for nephrostomy tubes consistent with professional standards of practice, resulting in an Immediate Jeopardy due to the likelihood for serious harm or death when Resident #10 required emergency transfer to the hospital for appropriate care including intravenous fluids, replacement of nephrostomy tubes, and antibiotic treatment for a serious infection.
Report Facts
Date of Survey Completed: Mar 1, 2023
Number of doses of Keflex ordered: 36
Number of doses of Keflex received: 20
Date of Immediate Jeopardy removal: Nov 7, 2022
Inspection Report — Mar 1, 2023
Complaint Investigation
Date: Mar 1, 2023
Visit Reason
Investigation of a complaint received on 2023-02-16 about nephrostomy tube care and medication administration.
Complaint Details
Failure to provide timely pain medication: established. Failure to monitor and care for nephrostomy tubes: established. Failure to administer antibiotics as ordered: established. Additional findings: lack of staff education and competency in nephrostomy tube care — established.
Findings
The facility failed to monitor and care for nephrostomy tubes consistent with professional standards of practice, resulting in an Immediate Jeopardy due to the likelihood for serious harm or death. The resident required emergency hospital transfer for infection and nephrostomy tube replacement. The facility also failed to ensure timely administration of prescribed antibiotics.
Deficiencies (1)
F 0691 Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services: the facility failed to monitor and care for nephrostomy tubes consistent with professional standards of practice, resulting in an Immediate Jeopardy due to serious infection and emergency hospital transfer of Resident #10.
Report Facts
Date of survey completed: Mar 1, 2023
Date of Immediate Jeopardy removal: Nov 7, 2022
Number of nursing staff educated: 25
Number of licensed nurses educated: 9
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