Inspection Reports for Qualicare Nursing Home

The inspection was conducted based on a complaint regarding the facility's failure to timely and appropriately assess a new onset leg pain for one resident (R901), resulting in prolonged severe pain and subsequent hospitalization.

The facility failed to promptly assess and treat R901's leg pain, which was initially ignored despite complaints and visible signs of injury, leading to a delayed diagnosis of a hip fracture requiring surgery. Multiple staff interviews and medical record reviews confirmed inadequate pain assessment and delayed hospital transfer.

This citation pertains to intake 2561232. The complaint involved allegations that on 7/7/25, resident R901 was heard screaming in pain with a visible injury to the upper thigh. Despite complaints and observations of severe pain over the weekend, the resident was not sent to the hospital until approximately 12:00 a.m. on 7/8/25. The hospital diagnosed a displaced hip fracture requiring surgery. Staff interviews revealed failure to assess the leg pain properly, delayed communication with the physician, and inadequate documentation.

The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, advance directives, medication administration, and medication storage at Qualicare Nursing Home.

The facility was found deficient in ensuring residents were assisted with eating in a dignified manner, ensuring residents or their legal representatives formulated advance directives upon admission, and properly storing medications during administration. Several residents were affected by these deficiencies, with minimal harm or potential for actual harm noted.

The inspection was conducted due to a complaint regarding inadequate supervision of a resident who eloped from the facility.

The facility failed to provide adequate supervision for one resident (R903), who left the facility unnoticed for six and a half hours. Interviews and record reviews confirmed the resident left via a first-floor window and nursing staff did not adequately monitor residents during their shifts.

This citation pertains to intake MI00145673. The complaint was substantiated as the resident left the facility without staff knowledge for six and a half hours due to inadequate supervision.

The inspection was conducted following a complaint alleging verbal abuse by a staff member towards a resident.

The facility substantiated verbal abuse by a Certified Nursing Assistant (CNA A) towards resident R801, who was called a derogatory name during care delivery. The CNA was terminated and reported to law enforcement and the State Nurse Aide Registry. The resident reported feeling safe despite the incident.

The complaint was substantiated based on investigation findings. The verbal abuse incident involved CNA A calling resident R801 a mean hateful term during care. CNA A was terminated and reported to authorities.

The inspection was conducted based on complaint intake MI00138460 and MI00142235 to investigate allegations related to failure in providing adequate activities of daily living care, pressure ulcer care, and catheter care for residents.

The facility failed to provide scheduled showers for one resident, delayed initiating a wound care consult for another resident's pressure ulcer, and failed to provide and document appropriate catheter care and urinary output for a third resident. These deficiencies were associated with minimal harm or potential for actual harm and affected a few residents.

The visit was complaint-related based on intake MI00138460 and MI00142235. The complaints involved failure to provide adequate ADL care, pressure ulcer care, and catheter care. The deficiencies were substantiated with documentation and interviews.

The inspection was conducted to assess compliance with regulatory requirements related to PASARR screening, restorative services, nutrition and weight management, infection prevention and control, and other care standards at Qualicare Nursing Home.

The facility was found deficient in updating PASARR Level 1 Screening forms for mental health diagnoses, providing restorative services as ordered to maintain range of motion and mobility, consistently weighing residents as per care plans, and ensuring proper infection control practices including storage of oxygen nasal cannulas and proper handling of clean and dirty linens.

The inspection was conducted to evaluate the facility's compliance with nutritional assessment and weight monitoring requirements for residents, specifically focusing on the accuracy and timeliness of weight documentation and nutrition assessments.

The facility failed to obtain accurate and timely weights and complete nutrition assessments for one resident (R76), resulting in the potential for undetected weight loss. Interviews and record reviews revealed inconsistent weight documentation and failure to follow facility policies on weight monitoring.