Manistee County Medical Care Facility

Based on interview and record review, the facility failed to ensure one Resident (#31) of five residents reviewed for eligible immunizations was offered a pneumococcal vaccine as recommended by the Centers for Disease Control and Prevention (CDC).Findings Include:Resident #31 (R31)Review of the electronic medical record (EMR) for R31, revealed initial admission to the facility on 7/19/16 with diagnoses including multiple sclerosis, dementia, and failure to thrive. The most recent pneumococcal immunization for R31 was administered on 6/27/17. The status of the next pneumococcal immunization read, refused.Review of R31's vaccination history on the Michigan Care Improvement Registry (MCIR), revealed the recommended date for the PCV20/PCV21(Pneumococcal 20-valent Conjugate/Pneumococcal 21-valent conjugate) vaccine was 6/27/22.No education regarding the benefits and risks of the immunization or declination of a pneumococcal immunization being offering could be located in R31's EMR.On 12/3/25 at 12:48 PM, an interview was conducted with Infection Preventionist (IP) B regarding R31's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the provision of dignified care and services for five Confidential Residents (C1, C2, C3, C4, and C5)) out of 13 residents reviewed for dgnity. This deficient practice resulted in feelings of intimidation, frustration, and fear of retaliation from facility staff. Findings include: Confidential Resident C2 Review of C2's Minimum Data Set (MDS) assessment, dated 9/23/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 of 15, reflective of intact cognition. During an interview on 10/07/24 at 12:29 p.m., Confidential Resident C2 was asked about the provision of dignified and respectful care and services by facility staff. C2 initially spoke in a whisper and said she did not want to discuss it, but then motioned this Surveyor closer and said there was one staff member that did not like her and did not treat her properly. When asked who the staff member was, C2 noted it was Staff T, who had refused to clean up a beverage C2 had spilled at lunch. C2 said she had spilled a lunch beverage, and it was all over…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficiency pertains to Intake MI00147245 and MI147343 Based on interview and record review, the facility failed to notify the state agency timely of reportable occurrences for one Residents (R199) of two residents reviewed for abuse. Findings include: Resident #199 On 9/26/24 at 1:00 a.m., Resident #199 (R199) was found unresponsive in his wheelchair. A nurse's progress note dated 9/26/24 at 1:44 a.m. documented R199 had been resting in his wheelchair until 1:00 a.m. when staff approached R199 about going to bed. Documentation in nurse progress notes indicate R199's arms and legs were flaccid, and the resident had a blank gaze when staff performed sternal rubbing. R199 was transferred to the Emergency Department (ED) on 9/26/24 at 1:35 a.m. where a urine drug screen (UDS) was performed. The results of the UDS were positive for cocaine. The ED physician documented, in part: .I reviewed the nursing home note and also his medication list. Nothing can account for the cocaine in his urine .A confirmation test…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure invasive blood sugar (glucometer) testing and insulin injections were administered by licensed nursing staff for one Resident (R19) out of 13 residents reviewed for qualified staffing. This deficient practice resulted in Certified Nurse Aide (CNA) B providing care outside the scope of practice when they administered insulin via injection and completed invasive blood glucose monitoring for R19. Findings include: During an interview on 10/08/24 at 9:22 a.m., R19 said [CNA B] came into their room and gave them two insulin shots. R19 stated, [CNA B] gave me the insulin . [CNA B] came in and gave it (insulin) to me on one side . and then came in later and gave it to me on the other side. This happened in May or June. It is almost like a bad dream . I knew it wasn't right . Review of R19's Physician Order Summary, as of 10/9/24, revealed the following orders to be administered by licensed nursing staff, in part: Humalog Injection Solution 100 Unit/ML (milliliter) (Insulin Lispro) Inject as per sliding scale; if 0-100 = 0…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide the necessary standards of care and services for diabetes management in one Resident (Resident #37) of one resident reviewed for diabetic management. This deficient practice resulted in the potential for diabetic related complications including organ damage, stroke, and death. Findings include: Resident #37 (R37) Review of R37's electronic medical record (EMR) revealed admission to the facility on 2/14/24 with diagnoses including Type 2 diabetes mellitus. R37's 8/19/24 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 2, indicative of severe cognitive impairment. R37 was also noted to have received seven insulin injections in Section N of the 8/19/24 MDS assessment. Review of R37's Medication Administration Record (MAR) revealed the following: Basaglar Tempo Pen Subcutaneous Solution Pen-injector 100 Unit/ML (milliliters) (Insulin Glargine) Inject 20 unit subcutaneously one time a day for DM (diabetes mellitus) HumaLOG Injection Solution 100 UNIT/ML…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide appropriate support surfaces for residents with wounds, develop care plan interventions for pressure-reducing support surfaces, accurately document the stage of a pressure injury, and provide ongoing weekly skin assessments for one (Residents R43) of four residents reviewed for pressure injury, resulting in the potential for worsening pressure ulcers. Findings include: Resident #43 On 10/7/24 at 12:20 p.m., Resident #43 (R43) said she hurt, and indicated the pain was in her gluteal area. R43 was sitting in a recliner with no visible chair cushion on the recliner. The mattress on R43's bed was a standard facility mattress. R43 was unable to answer questions regarding potential skin impairment. R43 had a quarterly Minimum Data Set (MDS) assessment completed on 7/22/24. The MDS documented R43 was dependent on staff for Activities of Daily Living (ADL), including dependence on staff for bed mobility, turning and repositioning. Physician's orders for R43 included treatment orders for a Stage 4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to implement interventions to address range of motion (ROM) for one resident (Resident #11) of two residents reviewed for limited range of motion. This deficient practice resulted in the potential for extreme pain, discomfort, and worsening of positions. Findings include: Review of R11's Electronic Medical Record (EMR) revealed an admission date of 3/17/20 and diagnoses including cerebral palsy, epilepsy, anoxic brain damage, and anxiety disorder. Review of R11's 8/19/24 Quarterly Minimum Data Set (MDS) assessment revealed they were unable to complete the Brief Interview for Mental Status (BIMS) score and was marked with severely impaired cognition. In Section O of the 8/19/24 MDS, R11 was noted to have received zero days of treatment for therapy services and restorative nursing program services. On 10/7/24 at approximately 3:00 p.m., R11 was observed sitting in her bed watching television. R11's bed was noted to be elevated at the head. R11 was nonverbal during this interaction but was observed with her head…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure all medications and biologicals were stored in locked compartments accessible only by authorized personnel in one medication room, of one medication storage room reviewed during the medication storage task. This deficient practice resulted in the potential for medication diversion when the medication room door was propped open without supervision and the medication refrigerator was unlocked and utilized for staff food items. Findings include: During an observation on 10/09/24 at 7:27 a.m. the second floor medication storage room was found propped wide open and unattended by any facility staff. This Surveyor walked into the medication storage room without supervision. Registered Nurse (RN) S, upon seeing this Surveyor walked into the second floor medication room. RN S acknowledged the medication room door was not supposed to be left open, unattended, and stated, I already shut this door once. When the unlocked, medication refrigerator was opened, three small plastic, storage containers with food, an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to adhere to Enhanced Barrier Precautions and follow infection control standards of practice in 2 of 2 residents (Resident #43 and Resident #12) review for infection control, resulting in the potential for the spread of infection. Findings include: Resident #43 Signage was posted outside the door to R43's room that read, in part, .Enhanced Barrier Precautions [EBP] . Put on PPE [Personal Protective Equipment] before entering for high contact care: 1. Hand Hygiene 2. Gown 3. Gloves . On 10/9/24 at 9:50 a.m., the Wound Nurse (Registered Nurse (RN) M) was observed completing treatments and dressing changes to R43's pressure injuries. The sacral wound was observed to be a Stage 3 pressure injury without a dressing. A stage 2 pressure injury was observed on the right buttock lateral to the superior gluteal fold. RN M wore gloves but did not wear a gown throughout the dressing change procedure in accordance with EBP instructions. Resident #12 Resident #12 (R12) had a stage 3 pressure injury on the right gluteus. EBP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to prevent proper supervision of coffee carts for three of four hallways during an observation of the lunch service meal. This deficient practice resulted in the potential for residents who were deemed unsafe to handle hot liquids independently, to subsequently suffer burns and burn related medical complications. Findings include: An observation was made of the lunch meal service on 11/14/23 at 11:50 a.m. During this time, carts were being delivered to their designated hallways. Observation of the first cart for rooms 101-116 with three staff members assisting in passing the hallway meals. It was observed that Registered Nurse (RN) D prepared coffee from a separate coffee cart, placing the coffee cups without lids on top of the trays, and then allowing the trays to go into resident rooms. After all meals were delivered, the coffee cart was left unattended in the hallway. An observation was made of the second hallway cart for rooms 117-131 on 11/1/243 at 12:00 p.m. RN D was again assisting in pouring coffee into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to securely store medications, for Resident #6 (R6), two of two medication rooms and one of two medication carts reviewed. This deficient practice resulted in the potential for expired medication use and misappropriation of Resident property. Findings include: On 11/14/23 at 12:35 PM, an observation was made of Resident #6 (R6) in her room. R6 was sitting up in her wheelchair and watching television. R6 had a dresser just to the right of her doorway and on top of the dresser was a plastic container with various items inside. Inside R6's plastic container on her dresser, two tubes of diphenhydramine cream and one tube of hydrocortisone cream were observed. R6 was asked why she had the creams in her room and replied, I use them for itching and for the rash on my back, and the Certified Nurse Aides will rub it on my back. On 11/15/23 at 7:50 AM, an observation was made of R6's room, and the three tubes of cream remained on top of her dresser inside the plastic container. A review of R6's care plan, physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain a medication administration error rate less than 5%, for 3 of 25 medication administrations. This deficient practice resulted in a medication administration error rate of 12.00%, with the potential for medical complications in resident treatment and conditions. Findings include: On 11/15/23 at 9:45 AM, an observation was made of Registered Nurse (RN) D preparing medication pass for Resident #15 (R15) in the medication storage room on the first floor. RN D grabbed a tray to place individual medication cups on, with one medication per cup, crushed, and dissolved in a small amount of water. RN D prepared three medications from a stock source including: aspirin, multivitamin, and vitamin D. RN D then grabbed a packet of medication pre-prepared by pharmacy which contained four medications. RN D opened the packet and dumped the medications in a cup and spilled three on the floor. RN D failed to notice she dropped three of the four medications on the floor. RN D dropped two white pills and one pink pill…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.