Mackinac Straits Long Term Care Unit
Non profit - Other
48 Beds
Independent
Data: November 2025
Trust Grade
90/100
#39 of 422 in MI
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Mackinac Straits Long Term Care Unit has received an excellent Trust Grade of A, indicating that it is highly recommended for families seeking care. The facility ranks #39 out of 422 nursing homes in Michigan, placing it in the top half of facilities in the state, and is the only option in Mackinac County. However, the facility is experiencing a worsening trend, with the number of issues increasing from 3 in 2024 to 6 in 2025. Staffing is a strong point, with a 5-star rating and a low turnover rate of 17%, which is significantly better than the state average. While there have been no fines reported, there were some serious concerns noted during inspections, including a failure to prevent pressure injuries for one resident and issues with medication management for another, highlighting the need for improvement in certain areas. Overall, while there are strengths in staffing and no fines, families should be aware of some concerning incidents that need addressing.
- Trust Score
- A
- In Michigan
- #39/422
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 17% annual turnover. Excellent stability, 31 points below Michigan's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Michigan facilities.
- Skilled Nurses ✓ Good
- Each resident gets 63 minutes of Registered Nurse (RN) attention daily — more than 97% of Michigan nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 12 deficiencies on record. Higher than average. Multiple issues found across inspections.
90/100
Top 9%
Needs review
3 → 6 violations
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 6 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Low Staff Turnover (17%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (17%)
31 points below Michigan average of 48%
Facility shows strength in staffing levels, staff retention, fire safety.
The Bad
No Significant Concerns Identified
This facility shows no red flags. Among Michigan's 100 nursing homes, only 1% achieve this.
The Ugly 12 deficiencies on record
1 actual harm
May 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently identify targeted behavior and implement non-pharmacol...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently identify targeted behavior and implement non-pharmacological interventions prior to the administration of PRN (as-needed) anti-anxiety medication for one resident (#28) of five resident reviewed for unnecessary psychotropic medication, resulting in the potential for oversedation, dependency on controlled medication and decreased quality of life.
Findings include:
Resident #28 (R28)
Review of the Minimum Data Set (MDS) assessment, dated 3/19/2025, revealed R28 was admitted to the facility on [DATE] and had diagnoses including anxiety disorder and depression. Further review of the MDS assessment, revealed R28 required substantial/maximal assistance with most Activities of Daily Living (ADLs) and was dependent on staff for transfers.
Review of R28's physician orders revealed an order for lorazepam [a controlled anti-anxiety medication] 0.5mg [milligrams] every 8 hours - PRN [as needed] . Special Instructions: May give 0.25, [one-half] 0.5mg tab no closer than [every] 8 hours for increased anxiety . Please monitor [R28] and call [provider] if [R28] shows signs or symptoms of increased confusion or over-sedation.
Review of R28's Medication Administration Record (MAR) for 5/01/25 through 5/28/2025 revealed R28 was administered the PRN lorazepam on 32 occasions. Further review of the MAR revealed indications for administration of the PRN lorazepam were listed on the MAR as Other Anxiety for 19 of the 28 administrations, Sleep for eight administrations, and Behavior Issue for one administration. It was noted in review of the MAR, documentation did not include specific target behaviors, or the sign and symptoms of anxiety warranting administration for each dose of the PRN lorazepam.
Review of R28's electronic medical record (EMR) revealed no documentation of behavior or signs and symptoms of anxiety targeting by administration of the PRN lorazepam or the use of non-pharmacological interventions attempted prior to 25 of 28 administrations of the medication from 5/01/2025 through 5/28/2025.
During an interview on 05/29/25 at 12:55 p.m., the Director of Nursing (DON) was queried about the process for administration of PRN psychotropic medication, including lorazepam. The DON reported staff were expected to document specific behavior, signs and symptoms targeted by administration of PRN anti-anxiety medication. The DON reported she was aware of staff administering PRN lorazepam to R28 without identifying the specific need for the medication. The DON stated, I keep telling them you can't just give it to him because he asks for it, there has to be a reason. The DON reported non-pharmacological interventions should be utilized in an attempt to alleviate R28's anxiety prior to administration of the PRN lorazepam to ensure the Resident is not administered unnecessary medication. The DON acknowledged the need for accurate and complete documentation related to administration of the medication to determine effectiveness of R28's medication regimen and if changes to the Resident's plan of care were warranted.
Review of the facility policy titled, Psychotropic Medications, revised 5/2024, revealed the following:
Physician will order psychotropic medications only for the treatment of specific medical and/or psychiatric conditions or when the medication meets the needs of the resident to alleviate significant distress for the resident not met by the use of non-pharmacological approaches . Orders for PRN psychotropic medications will be time limited and only for specific, clearly documented circumstances.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two Residents (#24 and #46) of twelve Residents reviewed for accuracy of MDS assessments. Findings include:
Resident #24 (R24)
R24 was admitted to the facility 12/19/24. The diagnoses list reviewed in R24's electronic medical record (EMR) included a diagnosis of Post-Traumatic Stress Disorder (PTSD).
Review of the EMR revealed a care plan dated 12/19/24 for past physical and emotional trauma experienced by R24.
A form titled Initial Trauma Informed Assessment dated 12/19/25 reiterated the information contained in the care plan.
Review of section I - Active Diagnoses on an admission MDS dated [DATE] and a quarterly MDS dated [DATE] revealed the PTSD was not documented in either MDS assessment. The PTSD, as assessed on admission and care planned, was not coded on the MDS.
Resident #46 (R46)
On 5/27/25 at 12:38 PM, R46 was observed with bed rails on both sides of the bed. R46 was unable to answer questions regarding the bed rails due to confusion and cognitive impairment.
Review of the EMR revealed R46 was admitted to the facility on [DATE] with a primary medical diagnosis of severe vascular dementia. The MDS assessment dated [DATE] documented R46 was dependent on staff for Activities of Daily Living (ADLs) including but not limited to bed mobility, turning, and repositioning.
An admission MDS dated [DATE], an MDS for significant change dated 2/11/25, and the quarterly MDS dated [DATE] were reviewed. None of the MDS documented the use of bed rails. The MDS coded bed rail use as 0 (not in use).
The MDS Nurse, Registered Nurse (RN) C, was interviewed via telephone in the presence of the Director of Nursing (DON) on 5/29/25 at 2:50 PM. RN C acknowledged coding MDS information. When asked why the MDS did not accurately code the status of R24 and R46, RN C said, I can't tell you why the information isn't coded - I don't have a good answer to your question. RN C acknowledged the information should have been included in the MDS assessments of both residents but had been erroneously omitted from the MDS assessments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #28 (R28)
Review of the MDS assessment, dated 3/19/2025, revealed R28 was admitted to the facility on [DATE] and had di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #28 (R28)
Review of the MDS assessment, dated 3/19/2025, revealed R28 was admitted to the facility on [DATE] and had diagnoses including anxiety disorder and depression. Further review of the MDS assessment, revealed R28 required substantial/maximal assistance with most Activities of Daily Living (ADLs) and was dependent on staff for transfers.
Review of R28's physician orders revealed an order for lorazepam [a controlled anti-anxiety medication] 0.5mg [milligrams] every 8 hours - PRN [as needed] . Special Instructions: May give 0.25, [one-half] 0.5mg tab no closer than [every] 8 hours for increased anxiety . Please monitor [R28] and call [provider] if [R28] shows signs or symptoms of increased confusion or over-sedation.
Review of R28's Medication Administration Record (MAR) for 5/01/25 through 5/28/2025 revealed R28 was administered the PRN lorazepam on 32 occasions. Further review of the MAR revealed indications for administration of the PRN lorazepam were listed on the MAR as Other Anxiety for 19 of the 28 administrations, Sleep for eight administrations, and Behavior Issue for one administration. It was noted in review of the MAR, documentation did not include specific target behaviors, or the sign and symptoms of anxiety warranting administration for each dose of the PRN lorazepam.
Review of R28's care plan revealed a focus area for Psychotropic Drug Use. Resident receives antianxiety medication [related to] anxiety, initiated 3/26/2025 with the goal of Resident will be prescribed the lowest effective dose of medication. Further review revealed the interventions were not updated to include precipitating factors, targeted behavior or signs and symptoms of anxiety to assist staff in recognizing the need for the antianxiety medication. It was also noted R28's care plan did not include non-pharmacological interventions to be utilized in targeting R28's anxiety and ultimately to determine the need for administration of the PRN lorazepam.
During an interview on 05/29/25 at 12:55 p.m., the DON was queried about the process for administration of PRN psychotropic medication, including lorazepam. The DON reported staff were expected to document specific behavior, signs and symptoms targeted by administration of PRN anti-anxiety medication. The DON reported behaviors along with sign and symptoms of anxiety should be included in R28's care plan along with non-pharmacological interventions to be utilized in attempts to prevent or alleviate the Resident's anxiety. The DON confirmed the use of non-pharmacological interventions prior to administration of PRN lorazepam was a standard of practice.
Review of the facility policy titled, Comprehensive Care Plan, revised 10/2023, revealed the following:
Each resident's comprehensive care plan will describe the following: Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The comprehensive care plan will: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Aid in preventing or reducing declines in the resident's functional status and/or functional levels; Promote resident safety; Reflect currently recognized standards of practice for the problem areas and conditions . The care planning/interdisciplinary team is responsible for review and updating of care plans: When there is a significant change in the resident's condition; When the outcome is not met .
Based on observation, interview, and record review, the facility failed to revise and update care plans for three Residents (#3, #29, and #28) of twelve residents reviewed for care plan accuracy and revision. Findings include:
Resident #3 (R3)
On 5/27/25 at 2:16 PM, R3 said she fell but could not recall when the fall occurred. Pressure sensor alarms were observed on R3's bed and wheelchair.
Review of the electronic medical record (EMR) revealed R3 fell and sustained a right hip fracture while in the bathroom on 4/10/25 at 8:30 AM. A nurse progress note dated 4/10/25 at 9:15 a.m. documented a tab alarm and safety checks every 30 minutes would be implemented.
A nurse progress note dated 4/10/25 at 10:30 AM documented, in part: . tab alarm in place and 30 minutes [sic] safety checks have begun.
An incident report dated as completed 5/2/25 for the fall event of 4/10/25 documented, in part: .INTERVENTIONS/TREATMENTS - Immediate measures taken. Tab alarm; 30 minute checks .
The care plan for R3 was reviewed on 5/28/25. The fall care plan contained an intervention documented as created on 5/2/25 that read: was put on 30 minute checks 4/10/24 [sic]. The care plans did not include alarming devices to the bed and wheelchair.
The Director of Nursing (DON) was interviewed on 5/29/25 at 10:48 AM. The DON said updates or revisions to fall care plan interventions should be completed the day of the fall or as soon as possible after fall occurrences. The DON acknowledged the care plan intervention for 30-minute safety checks was not entered as a care plan intervention until 5/2/25. The DON confirmed the bed and wheelchair alarms had not been added to R3's care plans. The DON reviewed and updated the care plan on 5/29/25 to include the intervention for the bed and wheelchair alarms.
Resident #29 (R29)
On 5/27/25 at 11:06 AM, R29 was observed lying in bed with both hands on his abdomen. R29 said he did not feel well and said he experienced pain when going to the bathroom. A bladder scanner was noted to be in the room next to R29's bed.
Review of the EMR revealed R29 was admitted to the facility 4/28/25. An admission Minimum Data Set (MDS) assessment dated [DATE] documented R29 was incontinent of bladder, and dependent on staff for toileting hygiene and personal hygiene.
A physician's progress note dated 5/13/25 at 3:19 PM documented, in part: .Physician notes from prior facility indicated that he was treated for MRSA [Methicillin Resistant Staphylococcus Aureus - a contagious, antibiotic-resistant bacteria that can cause serious infections, sepsis, or death] UTI [urinary tract infection] in March 2025 .The patient is minimally conversive and intermittently cries, admitting to lower abdominal pain . has a hx [history] of UTI .Concern for current UTI .lower urinary symptoms and history of UTI: patient with pustular drainage from his urethra and history of MRSA UTI. Recommend STAT straight cath UA sample, antibiotics will likely be needed .
A urine culture was obtained on R29 on 5/14/25 and identified MRSA in the urine.
The care plans for R29 did not include a plan of care for MRSA or the implementation of precautions to minimize the risk of spreading the bacteria to others. The care plans did not mention a history of UTI or contain interventions to provide staff with direction for minimizing the risks of infection.
The DON was interviewed on 5/29/25 at 10:48 AM. The current care plan and care plan history of R29 were reviewed with the DON. The DON acknowledged the UTI, MRSA, and infection history were not in R29's care plans. The DON said R29 should be in Enhanced Barrier Precautions (EBP - a type of infection control intervention designed to reduce transmission of multidrug-resistant organisms such as MRSA) due to having MRSA in the urine. The DON reviewed the care plan and confirmed the EBP was not included in the plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure bed rail assessments were completed to evaluat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure bed rail assessments were completed to evaluate entrapment risk prior to the use of bed rails, obtain a physician's order for the use of bed rails, attempt alternatives prior to the use of bed rails, provide medical reason for the use of bed rails, and document the risks and benefits of bed rails for one Resident (#46) of one resident reviewed for accident hazards. Findings include:
Resident #46 (R46)
On 5/27/25 at 12:38 PM, R46 was observed with bed rails on both sides of the bed. R46 was unable to answer questions regarding the bed rails due to confusion and cognitive impairment.
Review of the Electronic Medical Record (EMR) revealed R46 was admitted to the facility on [DATE] with a primary medical diagnosis of severe vascular dementia. A Minimum Data Set (MDS) assessment dated [DATE] documented R46 was dependent on staff for Activities of Daily Living (ADL) including but not limited to bed mobility, turning, and repositioning. The MDS documented a Brief Interview for Mental Status (BIMS - a test for cognitive status) score of 99 indicating R46 was unable to complete the BIMS due to having severely impaired cognition.
The EMR did not contain an assessment of the risk of entrapment prior to application of the bedrails. The physician orders for R46 did not contain an order for the bedrails. No documentation was found regarding alternatives that were attempted prior to installing bedrails. No medical symptoms or bedrail measurements were in the medical record.
A form Side Rail Assessment dated 1/14/25 was present in the EMR of R46. The form read, in part: .in addition to this signed form authorizing the use of bed rails for this resident, a written order from the resident's attending Physician, specifying the medical rationale and circumstances for use, must be obtained prior to the installation of this medical treatment device. It is also my understanding that the Facility will periodically review and re-evaluate the resident's need for bed rails and that the resident, responsible party and attending Physician will be consulted in this matter . The form was signed by the Resident Representative (RR) of R46 on 1/14/25.
A question on the Side Rail Assessment form asked, Why is side rail being used? The written response was When in bed. The form did not include the indication for use or the risks and benefits for the use of the side rails. An additional area of the form: Specific medical symptoms which require side rail use was blank and did not provide the medical symptoms to justify the use of the bed rails.
The Side Rail Assessment form did not document a review of the risks and benefits of side rail use to ensure the RR of R46 was provided sufficient information to make an informed decision regarding bed rail utilization.
Documentation of the bed's dimensions and measurements to ensure appropriateness for R46's size and weight were not found in the medical record.
On 5/29/25 at 10:03 AM, Certified Nurse Aide (CNA) D was observed providing hygiene to R46 with Registered Nurse (RN) E present. CNA D and RN E rolled R46 onto her right side. R46 did not utilize the bed rail to assist with the turning. RN E held R46 onto her right side until CNA D completed cleansing R46's back side. R46 made no attempt to utilize the bed rail to assist with turning and repositioning.
RN E was observed completing dressing changes to R46's pressure injuries on 5/29/25 at 10:18 AM. CNA D assisted RN E with turning and positioning R46 during the treatment completion. After the dressing changes, CNA D and RN E repositioned R46 onto her left side. R46 made no attempt to utilize the bed rail to assist with the turning and repositioning.
The Director of Nursing (DON) was interviewed on 5/29/25 at 10:38 AM. The DON said R46 should have a physician's order for bedrails because a physician's order was required to utilize bed rails. The DON reviewed the medical record of R46 and acknowledged there was not physician's order for the bed rails. The DON confirmed the medical reason and indication for use of bed rails were not documented in the medical record. The DON admitted no alternatives were attempted prior to installing the bedrails, and there were no documented risks or benefits to bed rail usage. The DON confirmed there was no assessment for bed rail usage aside from the modified assessment documented on the Side Rail Assessment form.
The DON said bed and rail measurements were completed by another department and were not maintained in R46's medical record. The DON said she would obtain the documented measurements for perusal. The bed and rail measurements were not provided by the end of survey.
The policy Bed Rails dated as effective 7/2024 documented, in part: .the resident or resident's legal guardian, advocate or other legal representative will be informed of the risks of bed rail use and the alternatives to bed rail use . an assessment will be performed by members of the Interdisciplinary Team to determine if bed rails are appropriate for this resident . An order must be obtained from the physician. The order must contain statements and determinations regarding medical symptoms, and it must specify the circumstances under which the bed rails are to be used . Bed rails applied to the bed must be individually selected for the resident based on their body weight, body size, head measurement, bed, rail, and mattress configurations . During the first five (5) days following initial use, the resident, bed frame, bed rails, and mattress must be monitored by each shift . Continued use of side rails must be reviewed quarterly by nursing .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0807
(Tag F0807)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide drinks, including water and other liquids consistent with resident needs for one resident requiring thickened liquids...
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Based on observation, interview, and record review, the facility failed to provide drinks, including water and other liquids consistent with resident needs for one resident requiring thickened liquids (#16) of one resident reviewed for fluid needs. Findings include:
On 5/27/25 at 10:38 AM, Resident #16 (R16) was observed lying in bed. Her lips were observed as dry and flaky. When asked if she was drinking enough fluids, R16 responded, I have to have that thick stuff, and I hate it so probably not. R16 stated the thermal 12 ounce covered mug on her bedside table was water with a straw inserted that had just been delivered. Upon inspection and discovery that the thermal cup contained non-thickened ice water, R16 exclaimed, Oh good!
During meal observations on 5/28/25 at 12:30 PM, R16 was eating lunch in her room. Her meal included two thermal 12 ounce covered mugs with lids. R16 was sipping from one mug which she stated was coffee. She stated she hated thick coffee and thick water. When the lids were removed and checked for consistency and content, the coffee was discovered without thickener. R16 did not receive nectar thick liquids per the physician order.
On 5/28/25 at 12:35 PM, Registered Dietitian RD A observed the beverages received by R16 and confirmed they were not thickened beverages. RD A said to R16, You should not have received the (unthickened) coffee. RD A indicated R16 was waiting to see the Speech Therapist (SLP) for an evaluation. R16 said, She (the SLP) was supposed to be here last Friday.
The medical record for R16 included a nursing progress note on 5/16/2025 at 12:42 PM which read as follows, This nurse was approached by dietary aide and speech therapist was talking with this nurse. Dietary aide informed that she hears (R16) coughing everyday at lunch time when she is drinking her liquids. Speech therapist informed that liquids can be downgraded until she can see the person and screen them. This nurse then went and sat with (R16) and her husband in the dining room. Asked (R16) if she notices that she coughs at mealtime. (R16) replied, Yes, I do cough when I drink liquids. Asked her if we could try a glass of nectar thick liquids and she agreed. Gave her a glass of cranberry juice nectar thick and she drank it with no coughing noted. She agreed to have her liquids nectar thick until speech can see her. Informed nursing supervisor and NP [Nurse Practitioner] and order written for her to be seen by speech next week.
The medical record included a nursing progress note written on 5/17/2025 at 7:40 AM which read in part, Order obtained for speech screen/eval r/t (related to) coughing when drinking thin liquids .
The medical record included a physician order dated 5/16/25 Diet: Regular diet, Nectar thick liquids. The care plan for R16: included, Please provide my diet as ordered, regular with nectar liquids. Edited: 05/162025.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control precautions were implemented...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control precautions were implemented and hand hygiene and glove changes were performed after touching potentially contaminated items for two Residents (#46 and #29) of six residents reviewed for infection prevention and control. Findings include:
Resident #46 (R46)
On 5/27/25 at 12:38 PM, R46 was observed lying in bed with urinary catheter drainage tubing extending from under a blanket into a drainage bag attached to the bedframe of the bed. The urine in the drainage tubing was observed to be dark yellow and cloudy with sediment. R46 was unable to answer questions regarding urinary tract infection (UTI) or the presence of the urinary catheter due to confusion and impaired cognition.
Signage was posted outside the door or R46's room indicating R46 was in Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of multidrug-resistant organisms [MDRO - pathogens that resist most available antimicrobial medications]). The posting directed staff to perform hand hygiene and wear gloves and gowns when performing high-contact resident care activities including the provision of personal hygiene to the resident.
Review of the Electronic Medical Record (EMR) revealed R46 was admitted to the facility 1/14/25 with a primary medical diagnosis of severe vascular dementia. R46 required an indwelling urinary catheter due to urinary retention.
A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS - a test for cognitive status) score of 99 indicating R46 was unable to complete the BIMS due to having severely impaired cognition. Further review of the MDS divulged R46 was dependent on staff for Activities of Daily (ADL), including but not limited to personal hygiene and toileting hygiene.
A care plan for the urinary catheter reflected R46 required the use of EBP and included an intervention dated 4/10/25 that read: Please provide me assistance with maintaining my indwelling urinary catheter including good urinary catheter hygiene.
On 5/29/25 at 10:03 AM, Certified Nurse Aide (CNA) D was observed preparing items to provide urinary catheter hygiene to R46. CNA D performed hand hygiene and donned a gown and gloves prior to entering R46's room. CNA D moved two waste baskets containing refuse next to the bedside of R46 then removed the plastic waste bags of refuse from the containers and tied them up before setting them aside and obtaining new plastic waste bags to place in the containers. CNA D did not change gloves or perform hand hygiene after touching the bags of refuse and before starting catheter care on R46.
The Director of Nursing (DON) was interviewed on 5/29/25 at 10:38 AM. The DON conveyed the expectation that staff remove gloves, cleanse hands, and put on new gloves after touching soiled and potentially contaminated items. The DON reiterated CNA D should have removed the gloves after touching the waste containers, then performed hand hygiene and put on another pair of gloves before providing catheter care to R46.
Resident #29 (R29)
On 5/27/25 at 11:06 AM, R29 was observed lying in bed with both hands on his abdomen. R29 said he did not feel well and said he experienced pain when going to the bathroom. A bladder scanner was noted to be in the room next to R29's bed.
Review of the EMR revealed R29 was admitted to the facility 4/28/25. An admission Minimum Data Set (MDS) assessment dated [DATE] documented R29 was incontinent of bladder, and dependent on staff for toileting hygiene and personal hygiene.
A physician's progress note dated 5/13/25 at 3:19 PM documented, in part: .Physician notes from prior facility indicated that he was treated for MRSA [Methicillin Resistant Staphylococcus Aureus - a contagious, antibiotic-resistant bacteria that can cause serious infections, sepsis, or death] UTI [urinary tract infection] in March 2025 .The patient is minimally conversive and intermittently cries, admitting to lower abdominal pain . has a hx [history] of UTI .Concern for current UTI .lower urinary symptoms and history of UTI: patient with pustular drainage from his urethra and history of MRSA UTI. Recommend STAT straight cath UA sample, antibiotics will likely be needed .
A urine culture was obtained on R29 on 5/14/25 and identified MRSA in the urine.
The EMR did not contain a physician's order for R29 to be in infection prevention and control precautions. The care plans for R29 did not include a plan of care for MRSA or the implementation of precautions to minimize the risk of spreading the bacteria to others. The care plans did not mention a history of UTI or contain interventions to provide staff with direction for minimizing the risks of infection.
The DON was interviewed on 5/29/25 at 10:48 AM. The DON said residents with MDROs were placed in EBP or Transmission-Based Precautions (TBP - safety measures implemented to prevent the transmission of infectious organisms). When asked if R29 was placed in TBP or EBP, the DON said R29 was placed in TBP through the completion of antibiotic therapy when the MRSA was identified. The DON said R29 should have been placed in EBP after antibiotics were completed.
R29's current care plan, care plan history, and physician orders were reviewed with the DON. The DON acknowledged the UTI, MRSA, and infection history were not in R29's care plans. The DON confirmed no physician's order had been obtained for R29 to be in TBP or EBP when MRSA was identified. The DON said, [R29] should be in enhanced barrier precautions - I will get on that today.
The policy Transmission-Based Precautions dated as last revised 12/2023 read, in part: .All [name of facility] employees .will use the Transmission-based Precautions (TBP) outlined in the policy on all patients requiring extra protection to interrupt the transmission of pathogens .
The policy Enhanced Barrier Precautions dated as effective 4/1/24 documented, in part: .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . An order for enhanced barrier precautions will be obtained for residents with any of the following: urinary catheters .infection or colonization with a CDC [Centers for Disease Control]-targeted MDRO with Contact Precautions [type of TBP] do not otherwise apply . epidemiologically important MDROs may include, but are not limited to: a. Methicillin-resistant Staphylococcus aureus (MRSA) .
Jun 2024
3 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure timely interventions to prevent facility acquir...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure timely interventions to prevent facility acquired pressure injuries for one resident (#16) and failed to ensure comprehensive wound documentation for two residents (#16 and #6), per professional standards of practice. This deficient practice resulted in harm when resident #16 developed two Stage 2 pressure injuries and the potential for worsening and delayed healing of Stage 3 pressure injury for resident #6.
Resident #16 (R16)
A review of the Electronic Medical Record (EMR) for R16 revealed admission to the facility on 8/22/17 with diagnoses of Alzheimer's disease (progressive memory disorder), Down Syndrome (intellectual and developmental delay condition), and seizures. R16's face sheet had a note which read, R16 is unable to answer questions appropriately. Hearing is adequate and does not require hearing aids.
A review of the MDS (Minimum Data Set) Braden Scale for Prediction of a Pressure Sore Risk for R16 dated 10/17/23 was scored at a 13/18, indicating a moderate risk for a pressure sore. Factors included having very moist skin, being chair fast, and having very limited mobility. The MDS indicated R16 was totally dependent on helpers for all activities of daily living.
On 11/10/23, the Weekly (head to toe) Skin Assessment indicated R16 had the following skin observations:
neck area reddened and superficial open area on buttocks.
In the section titled skin condition: reddened neck was indicated, but there was nothing about the open area on the buttocks, and the remainder of the assessment was not completed.
On 12/15/23, the Weekly (head to toe) Skin Assessment indicated R16 read in part:
skin to buttock with existing area, treatment in place. In the section titled skin condition: other- treatment in place to buttocks, with the remainder of the assessment incomplete.
A progress note, from 12/31/24 indicated R16 had a 1.5cm (centimeters) x 0.2cm open area on her left buttock, near the coccyx area. Some bleeding noted when cleansed/assessed. (R16) also has existing areas of sheared (when forces moving in opposite directions are applied to tissues in the body) skin near the same area. There was not a part in R16's care plan which addressed shearing.
Progress Notes reviewed revealed the following:
1/17/24: R16 had excoriated/skin sloughing to bilateral upper buttocks with a slit in the crevice of buttocks.
3/3/24: read in part, R16's wound measured R (right) buttocks: 2cm x 2cm of sheared skin, with a 0.5cm x 0.5cm open area. L (left) buttocks: 2cm x 1.5cm of redness with a 1.5cm x 1cm open area.
3/16/24: read in part, R16 had redness and excoriation observed to bilateral buttocks, blanchable.
3/23/24: read in part, R16 had redness and excoriation observed to bilateral buttocks, blanchable.
3/27/24: read in part, R16's Right buttock darker purplish area measuring 0.2cm x 4cm with intact skin. Left buttock had 4 areas of concern .The area at 3 o'clock on left buttocks measures 1cm x 0.5cm and is identified as skin shearing with the area superficial but center of area shiny red in appearance. The other 3 areas of concern are a darker purplish red in color on the left buttocks. The 12 o'clock area measures 0.7cm x 0.3cm. The two just below in on the left buttocks (6 o'clock) are very close to each other but not connected and each measure 0.6cm x0.3cm.
3/30/24: read in part, Area on left buttock open. Skin surface only.
3/31/24: read in part, right and left buttocks cheeks reddened with open areas noted calazime (skin protectant) applied. Areas do not seem to be improving, will suggest magic butt cream to speed up healing process to supervisor.
4/1/24: read in part, BL (bilateral) buttocks assessed and no yeast present. Magic Butt Cream is not appropriate at this time.
4/3/24: read in part, superficial opening/stage 2 PI (pressure injury) measuring 0.4.cm x 0.5cm the wound bed is red with crusted dry skin edges and bloody drainage. The left buttocks stage 2 PI measures 2.7cm x 1.3cm and has bright red wound bed with dry crusted skin surrounding and bloody drainage. The areas are dried out and in need of moisture to aid healing. At this time wound order are changed back to Mepilex dressings.
4/9/24: read in part, Left buttocks stage 2 pressure injury measures 5cm x 5cm, right buttocks stage 2 pressure injury measures 1.7cm x 4cm. The pressure injuries are beefy red in appearance and raised.
4/10/24: read in part, wounds have improved significantly overnight with use of A&D ointment and calazime mixture.
4/16/24: read in part Right PI measures 6.7cm x4.5cm. Left PI measures 6cm x 4.3cm. Also recommend continuing to offload pressure to buttocks frequent repositioning .
4/21/24: a late entry progress note, read in part, Pressure injuries remain the same, superficial, no change in size or appearance of dull reddish-purple color, slowly blanchable Wound measurements to continue weekly on Tuesday. No measurements to substantiate the documentation of no change in size or appearance noted in progress note.
4/23/24: a late entry progress note, read in part, Right pressure injuries measure 6.5cm x 5cm and has evidence of excoriation with superficial deep red purplish wound bed. The left pressure injury measures 7.0cm x 5cm and is superficial deep red purplish wound bed .the pressure injuries are slow to blanch. Wound order is to cleanse entire buttocks with warm water and no foam soap, and pat dry. Cleanse with NS (normal saline) and pat dry with 4x4 (4 inch x 4 inch) gauze. Apply thin layer of mixture of 1 packet A&D with 6 grams of calazime to pressure injuries. Skin prep surrounding pressure injuries. Mepilex dressing to secure. Change every 3 days and PRN (as needed) >50% saturation. Strongly encourage frequent repositioning to offload pressure from areas. CN (Charge Nurse) and CNAs (Certified Nursing Assistant) aware.
5/3/24: read in part, The left PI measures 6cm x 4.5cm with excoriation in the wound bed, surrounding tissue normal. The right PI measures 6cm x5.3cm with normal tissue surrounding. The wound care order has been changed to cleanse bilateral buttocks with warm water and mild soap, pat dry. Apply skin prep surrounding pressure injuries and let dry, apply new duoderm to each PI and change q (each, every) 5 days and prn >50% saturated.
5/16/24: read in part, Stage 2 PI left buttock measures 8cm x 3.5cm. Stage 2 PI right buttock measures 7cm x 3cm with lower part having excoriation within the wound bed. The wound beds are dark red and blanchable.
5/20/24: read in part, R (right) buttocks PI measures 6.8cm x 6cm with scant amount of excoriation within wound bed and surrounding. Left buttocks PI measures 8cm x 5cm with small amount of excoriation on edges .There is evidence of the duoderm dressing causing more excoriation from the adhesive as the pressure injuries are becoming wider in nature with excoriation. Therefore, the wound order is discontinued at this time and a new order is entered: cleanse entire buttocks with warm water and soap, pat dry. Cleanse pressure injury areas with NS and gauze 4 x 4, pat dry. Mix 1 packet A&D ointment with 6 grams of calazime, skin protectant and apply thin layer to bilateral buttocks pressure injuries. Skin prep surrounding pressure injuries where adhesive will be. Secure 2 separate small Mepilex dressings or sacral Mepilex dressing.
5/26/24: read in part, Stage 2 PI left buttocks measures 8cm x 5 cm purplish-red with 1.2cm x 1cm area of superficial red excoriation within. Right buttocks Stage 2 PI measures 8cm x 5cm and is light purplish in color . Order is updated .secure left buttocks with Mepilex dressing change q 3 days or PRN 50% saturated. Utilize body pillow to reposition and offload pressure from buttocks and bony prominences.
6/5/24: read in part, Right buttocks have 2 areas of shearing within red quickly blanchable area. Right superior area of shearing measures 1.2cm x 1.3cm, inferior area of shearing measures 0.6cm x 0.6cm. The left buttocks have 1 area of shearing measuring 0.4cm x 0.4cm. The left buttocks PI is observed to have too much moisture r/t (related to) Mepilex dressing and there is an attempt at healing with some loose scabbing. At this time, treatment is changed to cleanse buttocks with mild soap and water, pat dry. Apply thin layer of calazime to bilateral buttocks pressure injuries. Treatment BID (two times a day) and PRN brief changes.
6/11/24: read in part, Right buttocks Stage 2 PI has red sheared area measuring 1.2cm x 1cm. Left buttocks Stage 2 PI measures 1.2cm x 1cm and is scabbed.
6/19/24: read in part, Evidence of increased pressure to buttocks as right buttocks has deep red discoloration measuring 6.7cm x 3.5cm with area of dark purple shiny sheared skin measuring 0.7cm x 3cm. Left buttocks Stage 2 PI has red discoloration measuring 5cm x 3cm with excoriation within and superior area of excoriation measuring 2.2cm x 0.7cm.
R16's care plan last updated 5/11/24 stated: Pressure Ulcer/Injury I am at risk for skin breakdown and developing a pressure ulcer related to incontinence, impaired mobility, decreased sensory perception and a history of multiple cysts and infections. Please apply my blue pressure relieving boots to both feet when I am in bed to avoid pressure on my bony prominences and prevent skin break down (initiated 5/11/24). I have a Stage II pressure ulcer on my right and left buttock, please complete treatments as ordered (initiated 4/6/24). Please provide me with an air mattress for pressure injury care and prevention (initiated 4/5/24).
On 6/25/24 at 10:17 AM, during observation of morning care, resident has Stage 2 pressure ulcer to left and right buttocks, that was red, with uneven boarders, elongated in shape.
On 6/25/24 at 4:15 PM, during an interview with the Director of Nursing (DON), who reviewed R16's chart and agreed nursing needed to put measurements when they assessed the wounds on R16's buttocks. The DON stated nurses were expected to fill out the weekly skin assessment completely. The DON acknowledged while looking through progress notes, the wound started in March and the resident was not given an air mattress until 4/5/24. The DON acknowledged the air mattress took too long to implement based on R16's wound assessments and when they began.
A review of the EMR revealed an order for the air mattress dated 4/5/24.
On 6/26/24 at 9:30 AM, during observation of Registered Nurse (RN) C who performed wound measurements, indicated the wound was looking ruddier. RN C noted a small new wound on sacral area. RN C then applied a sacral Mepilex dressing due to this added area of concern. The new area was located on the sacrum, was small, oblong, and had uneven wound edges.
On 6/26/24 at 9:48 AM, a follow up interview was conducted with the DON, to discuss what might have caused the wounds on R16. The DON stated she did not see it when it first started but did thought it looked like the wounds were caused by shearing (mechanism of action in which uneven forces upon the skin increases the chance for skin tears, pressure injuries, and other wounds).
Resident #6 (R6)
Review of the facility's resident matrix revealed R6 had a facility acquired stage III pressure ulcer.
On 6/24/24 at 11:15 AM, an interview was conducted with the Director of Nursing (DON) and asked if R6 had any pressure ulcers or wounds and replied, R6 has a right ankle stage III pressure injury that he was admitted with. The DON was asked if he required any type of dressing changes and replied, No. He is observation only and open to air.
Review of R6's medical record revealed he was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, chronic obstructive pulmonary disease (COPD), and pressure ulcer of right ankle (stage 3).
Review of R6's admission and body assessment, date 4/19/24, revealed under the skin section a stage II right lower extremity pressure ulcer.
Review of R6's MDS assessment, dated 7/26/23 revealed he scored a 10/15 on the Brief Interview for Mental Status (BIMS) assessment indicating moderate cognitive impairment. This MDS also revealed he had one pressure ulcer stage III that was facility acquired and none that were present on admission.
Review of R6's care plan, dated 4/19/22, read in part .Problem: I am at risk for developing pressure ulcers, I have had pressure ulcers in the past .Approach .Please complete dressing order per MD (medical doctor) to my right malleolus (outer ankle area) .Please assess my skin .
Review of R6's physician order, dated 4/21/24 read in part, Pressure sore: Measure and Document progress weekly .
Review of R6's wound progress notes, dated between 4/19/22 through 6/26/24, revealed that the original pressure ulcer stage III on his right ankle had not healed and remained open.
Review of R6's wound progress notes, dated between 8/1/23 through 6/26/24, revealed the lack of weekly wound measurements as follows:
a.)
between 8/20/23 through 9/9/23,
b.)
between 9/25/23 through 10/21/23,
c.)
between 10/23/23 through 11/25/23,
d.)
between 11/27/23 through 12/23/23,
e.)
between 1/15/24 through 3/2/24 and,
f.)
between 3/4/24 through 3/22/24.
On 6/25/24 at 10:00 AM, an observation was made of R6 in his room sitting in his wheelchair and playing solitaire. R6 was asked about his right ankle pressure ulcer and replied, You can look at it if you want to. I have had that sore since 1987. I hit my ankle on a rock when I was walking down a sidewalk and ever since then it has not healed. R6's right ankle was observed to have a pressure ulcer to the right malleolus with an area the size of a nickel. No dressing was present, and the wound was open to air.
On 6/25/24 at 3:10 PM, an interview was conducted with the DON and asked if R6 had a facility acquired pressure ulcer stage III and replied, No. He was admitted to the facility with that pressure ulcer, and it has not healed yet. The DON was asked how often R6 has his wound measurements and replied, They are completed weekly by the nurse managers or me. The DON was asked if R6 should have any weekly wound measurements incomplete and replied, No. The DON was asked where the documentation was kept and if there were any other place wound measurements were charted in the electronic medical record and replied, The wound measurements are documented under the wound progress notes and that is the only place they are documented.
Review of policy titled, Decub/Skin Protocol, dated 3/31/17, read in part, .3. The program will be overseen by assigned Nursing Supervisor. All resident skin issues will be followed weekly by Nursing Supervisor .5 .a weekly skin assessment will be made out .6 .The care plan will be updated according to the resident's condition .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the Minimal Data Set (MDS) assessment was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the Minimal Data Set (MDS) assessment was accurate for two residents (Resident #6 and Resident #22) of 12 sampled residents reviewed for comprehensive assessments. Findings include:
Resident #6 (R6)
Review of the facility's resident matrix revealed R6 had a facility acquired stage III pressure ulcer.
On 6/24/24 at 11:15 AM, an interview was conducted with the Director of Nursing (DON) and asked if R6 had any pressure ulcers or wounds and replied, R6 has a right ankle stage III pressure injury that he was admitted with. The DON was asked if he required any type of dressing changes and replied, No. He is observation only and open to air.
Review of R6's medical record revealed he was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, chronic obstructive pulmonary disease (COPD), and pressure ulcer of right ankle (stage 3).
Review of R6's admission and body assessment, date 4/19/24, revealed under the skin section a stage II right lower extremity pressure ulcer.
Review of R6's MDS assessment, dated 7/26/23 revealed he scored a 10/15 on the Brief Interview for Mental Status (BIMS) assessment indicating moderate cognitive impairment. This MDS also revealed he had one pressure ulcer stage III that was facility acquired and none that were present on admission.
Review of R6's MDS assessment, dated 10/24/23 revealed he had one pressure ulcer stage III that was facility acquired and none that were present on admission.
Review of R6's MDS assessment, dated 1/23/24 revealed he had one pressure ulcer stage III that was facility acquired and none that were present on admission.
Review of R6's MDS assessment, dated 4/15/24 revealed he had one pressure ulcer stage III that was facility acquired and none that were present on admission.
Review of R6's wound progress notes, dated between 4/19/22 through 6/26/24 revealed that the original pressure ulcer stage III on his right ankle had not healed and remained open.
On 6/25/24 at 10:00 AM, an observation was made of R6 in his room sitting in his wheelchair and playing solitaire. R6 was asked about his right ankle pressure ulcer and replied, You can look at it if you want to. I have had that sore since 1987. I hit my ankle on a rock when I was walking down a sidewalk and ever since then it has not healed. R6's right ankle was observed to have a pressure ulcer to the right malleolus with an area the size of a nickel that lacked a dressing and was open to air.
On 6/25/24 at 11:05 AM, an interview was conducted with the DON and asked if R6 had a facility acquired pressure ulcer stage III and replied, No. He was admitted to the facility with that pressure ulcer, and it has not healed yet. The DON was asked why R6's MDS was coded to reflect a facility acquired pressure ulcer stage III and replied, The MDS is coded incorrectly. R6's MDS assessment should be coded as being present on admission.
Resident #22 (R22)
On 6/26/24 at 11:00 AM, an observation was made of R22 sitting in his wheelchair in the North Hall. R22 had a urinary catheter bag hanging from the bottom of his wheelchair.
Review of R22's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Lewy bodies, neuromuscular dysfunction of bladder, and retention of urine.
Review of R22's physician order, dated 4/18/24 revealed an order that read, insert a 16F (French) Coude (rigid tip for narrow difficult catheter insertions) catheter for urinary retention.
Review of R22's progress note, dated 5/23/24 read in part, .Foley patent to DD (dependent drainage) urine concentrated with sediment.
Review of R22's quarterly MDS, dated 5/24 revealed under section H, bowel and bladder no indication of having an indwelling catheter.
Review of R22's progress note, dated 5/26/24 read in part, .Urinary catheter has not being (sic) leaking since supervisor made adjustments.
Review of R22's care plan, dated 4/24/24 read in part, .Problem: I require an indwelling catheter for obstructive uropathy .
On 6/25/24 at 11:05 AM, an interview was conducted with the DON and was asked if R22's MDS was coded correctly to reflect he had an indwelling urinary catheter and replied, I would have to check. The DON reviewed R22's quarterly MDS, dated [DATE] and stated, No. His MDS is not coded correctly. I will call the MDS nurse to have her correct the coding. The DON was asked if the MDS nurse was involved in morning meetings and how frequently these occurred and replied, Every morning during the week we have them Monday through Friday and the MDS nurse is on the calls as she works remotely. The DON was asked if there was any reason why the MDS for R6 and R22 were coded incorrectly and replied, No. I will call her and have her correct them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify, evaluate, and implement interventions to prevent an avoida...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify, evaluate, and implement interventions to prevent an avoidable accident when bath aides failed to transport one Resident #3 (R3) of two residents reviewed for safety, safely to the bath via the bath lift in the tub room. This deficient practice resulted in bath lift tipping over while R3 aboard, causing a laceration to his left shin which required sutures.
Resident #3 (R3)
Review of R3's medical record indicated R3 was admitted to facility on 2/27/24 with diagnoses of age-related osteoporosis (when mineral density and bone mass decreases), Type II diabetes, muscle weakness, and traumatic brain injury.
A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R3 had a BIMS (Brief Interview for Mental Status) score of 15/15, indicating R3 was cognitively intact.
Review of R3's orders indicated clopidogrel (blood thinner) 75 mg (milligrams) was prescribed to R3 once a day at 9:00 AM. Clopidogrel is an antiplatelet medication that can cause increased potential for bruising and bleeding.
A review of R3's care plan initiated on 2/27/24 indicated at risk for falls related to impaired mobility, disease process, and possible side effects of medication. Please assist me (R3) with transferring and toileting as needed. I use a full mechanical lift. I use a blue sling.
A review of R3's progress notes dated 3/6/24 at 3:30 PM revealed the following: approximately 1520 (3:20 PM) in to get this nursing supervisor and provider for resident fall. This nurse went into tub room between north and south hall where resident was observed on the floor near tub with head against the wall facing the tub in supine position with bath trolley (bath lift) on top of resident. The resident was alert and oriented at baseline, reporting no pain anywhere during assessment. Vitals BP (Blood Pressure) 156/72, HR (Heart Rate) 95, T (Temperature) 98.2, R (respirations) 20, SpO2 (Oxygen Saturation) 97% on RA (Room Air). The bath aides reported they were getting ready to lower the resident into the tub when the trolley quickly tipped over resulting in the resident falling to the floor. Initially the resident is observed to have a laceration to anterior left shin and scant amount of bleeding form an abrasion to the posterior head. The provider evaluated the resident and determined need to transfer to the ER (Emergency Room) for a head CT (Computed Tomography) due to the resident on anticoagulant Plavix (clopidogrel) as well as need to repair leg laceration. Administrator advised of occurrence and resident's emergency contact notified.
A progress note from the Physician Assistant (PA) dated 3/6/24 at 3:30 PM, read in part fell from lift to hard floor during transfer to bath . just fell off lift during transfer to receive a bath. He struck his head and lacerated R (right) anterior leg (incorrectly identified by PA in note). Denies LOC . denies any pain, SOB (shortness of breath) or chest discomfort. Denies cervical, thoracic, or lumbar spine pain. Denies headache
A review of nursing progress notes on 3/6/24 at 6:43 PM, read in part, (R3) returned from the ER with sutures to the lower left leg laceration, tetanus shot updated, CT of head/C-Spine (cervical spine)/chest/pelvis/left leg with no acute injury or abnormalities. Resident has generalized pain from fall.
An interview with R3 on 6/26/24 at 7:48 AM, revealed the following:
R3 stated that during the fall it all happened too quick for him to alert staff something was wrong but felt something was not quite right while on the bath lift. R3 felt there was too much weight at one end.
During an interview conducted with the Director of Nursing (DON) on 6/26/24 at 9:02 AM, she stated that the R3's fall was investigated and the lift had been taken out of commission until it was evaluated by the external vendor, stating that they ' . fixed it'. She indicated the external vendor informed the facility the lift was nearing the end of its life and was being replaced. The DON stated the facility had determined that the resident was too heavy for the bath lift.
Review of manufacturers bath lift instructions for use, from medical supplier, indicated the maximum safe operating weight was 352 pounds for the bath lift. R3's chart indicated his weight at 309.5 pounds, which is under the safe operating weight. A review of the medical supplier's Inspection Report indicated that an incident report was completed and sent to complaints. Lift inspection completed no fault found, all functions working properly. Pictures of lift attached.
A review of the Event Report Safety Events - LTC (Long Term Care) Fall Occurrence Report explanation of incident read in part as R3 seat belt in with safety bar over legs of bath/gurney trolley. Trolley completely knocked over with R3 down on floor. R3's upper torso partially off end of trolley on floor, head propped up on stack of towels. Left shin up against safety bar with laceration noted. Bleeding noted from posterior head. Unbuckled from trolley and trolley pulled away per three staff.
On 6/26/24 10:16 AM, an interview was conducted with shower aide (SA) E, who was present at time of fall on 3/6/24. SA E stated she had resident sitting up with the bar over his leg, per bath lift protocol, brought R3 into the shower room, had R3 next to the bath and the apparatus just tipped over. SA E then proceeded to lean on the end of bath lift to show how hard it was to get it to lean. SA E stated she knew that R3 was not over the weight limit but after thinking about it she feels that R3's body makeup made him heavier on one side than the other and that is why it tipped.
A follow-up interview was conducted with the DON and the NHA (Nursing Home Administrator) in attendance on 6/26/24 at 10:30 AM, where they indicated they had reenacted the fall, and could not figure out why the bath lift had fallen over, calling it a freak accident.
Jul 2023
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide preventative care consistent with professional...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide preventative care consistent with professional standards of practice, for 1 resident (Resident #5) reviewed for the risk of the development of pressure injuries, resulting in impaired skin integrity, inaccurate/incomplete documentation, and the potential for the delay in treatment, the worsening of a wound, infection, and the overall deterioration in health status.
Findings:
Resident #5 (R5)
Review of an admission Record revealed R5 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: Stroke and Alzheimer's Disease.
Review of a Minimum Data Set (MDS) assessment for R5, with a reference date of 5/4/23 revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated R5 was severely cognitively impaired. Review of the Functional Status revealed that R5 required extensive 2 person assist for bed mobility.
Review of R5's Braden Scale For Prediction of Pressure Sore Risk dated 5/4/23 revealed a score of 15, indicating R5 was at risk for pressure injury/skin breakdown.
Review of R5's pressure injury prevention Care Plan revealed, I have decreased mobility, decreased ability to reposition independently, incontinence, and poor nutritional status therefore I am at risk for developing a pressure ulcer .Please turn and reposition Q2-3 (every 2-3) hours, as I allow, please note I cannot lay flat for 1 hour after my tube feedings . dated 3/1/23.
During an observation on 7/20/23 at 8:56 AM, R5 was in bed on her back with no offloading devices in place. R5's body pillow was on top of the chifforobe, folded in half, with no pillowcase.
During an observation on 7/20/23 at 10:21 AM, R5 was in bed on her back with no offloading devices in place. R5's body pillow was on top of the chifforobe, folded in half, with no pillowcase.
During an observation on 07/20/23 at 11:51 AM, R5 was in bed on her back with no offloading devices in place. R5's body pillow was on top of the chifforobe, folded in half, with no pillowcase.
During an observation on 07/20/23 at 1:00 PM, R5 was in bed on her back with no offloading devices in place. R5's body pillow was on top of the chifforobe, folded in half, with no pillowcase.
During an observation and interview on 07/20/23 at 2:34 PM, R5 was in bed on her back with no offloading devices in place. R5's body pillow was on top of the chifforobe, folded in half, with no pillowcase. Registered Nurse (RN) A had just completed the administration of R5's formula into R5's feeding tube. RN A reported that R5 should be repositioned with every check and change (brief assessment/change) at least every couple hours. RN A reported that R5's skin on her buttocks was fragile and the facility staff had been implementing new treatments and interventions for open/excoriated areas. RN A reported R5's buttock skin was improving but the skin breakdown/injury had not yet fully resolved. At that time RN A and Certified Nursing Assistant (CNA) B completed pericare for R5. The entirety of R5's buttocks was deep red, with areas of superficial and partial-thickness areas of breakdown surrounded by macerated tissue. There were 2 ruddy red, deep, intact linear indentations on the back of R5's bilateral thighs. On the front of R5's right thigh there was a ruddy red, deep, intact linear indentation. CNA B reported the deep, intact, linear indentions were due to R5's brief and reported the indentation on the front of R5's right thing was the result of incorrect placement of the brief.
CNA B reported that R5 required assistance with repositioning and was to be turned/repositioned every couple hours to prevent the worsening of her skin breakdown.
At approximately 3:00 PM, RN A directed CNA B to keep R5's head of bed up higher than 30 degrees for 30 more minutes before repositioning due to the recent administration of the formula into R5's feeding tube.
During an observation on 7/20/23 at 3:51 PM, R5 was in bed on her back with no offloading devices in place. The body pillow was on top of the chifforobe, folded in half, with no pillowcase.
During an observation and interview on 7/20/23 at 4:26 PM, R5 was in bed on her back with no offloading devices in place. CNA B reported R5 was to be repositioned using the body pillow (pointed to the body pillow on top of the chifforobe with no pillowcase). CNA B reported she was going to get new pillowcases for the body pillow. CNA B reported she had not repositioned R5 since she was last changed (at 2:34 PM) as RN A wanted her to wait because R5 had just had a bolus feeding through her feeding tube.
During an observation on 7/21/23 at 7:33 AM, R5 was in bed on her back with no offloading devices in place. The body pillow was on top of the chifforobe, folded in half, with no pillowcase.
Review of R5's Skin Assessment dated 6/30/23 revealed R5's skin was intact/no problems.
There was no Skin Assessment completed on 7/7/23.
Review of R5's Skin Assessment dated 7/14/23 revealed R5's skin was intact/no problems.
Review of R5's Skin Assessment dated 7/21/23 revealed R5's skin was intact/no problems and .skin intact with no concerns signed by RN D as completed.
During an interview on 7/21/23 at 12:00 PM, RN D reported she did not complete a skin assessment on (R5) that morning. RN D reported R5 had a history of redness on her bottom and was receiving treatment.
During an interview on 7/21/23 at 12:04 PM, DON was notified that RN D reported she had not completed a Skin Assessment on R5 but had documented that a Skin Assessment had been completed on R5's electronic health record the morning of 7/21/23. DON was notified that RN D documented that R5's skin was intact. DON reported that all licensed nurses would be educated on complete and accurate documentation and an order would be written/implemented to ensure the licensed nurse providing care for R5 would ensure R5 was turned and repositioned every 2 hours.
Review of R5's Order Summary dated 7/21/23 revealed, CN (charge nurse) to ensure that (R5) is turned frequently when in bed and nurse to visual turning and repositioning. Please chart in progress notes if she refuses to be turned. Twice A Day.
Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The presence and duration of moisture on the skin increases the risk of pressure injury. Moisture reduces the resistance of the skin to other physical factors such as pressure, friction, or shear. Prolonged moisture softens skin, making it more susceptible to damage. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1238). Elsevier Health Sciences. Kindle Edition.
Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Repositioning (turning) patients is a consistent element of evidence-based pressure injury prevention (EPUAP, NPIAP, PPPIA, 2019a). The twofold aim of repositioning should be to reduce or relieve pressure at the interface between bony prominence and support surface (bed or chair) and to limit the amount of time the tissue is exposed to pressure (Maklebust and [NAME], 2016). Elevating the head of the bed to 30 degrees or less decreases the chance of pressure injury development from shearing forces (WOCN, 2016). Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort (EPUAP, NPIAP, PPPIA, 2019a). A standard turning interval of 1.5 to 2 hours does not always prevent pressure injury development; repositioning intervals are based on patient assessment. Some patients may need more frequent position changes, while other patients can tolerate every-2-hour position changes without tissue injury. When repositioning, use positioning devices to protect bony prominences (WOCN, 2016). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1255). Elsevier Health Sciences. Kindle Edition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure annual performance reviews were conducted and education based on the outcome of the reviews were completed for two Certified Nurse A...
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Based on interview and record review, the facility failed to ensure annual performance reviews were conducted and education based on the outcome of the reviews were completed for two Certified Nurse Aides (CNA's), resulting in the potential for diminished quality and/or inadequate provision of care for all residents living at the facility.
Findings:
Review of the facility assessment last updated on 5/16/23 reflected Staff Competencies: Our Director of Nursing, in consultation with the Interdisciplinary Team as needed, determines what topics of training and competencies are offered and completed for our staff. We may also determine educational needs as identified through our QAPI process. In addition to the mandatory training topic, such as annual resident abuse awareness, other topics for training and competencies this year have included:
a)
Interacting and caring for Residents with Dementia
b)
Proper Hand Washing (infection prevention)
c)
Medication Administration
d)
Proper Documentation Techniques
e)
Fall Prevention and Interventions
f)
Residents Rights and Abuse Policies
g)
Emergency Preparedness
Education is provided through lecture/ presentations, on-line based learning, and hands on competency review.
A review of the employee file for CNA F revealed CNA F was hired in June of 2022. CNA F did not have an annual performance review.
Review of the employee file for CNA G reflected CNA G was hired to work at the facility as a nurse aide on 4/27/2020. CNA G had never had an annual skills evaluation and had never been given an annual performance evaluation.
During an interview on 7/21/23 at 9:45 AM, the NHA said the facility does not have a policy for annual skills evaluation or performance reviews.
During a follow-up interview on 7/21/23 at 10:36 AM, the NHA confirmed that CNA G did not have an annual competency skills check. No other records awaiting verification were discovered by the NHA who reported that it is clear the facility needs to correct annual reviews and ensure staff have skills checks and annual in-service to meet the standard.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one nurse aide completed required in-service training to evaluate nurse aide competence, resulting in the potential for inadequate a...
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Based on interview and record review, the facility failed to ensure one nurse aide completed required in-service training to evaluate nurse aide competence, resulting in the potential for inadequate and substandard quality of care for residents living at the facility.
Findings:
Review of the employee file for CNA G reflected CNA G was hired to work at the facility as a nurse aide on 4/27/2020. CNA G had not completed the required 12 hours of mandatory in-service training since hiring into the facility.
During an interview on 7/21/23 at 9:45 AM, the NHA reported there is not a policy for the requirement for 12 hours of in-service training for nurse aids. The NHA reported the requirement is not mentioned in the employee handbook it is just understood.
During a follow-up interview on 7/21/23 at 10:36 AM, the NHA reported that it is clear the facility needs to correct the lack of annual reviews and ensure staff have skills checks and annual in-service to meet the standard.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade A (90/100). Above average facility, better than most options in Michigan.
- • No fines on record. Clean compliance history, better than most Michigan facilities.
- • 17% annual turnover. Excellent stability, 31 points below Michigan's 48% average. Staff who stay learn residents' needs.
Concerns
- • 12 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Mackinac Straits Long Term Care Unit's CMS Rating?
CMS assigns Mackinac Straits Long Term Care Unit an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Michigan, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Mackinac Straits Long Term Care Unit Staffed?
CMS rates Mackinac Straits Long Term Care Unit's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 17%, compared to the Michigan average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Mackinac Straits Long Term Care Unit?
State health inspectors documented 12 deficiencies at Mackinac Straits Long Term Care Unit during 2023 to 2025. These included: 1 that caused actual resident harm and 11 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Mackinac Straits Long Term Care Unit?
Mackinac Straits Long Term Care Unit is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 48 certified beds and approximately 45 residents (about 94% occupancy), it is a smaller facility located in St. Ignace, Michigan.
How Does Mackinac Straits Long Term Care Unit Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, Mackinac Straits Long Term Care Unit's overall rating (5 stars) is above the state average of 3.2, staff turnover (17%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Mackinac Straits Long Term Care Unit?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Mackinac Straits Long Term Care Unit Safe?
Based on CMS inspection data, Mackinac Straits Long Term Care Unit has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Michigan. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Mackinac Straits Long Term Care Unit Stick Around?
Staff at Mackinac Straits Long Term Care Unit tend to stick around. With a turnover rate of 17%, the facility is 29 percentage points below the Michigan average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 21%, meaning experienced RNs are available to handle complex medical needs.
Was Mackinac Straits Long Term Care Unit Ever Fined?
Mackinac Straits Long Term Care Unit has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Mackinac Straits Long Term Care Unit on Any Federal Watch List?
Mackinac Straits Long Term Care Unit is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.