Gogebic Medical Care Facility

In the surveyor’s words

From the most serious findings on record at Gogebic Medical Care Facility, in the surveyor’s own words.

• Immediate jeopardy, isolatedF693Mar 4, 2025

  All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to replace a feeding tube in accordance with professional standards of practice for one Resident (#1) of two residents reviewed for enteral nutrition, which resulted in Immediate Jeopardy when Resident #1 subsequently suffered aspiration pneumonia requiring admission to the Intensive Care Unit (ICU) and ultimately resulted in Resident #1 being placed on comfort care measures. The Immediate Jeopardy (IJ) began on 1/11/25 when Registered Nurse (RN) J inserted a urinary catheter with 30 cc (cubic centimeter) balloon into the gastrostomy site of Resident #1 (R1) to use as a feeding tube. […]

• Actual harm, isolatedF688Mar 4, 2025

  Based on observation, interview, and record review, the facility failed to provide treatment, services, and equipment to maintain and/or prevent avoidable reduction in Range of Motion (ROM) for one Resident (R76) of one resident reviewed for mobility. This deficient practice resulted in harm with incorrect application of a back brace and worsening of R76's L1 (spinal) compression fracture. Findings include: All times noted are Eastern Standard Time (EST) unless otherwise noted. During an interview on 2/25/25 at 3:34 p.m., when asked about any care concerns while residing in the facility, R76 stated, I was sent to a specialty (neurosurgery) appointment on Wednesday, 2/21/25 and they told me that my back has gotten worse because I have not been wearing the back brace correctly. […]

• Actual harm, isolatedF726Mar 4, 2025

  All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to ensure licensed nurses had the knowledge, competencies, and skill sets to replace the feeding tube of one Resident (#1) of one resident reviewed for nurse training and competency for feeding tube replacement. This deficient practice resulted in R1 being admitted to the ICU when the feeding tube was found to be lodged in R1's esophagus with the balloon inflated. […]

• Actual harm, isolatedF883Mar 4, 2025

  All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to offer and provide pneumococcal vaccinations to three Residents (#28, #44 & #1) of five residents reviewed for immunizations. This deficient practice resulted in R28 being hospitalized for pneumonia and subsequently expiring from pneumonia-associated complications. Findings include: Resident #28 (R28) R28 was admitted to the facility [DATE]. An annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00 indicating R28 had severe cognitive impairment. R28's diagnoses included a primary medical condition of non-traumatic brain dysfunction. […]

• No harm, potential for more than minimal, widespreadF838Mar 4, 2025

  All times are Eastern Standard Time (EST) unless otherwise noted. Based on interview and record review, the facility failed to complete a comprehensive facility assessment that included training required to meet the needs of the resident population, resulting in the potential for unidentified resources necessary to provide care and services to all 80 residents. Findings include. Review of the Facility Assessment (FA) last revised 1/2025, did not include training on resident rights, dementia care, behavioral health, ethics, and Quality Assurance Performance Improvement (QAPI). […]