M I Nursing & Restorative Center

In the surveyor’s words

From the most serious findings on record at M I Nursing & Restorative Center, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 2, 2025

  Based on observations, interviews and record review, for one of one sampled residents (Resident #1) who required assistance of two staff members with bed mobility and incontinence care, the facility failed to ensure Resident #1 was free of incidents/accidents resulting in serious injury when care was rendered by one staff, resulting in a humeral (upper arm bone) fracture that required surgical repair. Findings include:Resident #1 was admitted to the facility in April 2022 with diagnoses including Alzheimer's Disease and the presence of a right artificial shoulder joint. Review of Resident #1's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a 99 on the Brief Interview for Mental Status (BIMS) which indicated he/she did not participate. […]

• Actual harm, isolatedF760Sep 27, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose diagnoses included diabetes mellitus and had Physician's orders for insulin to manage the condition, the Facility failed to ensure he/she was free from significant medication errors, when on 09/07/23, after the Physician wrote a new order for insulin, nursing misread and did not clarify the order, and it was transcribed incorrectly onto his/her Medication Administration Record. As a result, from 09/08/23 to 09/11/23, nursing administered 30 units (10 x the dose ordered) of insulin to Resident #1 instead of the 3 units as ordered by his/her Physician. […]

• No harm, potential for more than minimal, patternF550Jan 29, 2026

  Based on observation and interview, the facility failed to 1. provide a dignified dining experience on the 4A nursing unit and 2. ensure staff did not speak in a foreign language while providing care on the nursing units. Findings include: 1. Review of the policy titled the person centered dining approach undated, indicated: Person centered care and hospitality services, including dining, will be a vital part of everyday living. The person-centered dining approach will focus on each individual's needs related to food, nutrition and dining. 1. Each person will be treated like a special individual with a focus on personalizing all interactions and interventions, including nutrition care, food, beverages and dining. 13. […]

• No harm, potential for more than minimal, patternF656Jan 29, 2026

  Based on observation, record review and interview the facility failed to develop and implement a comprehensive person-centered plan of care for five Residents (#171, #4, #11, #3 and #14) out of a total sample of 38 Residents. Specifically,1. For Resident #171 the facility failed to implement heel booties (specialty booties utilized to relieve pressure on the heels). 2. For Resident #4 the facility failed to implement bilateral lower extremity ace wraps.3. For Resident #11 the facility failed to implement bilateral lower extremity compression stockings.4. For resident #3 the facility failed to implement bilateral fall mats while the Resident was in bed.5. For Resident #14 the facility failed to develop a comprehensive plan of care for a pacemaker. […]

• No harm, potential for more than minimal, patternF761Jan 29, 2026

  Based on observations and interviews the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically,For one Resident (#23) the facility failed to ensure medications were not unsecured and stored at the bedside, out of a total sample of 38 residents.The facility failed to ensure that treatment and medication carts were locked when unattended on two units (2B and 3A) out of six units.The facility failed to ensure medications were not left unattended at the nurse's station.Findings include:Review of facility policy titled Medication Storage, undated, indicated the following: -It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the… […]