Marquette County Medical Care Facility

In the surveyor’s words

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

• Actual harm, isolatedF684Jun 5, 2024

  Based on observation, interview, and record review, the facility failed to develop a care plan and offer/recommend diagnostic testing or consultation with a Gastroenterologist or Physician Specialist to determine the source of prolonged nausea and vomiting for one Resident (R16) of one Resident reviewed for change of condition. This deficient practice resulted in R16 sustaining a 27.3% weight loss in 6 months, a decline in activities of daily living (ADL), a significant change of condition, and the development of multiple pressure injuries. Findings include: Resident #16 (R16) R16 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF686Jun 5, 2024

  Based on observation, interview, and record review, the facility failed to implement and maintain interventions to prevent the development and progression of pressure ulcers (a wound affecting skin, fat, and muscle tissues) for two Residents (#62, #113) of three residents reviewed for pressure injuries. This deficient practice resulted in the development of three stage II pressure ulcers and worsening of pressure ulcers. Findings include: Resident #62 (R62): Review of R62's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including a collapsed vertebra, muscle weakness, peripheral vascular disease, and diabetes. […]

• Actual harm, isolatedF689Jun 5, 2024

  Based on observation, interview, and record review the facility failed to implement, update and revise comprehensive care plans to prevent falls for three Residents (#9, #26, #29) of three residents reviewed for falls. This deficient practice resulted in falls with major injury. Findings include: Resident #26 (R26) Review of R26's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including dementia, left femur fracture, and history of falling. Review of R26's 9/21/23 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 11/15, indicative of mild cognitive impairment. Further review of R26's MDS revealed she had a fall with fracture prior to admission to the facility. […]

• Actual harm, isolatedF689Mar 24, 2022

  Based on interview and record review, the facility failed to provide adequate supervision to prevent falls and to develop and implement appropriate care plan interventions for one Resident (#32) of six residents reviewed for supervision. This deficient practice resulted in a fall with major injury. Findings include: Review of a facility incident report dated [DATE] and written by Licensed Practical Nurse (LPN) G revealed Resident #32 experienced an unwitnessed fall in his room at 4:30 p.m. on [DATE]. The Resident was observed on the floor laying on his back by the wall opposite of his bed with his head on the bottom of the overbed table. The report further revealed, .States he hit his head. Floor wet. Incontinent of urine. […]

• No harm, potential for more than minimal, widespreadF812Mar 24, 2022

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any or all the 112 residents in the facility. Findings include: On 3/23/22 at 7:45 AM observations were made of the point of service on the 600 hall morning meal. Two cups of poached eggs were observed sitting on the counter. The temperature was measured using a metal stem thermometer and found to be 91°F. An interview with Activity staff C, who was serving the food was conducted and asked if the egg temperature had been measured. Staff C stated No. It was taken when it was in the kitchen. […]