Michaelsen Health Center

In the surveyor’s words

From the most serious findings on record at Michaelsen Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880Dec 16, 2021

  A. Based on observation, interview, and record review, the facility failed to follow their policy and CDC's (Centers for Disease Control and Prevention) recommendations regarding the use of PPE (Personal Protective Equipment) when caring for residents identified as PUI (Persons Under Investigation) for COVID-19. This applies to 2 of 8 residents (R45 and R262) reviewed for infection control practices in the sample of 17. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on December 6, 2021 at 12:13 PM, when V4 (Certified Nurse Assistant, CNA) entered R262's room without putting on full PPE for Contact and Droplet Isolation Precautions, exited the room, and then entered R45's room, again without donning full PPE for Contact and Droplet Precautions. […]

• Actual harm, isolatedF689Apr 10, 2026

  Based on observation, interview and record review, the facility failed to ensure a resident's arms were positioned safely outside the sling during a transfer using a sit-to-stand mechanical lift. This failure resulted in the resident falling through the sling, sustaining a head injury that required five staples. This applies to 1 of 4 residents (R2) reviewed for mechanical lift transfer safety. The findings include:R2's face sheet documents diagnoses of dementia, anemia, major depressive disorder, degenerative disc disease, gastro-esophageal reflux disorder, history of falling, cognitive communication deficit and dysphagia. […]

• Actual harm, isolatedF684Apr 18, 2025

  Based on interview and record review, the facility failed to provide timely and comprehensive pain and physical assessment after a fall. This delay resulted in R1 experiencing untreated prolonged pain for five hours from a fracture after a fall and a delay in treatment. This applies to 1 of 3 residents (R1) reviewed for fall-related incidents. The findings include: The Electronic Medical Record (EMR) showed that R1, an [AGE] year-old resident, had an extensive medical history, including but not limited to: B-cell lymphoma with lymph node metastasis, lung cancer, intracerebral hemorrhage, atrial fibrillation, heart disease, hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, venous insufficiency, left below-knee amputation, chronic kidney disease, anemia,… […]

• Actual harm, isolatedF689Apr 3, 2025

  Based on interview and record review, the facility failed to ensure a resident was rolled in a safe manner by two staff persons during incontinence care for 1 of 3 residents (R1) in the sample of 3 reviewed for safety and supervision. This failure resulted in R1 falling out of bed and sustaining fractures of her right and left femurs. The findings include: R1's Face Sheet dated 4/2/25 shows R1 was admitted to the facility on [DATE] with a diagnosis of osteitis deformans of other bones (chronic condition affecting bone structure). […]

• Actual harm, isolatedF689Feb 16, 2023

  Based on interview and record review, the facility failed to safely position a resident during a bed bath. This failure resulted in R1 falling out of the bed and sustaining a subarachnoid hemorrhage. This applies to 1 of 4 (R1) residents reviewed for falls and accidents. Findings include: On 2/14/23 at 11:40 AM, R1 said on the day of the fall (1/13/2023), V4 (CNA/Certified Nurse Aide) was giving her a bed bath. R1 said that V4 rolled her onto her left side, away from V4. R1 said her right leg went over her left leg and over the bed and she slipped and fell off the bed. R1 said she hit her head when she fell off the bed and she had a big bump on the back of her head. R1 said the staff called the ambulance and she was taken to the hospital. […]