Michigan Masonic Home

In the surveyor’s words

From the most serious findings on record at Michigan Masonic Home, in the surveyor’s own words.

• Immediate jeopardy, patternF600Aug 6, 2021

  This citation pertains to MI 332, MI 404, MI 202 and MI 618 Based on observation, interview and record review the facility failed to provide adequate supervision to protect residents from abuse for 8 residents (R 23, R 30, R 32, R 62, R 86, R 119, R 135, R 142) reviewed for being at risk for abuse resulting in an Immediate Jeopardy (IJ) that began on 05/18/21, as a result of the facility's failure to prevent R 30 from abusing other residents after she abused R 32, leading to R 142 and R 23 to be further abused by R 30 and suffer psychosocial harm. This deficient practice has the high likelihood to affect all residents in this facility potentially resulting in further harm, serious injury or death. […]

• Immediate jeopardy, isolatedF600Dec 3, 2021

  This citation pertains to intakes MI 338, MI 992, MI 417, MI 708, and MI 711: Based on observation, interview and record review, the facility neglected residents by failing to provide care and services for 4 resident's (R4, R6, R7, R8) and residents on the 1 South Unit on 11/23/21, reviewed for being at risk for abuse and neglect, resulting in an Immediate Jeopardy (IJ) that began on 11/23/21, as a result of the facility's failure to provide incontinence care and reposition residents leading to R4 having pain and discomfort, R6 developing an unstageable pressure ulcer, multiple Stage II ulcers, experiencing pain, R8 developing multiple stage II ulcers and experiencing pain, R7 experiencing pain and Residents on 1 South having the potential for skin breakdown and pain. […]

• Immediate jeopardy, isolatedF689Aug 6, 2021

  This citation pertains to MI 676 and MI 732 Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure safety and implement interventions to prevent falls for six residents (R 129, R 13, R 20, R 40, R 46, and R 62) reviewed for being at risk for falls, resulting in an Immediate Jeopardy (IJ) that began on 07/21/21, as a result of the facility's failure to prevent R 129 from falling and fracturing her hip after being left alone in the bathroom. This deficient practice has the high likelihood to affect all residents in this facility potentially resulting in harm, serious injury or death. […]

• Actual harm, widespreadF835Dec 3, 2021

  This citation pertains to intakes MI 992: Based on observations, interviews and record review, the Nursing Home Administrator and Director of Nursing failed to administer facility resources to effectively attain and maintain residents highest practical physical, mental and psychosocial well-being, resulting in residents experiencing pain and frustration when they were left soiled for extended periods of time, neglect when they were not provided care, and pressure ulcers. Findings include: According to CMS 2567 form dated 8/6/2021 the facility had deficient practices cited at an immediate jeopardy level for abuse and neglect. […]

• Actual harm, widespreadF867Dec 3, 2021

  This citation pertains to intakes MI 992: Based on interview and record review, the facility failed to identify and implement appropriate plans of action to correct quality deficiencies necessary to assure residents attained and maintained the highest practicable level of well-being, resulting in the potential for serious negative physical and psychosocial outcomes for all residents that resided at the facility. Findings include: According to CMS 2567 forms dated 8/6/2021 the facility had deficient practices cited at an immediate jeopardy level for abuse and neglect. […]