Mackinac Straits Long Term Care Unit

F 0605 During an interview on 05/29/25 at 12:55 p.m., the Director of Nursing (DON) was queried about the process for administration of PRN psychotropic medication, including lorazepam. The DON reported staff were Level of Harm - Minimal harm or expected to document specific behavior, signs and symptoms targeted by administration of PRN anti-anxiety potential for actual harm medication. The DON reported she was aware of staff administering PRN lorazepam to Resident R28 without identifying the specific need for the medication. The DON stated, I keep telling them you can't just give it to Residents Affected - Few him because he asks for it, there has to be a reason. The DON reported non-pharmacological interventions should be utilized in an attempt to alleviate Resident R28's anxiety prior to administration of the PRN lorazepam to ensure the Resident is not administered unnecessary medication. The DON acknowledged the need for accurate and complete documentation related to administration of the medication to determine effectiveness of Resident R28's medication regimen and if changes to the Resident's plan of care were warranted.

Review of the facility policy titled, Psychotropic Medications, revised 5/2024, revealed the following:

Physician will order psychotropic medications only for the treatment of specific medical and/or psychiatric conditions or when the medication meets the needs of the resident to alleviate significant distress for the resident not met by the use of non-pharmacological approaches . Orders for PRN psychotropic medications will be time limited and only for specific, clearly documented circumstances.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 11 235041 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235041 B. Wing 05/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mackinac Straits Long Term Care Unit 1140 North State Street Saint Ignace, MI 49781

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49310 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure bed rail assessments were completed to evaluate entrapment risk prior to the use of bed rails, obtain a physician's order for the use of bed rails, attempt alternatives prior to the use of bed rails, provide medical reason for the use of bed rails, and document the risks and benefits of bed rails for one Resident (#46) of one resident reviewed for accident hazards. Findings include:

Resident #46 (Resident R46)

On 5/27/25 at 12:38 PM, Resident R46 was observed with bed rails on both sides of the bed. Resident R46 was unable to answer questions regarding the bed rails due to confusion and cognitive impairment.

Review of the Electronic Medical Record (EMR) revealed Resident R46 was admitted to the facility on [DATE REDACTED] with a primary medical diagnosis of severe vascular dementia. A Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented Resident R46 was dependent on staff for Activities of Daily Living (ADL) including but not limited to bed mobility, turning, and repositioning. The MDS documented a Brief Interview for Mental Status (BIMS -

a test for cognitive status) score of 99 indicating Resident R46 was unable to complete the BIMS due to having severely impaired cognition.

The EMR did not contain an assessment of the risk of entrapment prior to application of the bedrails. The physician orders for Resident R46 did not contain an order for the bedrails. No documentation was found regarding alternatives that were attempted prior to installing bedrails. No medical symptoms or bedrail measurements were in the medical record.

A form Side Rail assessment dated [DATE REDACTED] was present in the EMR of Resident R46. The form read, in part: .in addition to this signed form authorizing the use of bed rails for this resident, a written order from the resident's attending Physician, specifying the medical rationale and circumstances for use, must be obtained prior to the installation of this medical treatment device. It is also my understanding that the Facility will periodically review and re-evaluate the resident's need for bed rails and that the resident, responsible party and attending Physician will be consulted in this matter . The form was signed by the Resident Representative (RR) of Resident R46 on 1/14/25.

A question on the Side Rail Assessment form asked, Why is side rail being used? The written response was When in bed. The form did not include the indication for use or the risks and benefits for the use of the side rails. An additional area of the form: Specific medical symptoms which require side rail use was blank and did not provide the medical symptoms to justify the use of the bed rails.

The Side Rail Assessment form did not document a review of the risks and benefits of side rail use to ensure

the RR of Resident R46 was provided sufficient information to make an informed decision regarding bed rail utilization.

Documentation of the bed's dimensions and measurements to ensure appropriateness for Resident R46's size and weight were not found in the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 235041 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235041 B. Wing 05/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mackinac Straits Long Term Care Unit 1140 North State Street Saint Ignace, MI 49781

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)