Every finding on record at Michigan Veterans Home of Chesterfield Township

This citation pertains to intake 2747949.Based on observation, interview, and record review, the facility failed to provide prompt care and services to one resident (R901) of three reviewed for quality of care. Findings include: On 03/03/26 at 8:50 AM, R901 was observed seated in their wheelchair, dressed interacting with a staff member who was working on the computer. At 2:54 PM, R901 was seated in an armchair with a walker toward the left of the chair, and a Certified Nurse Assistant (CNA) to their right. R901 stood independently from the chair and staff queried R901 on their needs providing a confused response and did not immediately sit back down.A review of R901's progress notes revealed R901 had a fall to the floor on 02/06/26 at 7:16 PM.Member decided to get up from chair and sit on the floor . A note at 11:21 PM documented R901 had one shoe on, and one non-slip sock on at the time of the fall. On 03/03/26 at 10:22 AM, Nurse A reported the care plan and the Kardex (care guide) are used for interventions to work through R901's behaviors. It was noted R901 had a history of falls, self-transfer, urinating, and disrobing in the common areas.On 03/03/26 at 10:30 AM, CNA B reported R901 was a fall risk who needed daily intermittent redirection related to standing, disrobing, public urination, and other inappropriate behaviors. CNA B reported specific care needs were noted on the Kardex.On 03/03/26 at 12:03 PM, Licensed Practical Nurse (LPN) C was asked about R901's fall to the floor on 02/06/26. LPN C reported R901 had been busy their whole shift that day and they often had to redirect R901 when the resident attempted to sit on the ground or sit in a chair that was not there. LPN C noted the fall occurred during the evening shift change between 7:00 PM and 7:30 PM. LPN C reported they heard CNA F say (R901) is on the floor. LPN C reported they turned around and observed R901 to be the floor playing with their feet and felt R901 was safe and continued to work on their documentation on the computer. LPN C indicated two nurses were at the nurse station and reacted in a similar way. LPN C then reported after a few minutes CNA F said they could not get R901 up off the floor.LPN C went on to say on review of the video R901 had been transferring themself back and forth between different chairs in the common area with CNA F in attendance monitoring and at one-point R901 missed the arm of the chair and went to the ground. CNA F was not able to be contacted for comment.On 03/03/25 at 1:20 PM, CNA E reported they had been working on R901's unit at the time of the fall but did not see the fall. CNA E reported R901 normally wanders and goes from chair to chair and when R901 winds down may be found asleep in one of the chairs for a while. CNA E reported CNA F tried to get R901 up but R901 was resisting and told the nurses to call for two male staff to help get (R901) up and they just looked at CNA F. CNA E reported after some time passed and no one came the nurses went over to help get R901 up. On 03/03/26 at 3:23 PM, the administrator reported all falls are reviewed and upon review of the video for R901's fall the CNA was seen to call in the direction of the nurse station and the nurses did not immediately get up to go and assess R901. The administrator commented they expected to see the nurses respond immediately and it was not acceptable to not assess the resident immediately. The administrator noted about 15 minutes had elapsed between the time of the resident's fall and the nurse's response. A review of the record for R901 revealed R901 was admitted into the facility on [DATE]. Diagnoses included Dementia, Adjustment Disorder with Anxiety and Depressed Mood, and Vitreous Opacities (Impaired Vision). A progress note dated 02/23/26 documented the Brief Interview for Mental Status (BIMS) score to be 3/15 which indicated severely impaired cognition. A review of the care plan: (R901) is at risk for falls (related to) r/t Alzheimer's, impaired safety awareness, arthritis, high blood pressure, and a history of stroke revealed: (R901) often refuses to wear a gait belt while ambulating despite safety education. (R901) often bends down to pick stuff up off the floor, (R901) bends down to (their) hands and knees to pick stuff up. Date Initiated: 08/03/2023 Revised 02/16/26; Assist (R901) to the floor if (R901) asks to sit onto the floor. Date Initiated: 02/10/2026 Revision on: 03/02/2026. If a fall occurs, follow facility protocol for post-fall. Review and document with the IDT to identify root cause and factors contributing to the fall. Date Initiated: 08/10/2023 . The Kardex (CNA care guide) documented, when (R901) is demonstrating less ability to walk use wheelchair .A review of the facility policy titled, Fall and Fall Risk, managing with review date of 05/05/25, revealed, .A fall is defined as (according to the MDS): unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Challenging a resident's balance and training him/her to recover from loss of balance is an intentional therapeuticintervention. The losses of balance that occur during supervised therapeutic interventions are not considered a fall .A review of the facility policy titled, Accident/Incidents, Investigation and Reporting with review date of 07/10/25, revealed, .6. In the event of an incident or accident, immediate assistance will be provided, or securement of the area will be initiated unless it places one at risk of harm. 7. Any injuries will be assessed by the licensed nurse or practitioner, and the affected individual will not be moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions. 8. The supervisor or other designee will be notified of the incident/accident. If necessary, law enforcement may be contacted for specific events .

Based on observation, interview, and record review, the facility failed to apply and/or document refusals of a palm protector for one resident (R82) out of one reviewed for range of motion, resulting in the potential for contractures and/or delay in treatment. Findings include: On 1/30/2023 at 9:55 AM, an interview was conducted with R82 regarding their stay in the facility. R82 stated that they enjoyed being in the facility, however they would like their therapy to be a little more intense. R82 stated that they would like to work more on their hands and sitting up. Nothing was noted on R82's hands. A review of the medical record revealed that R82 admitted into the facility on [DATE] with the following diagnoses, Muscle Wasting and Atrophy and Unspecified Injury at Unspecified Level of Cervical Spinal Cord. A review of the most recent Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R82 also required total two-person assistance with bed mobility and transfers. A review of the physician orders noted the following, Order: Remove Palm Protectors and evaluate skin integrity of bilateral hands, replace palm protectors, notify provider of any skin issues. Directions: Every Evening Shift. Status: Active. Start Date:9/7/2022 15:00 (3:00 PM). Further review of the Treatment Administration Record for the month of January did not reveal any refusals of palm protector application. A review of the task noted the following, Wash bilateral hands, ensure care between fingers, dry thoroughly and replace palm protectors. Notify Nurse of any skin issues observed. Further review of the task list for the last thirty days did not reveal any refusals of palm protector application. On 1/31/2023 at 9:41 AM, R82 was observed in the bed with no palm protectors on. R82 stated that they have not worn them 'in a while' and that no one has tried to put them on. R82 stated that sometimes they will use a towel because the current splint they have is uncomfortable. On 1/31/2023 at 10:32 AM, an interview was conducted with Therapy A regarding R82 not being observed wearing palm protectors. Therapy A stated that R82 refused them all the time and Occupational Therapy (OT) has tried three different type of hand splints. Therapy A stated that they have asked the nursing staff to be sure they document refusals. On 1/31/2023 at 12:54 PM, an interview was conducted with the Director of Nursing (DON) regarding R82's palm protectors. The DON stated that their expectation is that if R82 is in fact refusing to wear the palm protectors then that should be documented in the medical record. A review of a facility policy titled, Assistive Devices and Equipment noted the following, Policy: The home maintains and supervises the use of assistive devices and equipment for members.

Based on observation, interview, and record review, the facility failed to don a gown for a contact precaution room for one resident (R82) out of one reviewed for isolation precautions, resulting in the potential for the spread of infection. Findings include: A review of the medical record revealed that R82 admitted into the facility on [DATE] with the following diagnoses, Muscle Wasting and Atrophy and Unspecified Injury at Unspecified Level of Cervical Spinal Cord. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R82 also required total two-person assistance with bed mobility and transfers. A review of the physician orders noted the following, Order: Contact Precautions r/t (related to)continuing symptoms of ESBL(infection resistant to antibiotics)-post contact precautions sign outside the room and ensure visible (not on door)-PPE cart outside room with donning (putting on) sign-minimum of touchless trash can inside room with doffing (removal of) sign (may choose to use 3 bin cart .Status: Active. On 1/31/2023 at 9:40 AM, A contact precautions sign was observed in front of the room, as well as a Personal Protective Equipment (PPE) bin. On 1/31/2023 at 9:41 AM, Certified Nursing Assistant (CNA) D was observed at R82's bedside with gloves and no gown on. R82 stated that they were being cleaned up. On 1/31/2023 at 11:54 AM, an interview was conducted with Infection Control Preventionist (ICP) C regarding the observation. ICP C stated that if they are changing R82's (name of catheter) catheter then they should be wearing a gown, gloves, and goggles. ICP C stated that if they are going in to give care, they should be wearing a gown and gloves. A review of a facility policy titled, Isolation Precautions noted the following, Contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the member or the member's environment.

This citation pertains to intake MI 306. Based on observation, interview, and record review the facility failed to prevent resident to resident abuse, for four sampled residents (R901, R902, R903, and R904) of four reviewed for abuse, resulting in an injury to R901's head and R904's hand. Findings include: Resident #901 (R901) A review of the facility's report incident allegation noted, It was reported there was a resident-to-resident physical abuse incident which resulted in injury. On 6/7/22 at 12:03 PM, R901 was observed in the common area of the unit. R901 was interviewed and asked about the incident but was unable to recall the incident. A review of R901's medical record noted, Incident 4/25/2022 19:28. Incident Note Text: After walking past a member (R902) who was playing horseshoes there was a verbal disagreement between the two that was easily redirected by nursing staff. Shortly after [R901] was walking back to R901's room and past the member (R902) who there was a disagreement with earlier when [R902] pushed [R901] and [R901] walker down. Staff was present and stated member had hit [R901's] head when [R901] fell . Vital signs were taken and member assessed while laying on floor. [R901] continued to whimper and cry but would not answer any questions. Member then had an episode of emesis; [R901] was log rolled to [R901's] side at this time. EMS (Emergency medical services) was contacted to transport member to the hospital. Member's son was contacted and requested [R901] be sent to [local hospital]. He wanted to talk to [R901], so phone was given to member and [R901] talked with him and answered questions appropriately. Ambulance arrived placed a c-collar on the member and transferred her to the cart. On 6/7/22 at 12:10 PM, the unit Nurses were asked about the incident with R901 and R902 and explained they were not there for that incident. On 6/7/22 at 1:32 PM Nurse A was asked about the incident with R901 and R902 and stated, I was taking my garbage out, shift was changing when I came back, I heard the noise and the reaction. Nurse A explained that R901 and R902 had a verbal incident prior to R902 pushing R901, but they had intervened and kept them away from each other. Nurse A explained that after the verbal incident with R901 and R902, later that day R902 yelled from across the room and pointed at R901 and said stupid. R901 jumped up and became upset that R902 called them stupid. Nurse A further explained that right before the push that they had just took [R901] to [their] room around 7:00 pm. Nurse A further explained that when R901 was on the floor, [R901] said my pain my pain and grab at [their] head, then started to throw up and sounded like they were praying in a different language. On 6/7/22 at 1:40 PM, CNA B was asked about the incident and stated, It was getting close to end of the shift, I was pulling trash and doing charting. When I walked back [R901] was going down. CNA B explained that R902 was very hard to redirect that day. CNA C written statement, At 6:45pm I [CNA C] was coming from putting soiled linen and trash away I saw [R902] one of the members toss [R901] another member to the floor. [R902] grabbed [R901's] walker and proceeded to push [R901] and the walker. [R901] fell back and hit [their] head very hard and after 2 or 3 minutes [R901] started to vomit. [R902] hovered around while [R901] laid on the floor. CNA B written statement, At 645pm I was charting with (staff member) and suddenly I heard (staff member) scream [R902] No and immediately we both began running over to the situation. As we were running, [R901] was mid air falling and [R902] had [R901] walker in [their] hands and at that point we were trying to make sure [R901] was ok and stable. I was then directed by the nurse to get security. Prior to this happening it was brought to the house supervisor attention that [R902] has been exit seeking as well as being VERY agitated and aggressive towards staff members. We tried redirecting him multiple times, play horseshoes and calm [R902] down nothing was working. CNA D written statement, Upon my arrival to my shift at 6:45pm I walked on the unit [R902] and another male resident was talking then I noticed [R901] walking up to them then that's when [R902] grabbed her walker and slung her around then proceeded to push [R901] really hard and then threw her to the floor. Nurse A written statement, During pm shift, at 15:45 member (R902) was pacing, getting close to any doors. Around 16:25 writer took member for a walk, we stopped at Activity room, [R902] was shoving writer [their] projects. After returning to a unit [R902] had dinner, played horseshoes with writer and another member. While [R902] was playing, [R901] walked to [their] room, [R902] made a comment addressed to [R901] about interruption their game. [R901] member get into the [their] room, writer followed [them], [R901] showed writer picture of there son, shortly [R901] was coming back to common area, meeting [R902] again. Once again, [R902] made a comment, using inappropriate F word. [R901] member came back to the table, where [they] was working on puzzle, from the distance, [R902] member point to [R901] and called [R901] stupid, [R901] reacted back right away, [R901] stood up, raised both hands/fists and moved forward to [R901's] opponent. Writer stopped [R901] and calmed [them] down. Shortly, while writer was taking trash out to Soil room, writer heard a voice, when writer entered the unit, [R901] was on the floor, face up, head was on floor, eyes were closed. 4/27/2022 11:00. Nurses Progress Note Text: Writer spoke with nurse at [local hospital], nurse reported that [R901] is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of R901's medical record noted, Hospital discharge document, Visit Summary For: [R901] Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Comment: Discharge Wound Care Instructions: May remove dressing in 24 hours . R901 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum Data Set (MDS) assessment noted a severe cognitive impairment. Resident #902 (R902) R902 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS assessment noted a severe cognitive impairment. According to the facility's summary R902's care plan identifies [R902] as being high risk for wandering and elopement, having inappropriate sexual behaviors and physical aggression/agitation, having impaired cognitive function due to Alzheimer's, communication deficit due to hearing loss, use of [CONDITION(S)] medications, and having mood problems related to depression, anxiety and [CONDITION(S)] ([CONDITION(S)]). Some interventions for R902 include a wander guard for safety, frequent intentional rounding, redirection and distraction with food, offering activities of [R902] liking, and walks. Resident #903 (R903) On 6/7/22 at 12:10 PM, the unit Nurses reported that there was a unwitnessed incident with R903 and R904. The Nurse explained that R904 came into their (R903) room and grabbed their arm and they scratched R904's hand. On 6/7/22 at 12:10 PM, R903 was asked about the incident with R904 and was unable to be interviewed due to cognitive impairment. On 6/7/22 at 1:40 PM, CNA B was asked about the incident with R903 and R904 and stated, I was on break they gave me report and told me what happened. A review of R903's medical record revealed, 5/31/22 17:15 Nurses Progress Note Text. Writer noted that member came out of room with increased agitation and pacing. Member verbally stated that she was angry and that there was a man in her room that did not belong. Upon assessment member was calmed and assured her that she was safe. There were no noted injuries and member denied pain. Member stated that the man came in her room and grabbed at her hand . R904 On 6/7/22 at 12:18 PM, R904 was interviewed and asked about the injury to their hand and was unable explain it due to cognitive impairment. A review of R904's medical record revealed, Altercation form: Date 5/31/22 Writer sitting at nurses' station, when CNA came from back hallway reporting a hand injury. Member ambulated towards nurse with blood dripping from hand. Sat at table in common area. Wound cleaned, steri-stripped and bandage. No anxiety noted . Progress note revealed, 5/30/22 22:37 Behavior Note Text: Member has been very agitated, yelling at staff, refusing medication, and refusing to use walker when reminded. Member still refusing after educated on why medication and walker are important. 5/31/22 20:16 Alert Note Text: Member attempted to hit CNA in her face. Other staff intervened nurse notified. Attempted to redirect member and offer a snack and activities, member refused. On 6/7/22 at 1:08 PM, the Director of Nursing and Nursing Home Administrator (NHA) was interviewed about the incident and confirmed the details from the witnesses, and that education was provided to staff after the incident. The NHA was asked about the incident with R903 and R904 and explained, therapy had just left R904's room, R904's room was next to R903 and the room was changed after the incident. A review of the facility's policy revealed, titled, Abuse & Neglect Prevention: Abuse Prevention Program dated 4/16/21 noted, POLICY: Our members have the right to be free from abuse, neglect, misappropriation of property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the member's symptoms. GUIDELINES Policy Explanation and Compliance Guidelines: As part of the member abuse prevention program, the home's administration will: 1. Protect our members from abuse by anyone including, but not necessarily limited to staff, other members, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual .