Every finding on record at Northville Manor

Based on observation, interview, and record review, the facility failed to ensure the resident and/or legal representative formulated an Advance Directive to grant and/or withhold life sustaining treatment (Cardiopulmonary Resuscitation/CPR, Artificial Nutrition/Peg Tube, Artificial Hydration/ IV, and Diagnostic Testing) according to their wishes upon for two residents (6 and 25) of five residents reviewed for advance directives, potentially resulting in inaccurate life sustaining or life withholding medical treatment. Findings include:R25-On [DATE] at 10:48 p.m. R25 was observed resting in bed. R25 presented as alert and oriented to person and place only with difficulty with hearing. R25 became confused while attempting to answer interview questions. R25 was unable to complete the initial interview.On [DATE] at 2:07 p.m. review of the clinical electronic medical record documented R25 was initially admitted into the facility on [DATE] with diagnosis that included epilepsy, dementia, major depressive disorder and chronic kidney disease. According to the annual Minimum Data Set (MDS) assessment dated [DATE], R25 was severely cognitively impaired (BIMS-6) and required total assistance from staff with activities of daily living. Review of the Resident Code Status form dated [DATE] documented a Do-Not-Resuscitate (DNR) code status that was signed by the healthcare legal decision maker. Review of the physician order dated [DATE] documented: DNR- Do Not Resuscitate.Review of face sheet documented R25 had a Durable Power of Attorney (DPOA-A power of attorney is a legal document that allows someone else to handle your legal, medical, or financial affairs). Review of the DPOA document in the electronic medical record was for finances, not medical. On [DATE] at 1:08 p.m. the facility submitted R25's DPOA document for finances due to a Medical DPOA being not available. Review of the care plans revealed the absence of a DNR care plan. Review of the social service and care conference progress notes revealed no discussion with the legal representative (for finances) requesting legal documents to make medical decisions.On [DATE] at 11:56 a.m. Social Service Tech (SST) A was interviewed about the facility's process for ensuring advance directives were properly formulated. SST A said a Medical DPOA had not been requested and the DPOA for finances should not have signed an order for DNR. SST A also said R25's level of decision making had not been confirmed. R6-On [DATE] at 11:19 a.m. R6 observed resting in bed and presented as alert and oriented to person and place. R6 said they were not feeling well today but could not verbalize the reason. R25's voice low and with some incoherent speech. R25 did not understand what an advance was exhibited by shrugging shoulders. Review of the EMR documented R25 was initially admitted into the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease, generalized anxiety, schizophrenia disorder, and dementia. According to the quarterly MDS assessment dated [DATE] R25 had moderate impaired cognition and required partial assistance with activities of daily living. Review of the face sheet revealed R25 had a court appointed legal guardian.Review of the Resident Profile page in the EMR documented a Full Code status for an advance directive.There was no evidence that an advance directive was formulated with the legal guardian and placed in the EMR. There was no evidence a code status was established by the legal guardian.There was no evidence of an advance directive being addressed in Social Service progress notes. On [DATE] at 10:54 a.m. R6's advance directive was requested and had not been provided by the end of the survey.On [DATE] at 11:51 a.m. Social Service Tech (SST) A was interviewed about the facility's process to ensure advance directives were properly formulated. The SST said the advance directive had not been uploaded to the electronic medical record due to not being able to reach the legal guardian. Contact with legal guardian had been made via email and fax. SST A said there was no documentation that contact was made. There have been no attempts to contact since February 2026.On [DATE] at 2:30 p.m. the Nursing Home Administrator (NHA) was interviewed and said they had to work with the Social Service Department to ensure all residents have the correct advanced directives. Review of the facility's policy titled Residents Rights Regarding Treatment and Advance Directives revised date [DATE] documented in part the following: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. The facility will provide the resident or resident representative with information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive. Upon admission, should the residents have an advanced directive, copies will be made and placed on the chart as well as available to the staff in the EMR.

Based on observation, interview, and record review the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms, affecting seven (2, 7, 10, 11, 12, 14, 15) of 15 resident rooms. Findings include:On 05/28/26 at 9:15 AM, observation of resident rooms and record review of the facility documentation revealed the following:Room # Sq./Ft # # of Beds current #residents in room2 283 4 27 218 3 110 225 3 311 215 3 312 154 2 114 144 2 215 144 2 2Observations and interviews with various residents revealed no specific complaints and no specific health/safety concerns.

Based on observation, interview, and record review the facility failed to post revised menus and planned menus in advance for residents, resulting in the potential for a decline in nutritional status and resident dissatisfaction with meals. This deficient practice affected 27 of the 28 residents that consumed meals from the kitchen. Findings include: On 4/15/25 at approximately 10:35 a.m. posted in the dining room revealed the posted lunch menu listed: Braised Beef Tips, Parsley Noodles, Seasoned carrots, wheat rolls, Boston cream pie, coffee or tea, milk. However, during the lunch observation at 12:00 p.m. residents were instead served the following: Hamburger/Bun, lettuce, tomato, onion, pickles, ice cream, beverage of choice. At 1:30 p.m., an interview with Dietary Manager (DM) A was conducted regarding the inconsistency between the posted menu and the meal served. DM A explained on 4/13/25 a new dietary employee had mistakenly used the meat intended for Tuesday's lunch meal, and it was too late to place a new order from the facility's food vendor. DM A stated, whenever an item is unavailable or a situation like this arises, a meeting is held with the residents to vote on the substitute menu, with the majority determining the outcome. When further questioned about the complete menu change, including the dessert substitution, DM A stated although the Boston Cream Pie was available in the freezer, an unspecified decision was made to change the entire menu. DM A indicated that while residents in the dining room and in their rooms were consulted, no evidence could be produced to show that the menu changes were formally posted or that official meetings were documented for any of the days when substitutions occurred. On 4/16/25 at approximately 9:00 A.M. a request was made to review the substitution log for the current winter cycle. The review revealed on 3/28 Potato salad was to be served but was substituted with potato chip and on 4/14/25 Salmon Croquettes for the dinner meal were replaced with resident's choice of pizza and salad. The substitution Logs documenting these changes were not provided until 4/17/25 after DM A and [NAME] K said they were not aware the resident's posted menus should be changed or modified when there was a change in the planned menu. During interview with DM A regarding the planning of Easter Sunday menu, DM A stated the menu would probably change because it was a special occasion. DM A further explained that Saturday's planned lunch would be switched with Sunday's lunch but admitted that the residents had not been informed of the changes and that the planned menu had not yet been posted or completed. On 4/17/25 at 10:00 A.M. and at 3:30 P.M. during the exit conference with the Corporate (Registered Dietitian) RD, the Director of Nursing, and the Administrator, no additional information or evidence was presented explaining why resident's menus were not updated or posted in accordance with changes made to the planned menu.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 28 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 04/14/25 at 01:25 P.M., A common area environmental tour was conducted with Director of Maintenance I. The following items were noted: Resident Restroom [ROOM NUMBER]: The overhead clear plastic light lens cover was observed soiled with (dust, dirt, numerous dead insect carcasses). Director of Maintenance I indicated he would have staff clean and sanitize the light lens cover as soon as possible. Shower Room: The shower wand assembly was observed missing an atmospheric vacuum breaker. Director of Maintenance I indicated he would install an atmospheric vacuum breaker as soon as possible. Resident Restroom [ROOM NUMBER]: The hand sink faucet assembly was observed (etched, scored, particulate, corroded). Director of Maintenance I indicated he would install a new faucet assembly as soon as possible. On 04/14/25 at 01:50 P.M., An interview was conducted with Director of Maintenance I regarding the facility maintenance work order system. Director of Maintenance I stated: We have a manual work order system. Director of Maintenance I also stated: The maintenance logbook is located at the Nurses Station. Nursing Station: The black vinyl padded chair was observed (etched, scored, particulate), exposing the inner Styrofoam padding. The damaged black vinyl surface measured approximately 3-inches-wide by 30-inches-long. Director of Maintenance I indicated he would replace the worn chair as soon as possible. The Hallway Corridor carpeting was observed (stained, worn, buckled). One large red colored carpet stain was also observed directly beneath the resident call system panel. The stained carpet surface measured approximately 12-inches-wide by 12-inches-long. On 04/14/25 at 02:07 P.M., An interview was conducted with Nursing Home Administrator (NHA) regarding a replacement plan for the facility hallway corridor carpeting. (NHA) stated: No, not at this time. The Day Room carpeting was observed (stained, worn, pilled). On 04/14/25 at 03:50 P.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance I. The following items were noted: 2: The Bed 1 and Bed 3 overbed light shades were observed heavily soiled with accumulated and encrusted dust/dirt deposits. 7: The Bed 1, Bed 2, and Bed 3 overbed light shades were observed heavily soiled with accumulated and encrusted dust/dirt deposits. 11: The Bed 3 stationary desk fan was observed heavily soiled with accumulated and encrusted dust/dirt deposits. Director of Maintenance I indicated he would have housekeeping thoroughly clean and sanitize the desk fan as soon as possible. 14: The Bed 1 and Bed 2 overbed light shades were observed heavily soiled with accumulated and encrusted dust/dirt deposits. Director of Maintenance I indicated he would have housekeeping thoroughly clean and sanitize the soiled light shades as soon as possible. On 04/17/25 at 08:00 A.M., Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 11/02/2022 revealed under Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 11/02/2022 further revealed under Policy Explanation and Compliance Guidelines: (1) The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. On 04/17/25 at 08:15 A.M., Record review of the Policy/Procedure entitled: Cycle Cleaning dated 10/26/2022 revealed under Policy: It is the policy of this facility to identify the functional areas in the facility that require cleaning and to use cycle cleaning schedules to outline the frequencies and maintain scheduled environmental service tasks. Record review of the Policy/Procedure entitled: Cycle Cleaning dated 10/26/2022 further revealed under Policy Explanation and Compliance Guidelines: (1) Routine cleaning of environmental surfaces and non-critical resident care items shall be performed according to a predetermined schedule and shall be sufficient enough to keep surfaces clean and dust free.

Based on observation, interview, and record review the facility failed to (1.) provide a dignified dining experience for three residents (R2, R3, and R7) of 25 residents observed during dining, resulting in staff standing over residents while assisting with feeding and (2.) meals served with an assortment of dinnerware, compromising the residents' rights to a respectful and individualized dining experience. Findings include: On 4/14/25 at approximately 10:20 A.M., R3 who was alert and oriented stated, They serve my food on plastic plates. I would like real silverware not paper and plastic. Observations at that time showed a stack of plastic ware on the resident's bedside table. On 4/15/25 at 12:30 p.m. during a lunch observation, Nurse J was observed standing over R7 while assisting with the resident's meal. Initially Nurse J positioned himself in front of R7 in a squatting position before standing to R7's right side, cueing and prompting the resident while intermittently checking the medication cart returning to R7's side placing spoon or pieces of food in the resident's mouth and hands without consistent engagement. While Nurse J was obtaining a napkin for R7, R2 seated at another table, self-propelled herself out of the dining room to the front lobby area wearing a soiled clothing protector. R2 was later returned to the dining room where her hands and face were cleansed and the soiled protector removed. Additionally, during this lunch observation, some residents were observed without napkins or plastic ware causing residents to delay starting their meal requesting staff to assist with cutting their hamburgers. On 4/16/25 at 12:00 P.M. at lunch approximately 15 residents in the dining room were served their meal with an assortment of dinnerware including Styrofoam cups and dessert plates, plastic utensils, and 6--inch melamine plates which were insufficient in size to accommodate both the entree and salad served. At 12:23 P.M., Dietary Manager (DM) A was asked to observe the meal service. When questioned regarding the use of assorted and inadequate tableware, DM A explained the facility had a full set of dishes available, there were no call-ins that day, and the dish machine was operational. I am not sure why cook (K) is not using those dishes. In a follow up interview at 3:45 P.M., [NAME] K was unable to provide a reason why assorted dinnerware was used during the meal service. During this same observation, Nurse L was observed standing while feeding R2. When asked, whether staff should stand when assisting residents with meals, Nurse L stated, We try to cue residents who cannot feed themselves, but sometimes the dining room get crowded and there is not sufficient room to provide one-on one feeding. On 4/17/25 at 11:00 A.M., a review of the facility policy titled, Promoting/Maintaining Resident Dignity, dated 11/1/2022, revealed that while the policy emphasized promoting respect and dignity and enhancing resident's quality of life by recognizing each resident's individuality, it did not specifically address dignity practices during dining. Upon exiting the facility on 4/17/25 at 3:00 P.M., no additional information regarding these concerns was provided.

Based on observation, interview, and record review the facility failed to provide behavioral health services for five residents (R6, R7, R8, R9 and R16) out of twelve residents reviewed for behavioral health resulting in the potential for residents not to attain or maintain their highest practicable mental and psychosocial well-being. Findings included: R6 On 4/14/25 at 10:56 AM R6 was observed sitting in a wheelchair holding a stuffed animal in her left hand, leaning to the right with a bruise on her right elbow. When R6 was asked about the bruise on her R elbow R6 could not recall how she got the bruise. Record review of R6's Electronic Health Record revealed R6 was admitted to the facility on [DATE] with pertinent diagnoses that included Alzheimer's Disease, adjustment disorder with anxiety, adjustment disorder with depressed mood, unspecified intellectual disabilities, and unspecified dementia. Review of the Minimum Data Set (MDS) dated [DATE] revealed that R6 had severely impaired cognition and was wheelchair bound. Review of the nurse's progress note dated 1/28/25 revealed R6 had a fall on 1/28/2025 with no injuries. Review of R6's physician orders revealed R6 was prescribed diazepam (antianxiety) and sertraline(antidepressant) medications. On 4/15/25 at 2:55 PM the Nursing Home Administrator (NHA) was interviewed and said R6 was last seen by the psychiatric practitioner on 8/12/24 to address the psychotropics and antidepressants. Review of the physician progress notes dated 1/21/25, 2/26/25 and 3/17/25 revealed Psych follows the patient for history of dementia. Dementia-continued input from Psych appreciated. Review of R6's care plan revealed Problem start date 4/5/23 I have verbal behavioral symptoms directed toward others; I have physically aggressive behavior towards others. Approach start date 4/25/23 obtain a psych consult/psychosocial therapy as needed. R8 On 4/14/25 at 10:44 AM R8 was observed sitting in her wheelchair in her room yelling out. When R8 was asked about how she felt R8 yelled out, Fine and [NAME] just like candy. On 4/15/25 at 8:20 AM R8 was observed in her room slumped in her wheelchair yelling out. On 4/16/25 at 12:26 PM R8 was observed in the dining room banging the table with frequent yelling. On 4/17/25 at 8:25 AM R8 was observed sitting alone in her room banging an empty glass on plate yelling out. On 4/15/25 1:30 PM Social Worker F was interviewed about R8's behaviors and said psychiatric services last saw R8 on 8/24 and the expectation is for the resident to receive psychiatric services at least quarterly. Record review of R8's Electronic Health Record revealed R8 was admitted to the facility on [DATE] with most recent readmission on 8/31/2024 with pertinent diagnoses that included reaction to severe stress, unspecified, major depressive disorder, recurrent unspecified, vascular dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) dated [DATE] revealed that R6 had severely impaired cognition and was wheelchair bound. Record review of physician orders revealed order date 8/4/23 may have ancillary services psychiatric. Record review of R8's care plan revealed, Problem Start Date: 07/05/2023 Category: Behavioral Symptoms I am at risk of displaying signs and symptoms of mood distress R/T dx of major depressive disorder recurrent unspecified. Approach Start Date: 07/05/2023 Obtain a psych consult as needed. Problem Start Date: 07/05/2023 Category: Behavioral Symptoms I have behavioral symptoms not directed to others. I yell out. I remove my clothing. I pull my shirt over my head which exposes my chest/torso area. Approach Start Date: 07/05/2023 Obtain a psych consult as needed. Review of the physician progress notes dated 2/11/25 and 3/17/25 revealed Patient is followed by psych, with recommendations to continue current treatment regimen. Dementia: Psych is following. On 4/17/25 at 10:00 AM the Director of Nursing (DON) was interviewed and said the expectation is for psychiatric services to follow residents who are prescribed antipsychotic medications and/or exhibit behaviors at least quartetly. The DON said R6 and R8 were last seen by psychiatric services in August of 2024 and that there is not a current pscychiatric group servicing the building. 50634 R16 On 4/14/25 at 11:00 AM, R16 was observed in dinning room in wheelchair. R16 had multiple bruises on the face from a previous fall. On 4/15/25 at 12:45 PM, R16 was observed in the dinning room crying. R16 was crying saying she did not know what she should be doing and could not remember who she was. Registered Nurse (RN) J reminded her of her name and where she was. R16 continued to repeat they did not know who they were. On 4/17/25 at 10:00 PM, R16 was observed in the dinning room crying. RN J was sitting next to R16 talking to her. R16 continued to cry. Record review of R16's Electronic Medical Record (EMR) revealed that R16 had not received Psychiatric services since 11/5/24. Record review of R16 (EMR) documented R16 was admitted on [DATE] with a pertinent diagnosis of Major depressive disorder, anxiety disorder, dementia and mild cognitive disorder. Review of R16, Quarterly Minimum Data Set (MDS) dated [DATE] for Brief Interview for Mental Status (BIMS) R16 was severely cognitively impaired with a score of 99. R9 On 4/14/25 at 2:00 PM observed R9 in room sitting on bed in room talking with other residents. Record review of R9's (EMR) revealed that R9 had not seen Psychiatric services since 8/12/24. Record review noted R9 was admitted on [DATE] with a pertinent diagnosis of Major depressive disorder, dementia, paranoid personality disorder, adjustment disorder with mixed anxiety and depressed mood, psychotic disorder with hallucination. Review of R9 Quarterly (MDS) dated [DATE] for BIMS R9 was moderately cognitively impaired with a score of 9 out of 15. R7 On 4/15/25 at 12:45 PM, R7 was observed in the dinning room eating. Record review of R7's (EMR) revealed R7 had not seen since Psychiatric services since 7/15/25. Record review noted R7 was admitted on [DATE] with a pertinent diagnosis of Vascular dementia with mood disturbances, psychotic disorders with delusions, schizophrenia, adjustment disorder and mood disorder. Review of R7's (MDS) dated [DATE] for BIMS R9 was severely cognitively impaired with a score of 99. On 4/16/25 at 2:00 PM, Social Worker (SW) F was interviewed about residents not receiving Psych services. SW F said they had recently started coming back to this facility in February after a staff change and they are working on getting services established with a Psychiatric services provider. On 4/16/25 at 2:15 PM, the Director of Nursing (DON), was interviewed and said the previous provider would meet with her and keep her up to date on resident's care. When the new provider started coming out, they did not meet, so she was unaware the residents where not receiving services. On 4/16/25 at 2:15 PM, the Nursing Home Administrator (NHA), was interviewed and said if they would have noticed any changes in residents' behavior they would have communicated the changes to the provider.

This citation includes two Deficient Practice Statements. Deficienct Practice Statement #1: Based on observation, interview and record review, the facility failed to ensure proper cleaning and disposal of loose medications were conducted for one medication cart (North Hall Cart) reviewed for medication storage and cleanliness. Findings include: On 04/17/25 at 09:00 AM, an observation and an interview were conducted with Registered Nurse (RN) J on the North Hall medication cart. Upon inspection of medication cart a total of 13 loose pills were scattered on the bottom of the first and second drawers of the medication cart. The loose pills varied in shapes, colors and sizes. On 04/17/25 at 09:05 AM, an interview was conducted with RN J regarding the loose medications of North Hall medication cart. RN J said they were probably pills that were being popped from the packet but dropped. When asked about their policy for loose medications, RN J said the pills should have been discarded. On 04/17/25 at 9:15 AM, an interview was conducted with the Director of Nursing (DON) regarding the 13 loose pills found in the North Hall medication cart. The DON said that the nurses are expected to clean the cart when they take it over, because they oversee the medication cart. On 4/17/25 at 12:30 PM, an interview was conducted with the Nursing Home Administrator (NHA) about the 13 pills found in the North Hall medication cart she said the midnight nurses are responsible for cleaning the medication carts. The NHA supplied a sheet titled Medication Cart Check list which noted it is the duty of the midnight shift to clean med cart drawers and remove any loose pills. Review of the facility document titled Medication Administration with a revision date of 6/12/24, noted the medication cart should be kept clean and organized. Deficient Practice Statement #2: Based on observation and interview the facility failed to ensure expired medication were disposed of in a timely manner. Findings include: On 4/17/25 at 9:30 AM, an observation and interview were conducted of three of the medication rooms with the Director of Nursing (DON.) Identified expired medication in the facility's main storage room included Geri Lanta (expired 9/24) and Benadryl (expired 2/25). These finding were acknowledged by the DON at the time of the observation. On 4/17/25 at 11:00 AM, the DON was interviewed and said medication supply staff are responsible for the medication storage room. In addition, the DON said the stock is checked weekly by the medication supply staff. The DON said expired medication should be brought to them so they can be put in the drug buster (a system used to secure and destroy unused medication.) On 4/17/25 at 12:30 PM, the Nursing Home Administrator (NHA) was interviewed about the expired medications identified in the medication storage room. The NHA said it is the duty of the medical supply staff to review dates on medical supplies in the storage room. The NHA said the medical supply staff should be going through and checking dates monthly. Review of a facility document titled Medication Administration with a revision date of 6/12/24 noted if medication is expired the staff should notify the nurse manager.

Based on observation, interview and record review the facility failed to ensure hygienic practices were performed while serving resident meals, resulting in the potential for food contamination. This deficient practice had the potential to effect 27 of the 28 residents that consumed food from the kitchen. Findings include: On 4/15/25 at 12:30 P.M. during a lunch meal observation, Certified Nurse Aides (CNA's) C, D, and H were observed serving food to residents without any form of hair restraint or their hair pulled back off their faces. CNA C and CNA H were observed with (loose braided) hair extensions (approximately 50 inches long) that hung over their shoulders and reached their buttocks. CNA D natural hair extended down her back and was seen repositioning her hair behind her ears to prevent hair from touching resident's food. Additionally, CNA D was observed wrapping silverware without wearing gloves. While the silverware was positioned correctly in the cylinder CNA D manipulated the eating surfaces of the utensils while attempting to wrap them in napkins. CNA H poured beverages for resident and passed the drinks by holding them at the rim of the drinking surface instead of the base. During the observation Dietary manager (DM) A was interviewed regarding the handling of the silverware and glasses. DM A confirmed that while the silverware was properly positioned in the cylinders, staff should not have been handling the eating portions of the utensils at all. DM A was asked should gloves be applied? Dietary Manager A responded YES. On 4/17/25 at 10:00 A.M., a policy was requested regarding the use of hair restraints during dining and handling of resident's eating utensils. At 11:50 A.M. a policy titled, Dress Code was provided. However, it was not specific to food service personnel. Under the Policy Explanation and Compliance Guidelines, item #5 documented that depending on the duty assignment or work area, an employee with long hair may be required to wear a hair net. According to the 2009 Michigan Modified Food Code, section 2-402.11 (A) Except as provided in (B) food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils and linens; and unwrapped single-service and single-use articles.

Based on observation, interview and record review, the facility failed to follow professional standards of practice by ensuring medications were administered according to physicians' orders for three residents (R28, R2, and R21) of seven residents reviewed for medication administration, resulting in the potential for less than the therapeutic effect of the prescribed medication when medications were not taken as ordered. Findings include: On 4/15/2025 at 1:57 PM, observed Registered Nurse (RN) J administer 9 AM medications to R8. The following medications were administered: Keppra 6oo mg, Metoprolol 75 mg, Vitamin D3, and Ramipril 5 mg. Vital signs were blood pressure 132/85 and heart rate of 86. Keppra 600 mg, and Metoprolol were medications that were ordered twice a day at 9 AM and 9 PM. Keppra is a medication used to treat seizures. Metoprolol is used to treat heart disease and blood pressure. R8 was admitted on [DATE] with a pertinent diagnosis of Major depressive disorder, vascular dementia with behavior disturbances, hypertension, and seizures. Review of R8 Quarterly Minimum Data Set (MDS) dated [DATE] for Brief Interview for Mental Status (BIMS), revealed R8 was severely cognitively impaired with a score of 7 out of 15. On 4/15/25 at 2:49 PM, RN J was observed to administer 9 AM medications to R28. The following medications were administered Keppra 500 mg, Vitamin D3, Sertraline 50 mg, Remeron 15 mg, The Keppra was a medication that was ordered to be given twice a day at 9 AM and 9 PM. Keppra is a medication to treat seizures. R28 was admitted on [DATE] with a pertinent diagnosis of Epilepsy, adjustment disorder with disturbances of conduct, major depressive disorder, dementia, and atherosclerotic heart disease (buildup of plaques in the arteries.) Review of R28 Annual MDS dated [DATE] for BIMS R28 was moderately cognitively impaired with a score of 12 out of 15. On 4/15/25 at 2:54 PM, RN J was observed to administer 9 AM medications to R2. The following medications were administered Duloxetine, Vitamin C, Vitamin B12, Vitamin D3 and Probiotic. The Duloxetine was a medication that was ordered to be given twice a day at 9 AM and 9 PM. Duloxetine is a medication used to treat depression. R21 was admitted on [DATE] with a pertinent diagnosis of Alzheimer's disease, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and atherosclerosis of the aorta (buildup of fat on the artery walls.) Review of R21, Quarterly MDS dated [DATE] for BIMS, revealed R21 was severely cognitively impaired with a score of 00. On 4/15/25 at 3:00 PM, RN J was interviewed about they were administering 9 AM medications after scheduled time. RN J said he got behind after a medical emergency that had occurred around 10:30 AM. RN J was queried if they had advised the Director of Nursing (DON) that he was late passing medications. RN J said no. On 4/17/25 at 11:00 AM, the DON was interviewed about medications that were administered after the scheduled medication administration time. The DON said they would expect medications to be given within the scheduled administration time. The DON said if the nurse is unable to pass medications in the scheduled time the nurse should let her know, so she could assist them. The DON was queried about the medications administered after scheduled medication time the DON said she was aware there were late medications given. The DON was queried if the provider was contacted about medications given late to see if they should have been rescheduled. The DON said the provider was not contacted about late medications. The DON acknowledged that giving medications outside the scheduled time frame can cause adverse effects. On 4/17/25 at 12:30 PM, the Nursing Home Administrator (NHA), was interviewed about medications given outside of the scheduled medication administration time. The NHA said the expectation is for medications to be administered as ordered. Record review of the facility document titled, Medication Administration with a revision date of 6/12/24, noted medications are to be administered by licensed nurse or other staff members who are legally authorized to do so under the laws of this state. In addition, the policy noted medications should be administered within 60 minutes prior or after the scheduled administration time. The scheduled administration time can be adjusted by the physician.

Based on interview and record review, the facility failed to ensure one resident (R21) out of five residents reviewed for immunizations were provided pneumococcal vaccination and education, resulting in the potential for development and spread of influenza among vulnerable residents in the facility. Findings include: On 4/15/25 at 2:32 PM the Director of Nursing (DON)/Infection Preventionist (IP) was interviewed and reported R21 did not have documentation of a current influenza immunization or refusal. Review of the Electronic Health Record (EHR) for R21 revealed admission to the facility on [DATE] with diagnoses of adjustment disorder with mixed anxiety and depressed mood, and asthma. Further review of EHR revealed R4 did not have documentation to indicate that the influenza vaccine was offered or was contraindicated. On 4/17/25 at 8:52 AM the DON was interviewed and said residents and or guardians should be educated and given the opportunity to receive vaccinations. The DON agreed R21 should have been offered the influenza vaccine for the 2024/2025 flu season. Review of the facility policy titled Influenza Vaccination date implemented 11/1/2022 revealed in part: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine. The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal.

Based on observation, interview, and record review the facility failed to provide 80 square feet of space per bed within six (2, 7, 10, 11, 12, and 14) of 15 resident rooms, resulting in the increased likelihood for resident dissatisfaction with the amount of provided living space. Findings include: On 4/17/2025 at 10:31 AM observation of resident rooms and record review of the facility bed count information with the Nursing Home Administrator (NHA) revealed the following: Room # Sq./Ft # Beds #Residents in Room 2 283 4 3 7 218 3 3 10 225 3 3 11 215 3 3 12 154 2 2 14 144 2 2 Observations and interviews with various residents revealed no specific complaints and no specific health/safety concerns.

This citation pertains to intake MI00149274. Based on observation, interview, and record review the facility failed to prevent physical restraint use for one resident (R401) out of 3 residents reviewed for abuse. Findings include: On 1/13/25 at 9:50 AM R401 was observed sitting in her bedside chair. R401 was unable to answer questions due to confusion. R401 was observed getting out of the bedside chair and walking into the hallway where staff directed her back to her room. Record review of Electronic Health Record (EHR) revealed R401 admitted to facility on 9/3/2020 with most recent readmission on 12/19/2023 with diagnoses which included Alzheimer's disease, adjustment disorder with mixed anxiety and depressed mood and major depressive disorder. Review of the Minimum Data Set (MDS) dated [DATE] for R401 revealed severely impaired cognition. Record Review of facility reported incident file folder dated 12/20/2024 revealed abuse coordinator was notified by Certified Nursing Assistant (CNA) A that on 12/20/2024 she found R401 sitting in her sofa chair in her room with a white flat sheet wrapped around her waist and tucked behind the chair. Abuse coordinator interviewed CNA B where CNA B admitted that she wrapped a sheet around R401. On 1/13/25 at 11:59 AM CNA B was interviewed and said she was assigned to work with R401 on 12/20/2024 and stated, I wrapped a sheet around the resident so she wouldn't be able to get up. CNA B further said R401 was going into other resident's rooms and was not following instructions. On 1/13/25 at 4:00 PM CNA A was interviewed and said on 12/20/204 she found R401 tied up in her chair with a bed sheet. The sheet was tied behind the chair and R401's arms were held down by the sheet. There was no way the resident could have untied the sheet to get up. Record review of the clinical chart revealed no orders for use of restraints, no consents, no restraint assessments completed and no care plans for restraint use. On 1/13/25 at 2:00 PM the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed and said the facility is a restraint free building. The DON agreed there were no orders, consents, assessments and/or care plans for the use of restraints for R401. Record review of the facility policy titled Restraint Free Environement date implemented 11/1/2022 revealed in part: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident ' s body that the individual cannot remove easily which restricts freedom of movement or normal access to one ' s body. Physical restraints may include tucking in a sheet tightly so that the resident cannot get out of bed, or fastening fabric or clothing so that a resident ' s freedom of movement is restricted. The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident ' s medical symptoms.

This citation pertains to intake MI00149272. Based on interview, and record review the facility failed to review/revise a care plan in a timely manner for one resident (R401) out of three residents reviewed for care planning. Findings include: On 12/19/2024 at 8:51 AM a facility incident report was submitted to the State Agency regarding R401 sustained an injury of unknown origin. Record review of the Electronic Health Record (EHR) revealed R401 admitted to the facility on [DATE] with most recent readmission on 12/19/2023 with diagnoses which included Alzheimer's disease, adjustment disorder with mixed anxiety, and depressed mood and major depressive disorder. Review of the Minimum Data Set (MDS) dated [DATE] for R401 revealed severely impaired cognition. Record review of the facility reported incident report folder dated 12/19/2024 revealed R401 was observed to have a slight discoloration under left eye. Review of the incident and accident report dated 12/10/2024 revealed R401 was observed on the floor in her room. Record review of R401's active care plans revealed the following: Problem start date 9/6/2022, Category: Falls, resident at risk for falling related to unsteady gait at times, decreased safety awareness. Goal, Long term goal target date: 3/20/2025 resident will have risk for fall/injury minimized through the review date. Approach Start Date: 09/06/2022 Give resident verbal reminders not to transfer without assistance. Approach Start Date: 09/06/2022 Keep bed in lowest position when care is not being rendered. Approach Start Date: 09/06/2022 Keep call light in reach at all times. Approach Start Date: 09/06/2022 Keep personal items and frequently used items within reach. Approach Start Date: 09/06/2022 MONITOR FOR MEDICATION RELATED SIDE EFFECTS: Approach Start Date: 09/06/2022 Orient resident to surroundings as needed. Approach Start Date: 09/06/2022 provide proper, well-maintained footwear. Approach Start Date: 09/06/2022 Provide resident an environment free of clutter. Approach Start Date: 09/06/2022 provide toileting assistance as needed. Last reviewed/revised 12/8/2024. On 1/13/24 at 2:00 PM the Director of Nursing (DON) was interviewed and said R401's fall care plan was reviewed on 12/8/24 but did not have any updates since 9/6/2022 nor did it include the actual fall on 12/10/2024 and updated approaches/review based on that fall. The DON agreed the care plan should be updated regarding R401's recent falls. Review of the facility policy titled Care Plan Revisions Upon Status Change date implemented:10/26/2022 revealed in part . The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 3. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs, affecting all 27 residents who resided in the facility. Findings include: On 5/30/2024 at 2:22 PM review of the staffing timecards with Scheduler B for the following dates revealed there was no consecutive 8 hour scheduled RN coverage: April 1st, 2nd, and 15th. (2024) May 12th, 14th and 26th. (2024) On 5/30/2024 at 2:25 P.M. the Director of Nursing (DON) was interviewed and said that he recently accepted the position as the DON and that there was another RN that worked midnights and weekends but went on an extended vacation. When asked how the facility ensured there was daily 8-hour RN coverage the DON replied, We just hired another RN to help cover when I am not working. The DON agreed there needs to be daily 8 consecutive hours of RN coverage and acknowledged there was a problem with staffing. Review of the Facility Policy titled Nursing Services-Registered Nurse, RN revealed in part .The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day 7 days per week.

Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) effectively date mark all potentially hazardous ready-to-eat food products effecting 27 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, resident foodborne illness. Findings include: On 05/29/24 at 09:10 A.M., An initial tour of the food service was conducted with Dietary Manager E. The following items were noted: One-half gallon of Prairie Farms whole milk was observed with a manufacturer's use-by-date that read May 26. The half-gallon of whole milk was also observed within the Traulsen 2-door reach-in cooler without an open or out date. Dietary Manager E stated: We date mark the product when opened for a total of 7 days, if the manufacturer's use-by-date allows. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The Traulsen 2-door reach-in cooler door gaskets were observed heavily soiled with accumulated and encrusted dust and dirt deposits. The Traulsen 2-door reach-in-freezer door gaskets were observed heavily soiled with accumulated and encrusted dust and dirt deposits. The can opener assembly mounting plate was observed heavily soiled with (dust, dirt, grime) deposits between the mounting plate perimeter and table surface. Dietary Manager E indicated she would have maintenance remove the mounting plate for appropriate cleaning as soon as possible. The Ice-O-Matic ice machine interior plastic resin retention plate was observed soiled with accumulated and encrusted dirt deposits. The garbage disposal overhead spray valve assembly was observed heavily soiled with accumulated and encrusted dust, dirt, and food debris deposits. Dietary Manager E indicated she would have staff thoroughly clean and sanitize the valve assembly as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 11 of 24 overhead light assembly end caps were observed missing. Dietary Manager E indicated she would contact maintenance for end cap installation as soon as possible. The 2017 FDA Model Food Code section 6-202.11 states: (A) Except as specified in (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. 180 181 (B) Shielded, coated, or otherwise shatter-resistant bulbs need not be used in areas used only for storing FOOD in unopened packages, if: (1) The integrity of the packages cannot be affected by broken glass falling onto them; and (2) The packages are capable of being cleaned of debris from broken bulbs before the packages are opened. (C) An infrared or other heat lamp shall be protected against breakage by a shield surrounding and extending beyond the bulb so that only the face of the bulb is exposed. Basement: The Kelvinator refrigerator interior flooring surface was observed severely corroded and particulate. Dietary Manager E stated: We have a new refrigerator currently on order. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 05/31/24 at 01:00 P.M., Record review of the Policy/Procedure entitled: Sanitation Inspection dated 01/2024 revealed under Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. Record review of the Policy/Procedure entitled: Sanitation Inspection dated 01/2024 further revealed under Policy Explanation and Compliance Guidelines: (1) All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, flies, and other insects. On 05/31/24 at 01:15 P.M., Record review of the Policy/Procedure entitled: Ice Machines and Portable Ice Carts dated 03/08/2024 revealed under Policy: It is the policy of this facility to ensure that ice machines/carts are working in proper order, cleaned, and maintained as per Federal, State, local, or facility guidance, according to manufacturer's instructions and current standards of practice. Record review of the Policy/Procedure entitled: Ice Machines and Portable Ice Carts dated 03/08/2024 further revealed under Policy Explanation: Ice machines/carts can be prone to microbial contamination due to improper handling or storage of ice, poor cleaning, or maintenance of equipment, or through ice handling equipment. Proper cleaning, maintenance, and infection control in relation to ice machines is important to decrease the risk of illness to residents, staff, and visitors.

Based on observation, interview, and record review the facility failed to effectively maintain continuity of internal programs throughout leadership changes, such as: reporting of abuse, Minimum Data Set (MDS) assessments, Quality Assurance and Improvement (QAPI/QAA) meetings, in-service, competencies/employee training, staffing, infection control, and vaccine policy affecting all 27 residents. Findings include: On 5/30/24 at 9:06 AM during interview with the Minimum Data Set (MDS) Coordinator L review of resident MDS assessments revealed a delay in the processing of the assessments. The MDS Coordinator L explained the facility had been without an MDS Coordinator for about a 3 month period. The current MDS Coordinator L hire date was 3/25/24. We are pretty far behind she said. MDS records over 120 days late were for the following residents: R15, R 2, R22, R21, R 12 and R20. On 5/31/24 at 3:29 PM the NHA was interviewed and acknowledged the lapse and explained the MDS assessments need to be completed and submitted on time in order to be in line with state regulations and policies and procedures. On 5/30/2024 at 2:25 P.M. the DON was interviewed about staffing concerns regarding the lack of consecutive 8-hour Registered Nurse (RN) coverage. The DON said that he recently accepted the position as the DON and that there was another RN that worked midnights and weekends but went on an extended vacation. When asked how the facility ensured there was daily 8-hour RN coverage the DON replied, We just hired another RN to help cover when I am not working. The DON agreed there needs to be daily 8 consecutive hours of RN coverage and acknowledged there was a problem with staffing. On 5/30/24 at 3:45 PM the state required 12-hour Certified Nurse Assistant (CNA) in-service and competencies (including abuse and dementia training) programs were discussed and the records for five sampled CNAs (B, H, I, J, and K) were reviewed. The Director of Nursing (DON) stated, I do not have a record of 12 hours of in-services for any staff. I took over as DON recently and there are no records from the previous DON and to date, I have not held formal in-service training. The DON acknowledged there needs to be 12 hours of training for CNAs which would include the abuse and dementia training. On 5/31/24 at 9:49 AM, the facility's Infection Control Program was reviewed with the DON who was the Infection Preventionist, and the following was noted: 1. The DON received certification as an Infection Preventionist on 5/20/24. The facility's previous Infection Preventionist's employment ended November 2023. 2. The DON indicated that documentation of infection identification, tracking, monitoring, analysis of surveillance data, responding follow-up activity, and antibiotic stewardship ended November 2023. 3. The facility's Influenza Vaccination policy was last updated 11/1/22. 4. The staff call-in log was not available for review. The DON stated, I don't know where it is at. I don't know how to pull it up. On 5/31/24 at 3:25 PM, the NHA said there should have been an Infection Preventionist appointed, and the work should have been done. On 5/31/24 at 10:31 AM Quality Assurance and Improvement (QAPI) survey meeting was held with the NHA. The past resident, family and staff concern sheets, titled, (Facility Name) Health Care Management Concern Form, were reviewed. The NHA said there had not been any concern forms submitted since 1/5/24. When asked about the value of reviewing past concerns to ensure the concerns had been addressed, the NHA stated, I could have. I didn't. On 5/31/24 at 12:22 PM, during the Nursing Home Administrator (NHA) interview, review of a resident-to-resident abuse disclosed an eleven-day delay in reporting of the incident to the State Agency. During interview the administrator acknowledged the delay and spoke of the administrative change of personnel during that time period: The abuse incident occurred 3/16/24; the new administrator (NHA) took over the position 3/20/24; the Facility Reported Incident (FRI) was not reported to the state until 3/26/24. On 5/31/24 at 3:17 PM during an interview with the owner of the facility, Facility Owner/CEO N questions were asked about changes in leadership and the ineffective transitions for operations. Facility owner/CEO N said that he was well-aware of the leadership changes and added that he is personally responsible as ultimate decision-maker for leadership personnel hiring. When queried about specific concerns, the Facility Owner/CEO N responded I was unaware of the concerns, because concerns had not been communicated and said that moving forward changes will be made and there will be improvement. Review of the facility policy titled Abuse, Neglect, and Exploitation with a date of implementation of 11/1/2022, states in part, The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily harm. Review of the facility policy titled Abuse, Neglect, and Exploitation with a subheading of Employee Training with a date of implementation of 11/1/2022, states in part, New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation. Existing staff will receive annual education through planned in-services and as needed. Review of the facility policy titled Infection Prevention and Control Program with a date of revision 3/13/24, states in part, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on interview and record review, the facility failed to consistently implement a comprehensive infection control program that conducted proper facility surveillance to readily identify trends of infections, resulting in missed opportunities for corrective actions and the potential for spread of infectious organisms throughout the facility affecting the entire census of 27 residents. Findings include: On 5/31/24 at 9:49 AM, the facility's Infection Control Program was reviewed with the Director of Nursing (DON) who was the Infection Preventionist, and the following was noted: 1. The DON received certification as an Infection Preventionist on 5/20/24. The facility's previous Infection Preventionist's employment ended November 2023. 2. When asked for documentation regarding infection identification, tracking, monitoring, analysis of surveillance data, responding follow-up activity, and antibiotic stewardship, the DON said this had not been completed since November 2023. 3. The facility's Influenza Vaccination policy was last updated 11/1/22. 4. The staff call-in log that documents the staff's reasons for calling in was not available for review. The DON stated, I don't know where it is at. I don't know how to pull it up. On 5/31/24 at 3:25 PM, the Nursing Home Administrator (NHA) said there should have been an Infection Preventionist appointed, and the work should have been done. A review of the facility policy titled, Infection Prevention and Control Program, dated 3/13/24 documented in part the following: - This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. - A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. - An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. - The facility will conduct an annual review of the infection prevention and control program, including associated programs and policies and procedures based upon the facility assessment which includes any facility and community risk. On 5/31/24 during the exit conference, the facility Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 27 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 05/30/24 at 09:30 A.M., A common area environmental tour was conducted with Director of Housekeeping and Maintenance D. The following items were noted: Resident Restroom: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated dust and dirt deposits. The facility corridor carpeting surface was observed soiled with accumulated and encrusted dust, dirt, and stain deposits. Director of Housekeeping and Maintenance D indicated the facility had purchased a floor machine for extracting stubborn stains and accumulated soils. Dining Room: 2 of 2 oscillating wall mounted fans were observed soiled with accumulated and encrusted dust and dirt deposits. The sliding patio door tracks were also observed heavily soiled with accumulated and encrusted dust, dirt, debris (paper products). Director of Housekeeping and Maintenance D indicated he would have staff thoroughly clean and sanitize the door tracks as soon as possible. Day Room: The front double door tracks were observed with accumulated and encrusted dust, dirt, debris (paper products). Front Entrance: The front step handrail support system was observed loose-to-mount. The upper wooden rail was also observed rotted and splintered. The entire handrail support system could be moved from side to side approximately 6-8 inches. Laboratory Specimen Refrigerator: The interior refrigeration unit surfaces were observed soiled with accumulated and encrusted dust and dirt deposits. One container of Chobani greek yogurt was also observed stored within the Laboratory Specimen Refrigerator. The interior dial thermometer was further observed to read 48-50 degrees Fahrenheit. On 05/30/24 at 10:45 A.M., An interview was conducted with Director of Housekeeping and Maintenance D regarding the facility maintenance work order system. Director of Housekeeping and Maintenance D stated: We have a manual maintenance logbook. On 05/30/24 at 12:05 P.M., An environmental tour of sampled resident rooms was conducted with Administrator Support G. The following items were noted: 3: The drywall surface was observed (etched, scored, particulate), adjacent to Bed 1. The damaged drywall surface measured approximately 12-inches-wide by 36-inches-long. 5: An electrical junction box was observed without the protective cover, adjacent to Bed 2. The uncovered electrical junction box was also observed with black taped wires protruding from the receptacle. 6: The restroom hand sink faucet assembly was observed loose-to-mount. The Bed 2 plastic pillow cover was also observed (etched, scored, particulate). Administrator Support G indicated she would discard the faulty pillow as soon as possible. 12: The Bed 1 overbed light assembly was observed loose-to-mount. The Bed 1 and Bed 2 overbed light assemblies were also observed non-functional. The ceiling perimeter electrical conduit was further observed disconnected and dangling loose-to-mount from the wall surface. 14: The entire resident room was observed extremely malodorous. On 05/31/24 at 10:00 A.M., Record review of the Maintenance Log Sheets for the last 90 days revealed no specific entries related to the aforementioned maintenance concerns. On 05/31/24 at 10:15 A.M., Record review of the Policy/Procedure entitled: Cycle Cleaning dated 10/26/2022 revealed under Policy: It is the policy of this facility to identify the functional areas in the facility that require cleaning and to use cycle cleaning schedules to outline the frequencies and maintain regularly scheduled environmental service tasks. On 05/31/24 at 10:30 A.M., Record review of the Policy/Procedure entitled: Environmental Services Inspection dated 10/26/2022 revealed under Policy: It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis. On 05/31/24 at 10:45 A.M., Record review of the Policy/Procedure entitled: Nursing Environmental Inspection dated 11/01/2022 revealed under Policy: It is the policy of this facility to regularly monitor the nursing services environment to ensure the facility is maintained in a safe and sanitary manner. 34901 On May 29, 2024 at 9:38 AM, the floor underneath Resident #128's (R128) tube feeding pole and at the head of R128's bed was soiled with debris, including torn paper, personal protective equipment (PPE) ties, fingernail clippings, a plethora of small unidentifiable particles, and clumps of hair. On May 30, 2024 at 8:07 AM, the floor underneath R128's tube feeding pole and at the head of R128's bed remained soiled with debris, including torn paper, personal protective equipment (PPE) ties, fingernail clippings, a plethora of small unidentifiable particles, and clumps of hair. On May 30, 2024 at 10:44 AM, Housekeeper C said she was responsible for processing the laundry, cleaning the common areas, and sweeping and mopping all of the residents' rooms but had not been able to do it all. Housekeeper C stated, I try to do it, because the residents should have a clean room. Housekeeper C stated that today she had cleaned the high numbered rooms. This included R128's room. On May 31, 2024 at 8:53 AM, the floor underneath R128's tube feeding pole and at the head of R128's bed remained soiled with debris, including torn paper, personal protective equipment (PPE) ties, fingernail clippings, a plethora of small unidentifiable particles, and clumps of hair. On May 31, 2024 at 11:36 AM, when the floor underneath R128's tube feeding pole and at the head of R128's bed was observed with Maintenance and Housekeeping Supervisor D, he stated, That should have been cleaned. I'll get that swept up.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were signed and submitted to CMS (Centers for Medicare and Medicaid Services) in a timely manner for six residents (R2, R12, R15, R20, R21, and R22), resulting in a delay in monitoring of the quality of care provided to the facility's residents and potential for delay in the identification of resident's health concerns. Findings include: On 5/30/24 at 9:06 AM, Licensed Practical Nurse (LPN)/MDS Coordinator L, was queried about MDS submissions to CMS. LPN L said her hire date was 3/25/24 and that the facility was without a MDS coordinator for about three months. LPN L stated, We are pretty far behind. A review of MDS submissions was conducted with LPN L to determine compliance with CMS guidelines. According to LPN L, the following MDS assessments have not been submitted and are considered late: 1. Resident #2's quarterly MDS assessment dated [DATE] was due for submission on 5/6/24 but had not been submitted. 2. Resident #12's quarterly MDS assessment dated [DATE] was due for submission on 4/1/24 but had not been submitted. 3. Resident #15's quarterly MDS assessment dated [DATE] was due for submission on 3/30/24 but had not been submitted. 4. Resident #20's quarterly MDS assessment dated [DATE] was due for submission on 4/3/24 but had not been submitted. 5. Resident #21's quarterly MDS assessment dated [DATE] was due for submission on 3/31/24 but had not been submitted. 6. Resident #22's quarterly MDS assessment dated [DATE] was due for submission on 4/3/24 but had not been submitted. On 5/31/24 at 3:29 PM, the Nursing Home Administrator (NHA) stated her expectations for timely submissions of MDS assessments were, so we are in line with state regulations and policies and procedures. A review of the facility policy titled, MDS 3.0 Completion, dated 2/23/24 documented in part the following: - Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. - Transmission Requirements: All assessments shall be transmitted to the designated CMS system within 14 days of completion. On 5/31/24 during the exit conference, the NHA and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

Based on interview and record review, the facility failed to ensure certified nurse aides (CNAs) fulfilled the requirement to complete 12 hours of in-service education annually for four of five certified nurse aides (B, H, I, J) resulting in the potential for unmet resident care needs. Findings include: On 5/30/2024 at 2:30 PM, the following five certified nurse aide annual 12-hour nurse aide training/ in-services were reviewed: -CNA B was hired on 6/26/21. There were no 12-hour training/ in-services provided by the facility. -CNA H was hired on 10/25/22. There were no 12-hour training/ in-services provided by the facility. -CNA I was hired on 12/1/23. There were no 12-hour training/ in-services provided by the facility. -CNA J was hired on 9/7/23. There were no 12-hour training/ in-services provided by the facility. There was no evidence provided by the facility that annual 12-hour trainings/ in-services were completed for the certified nurse aides reviewed. On 5/30/24 at 3:45 PM the Director of Nursing (DON)/Staff Development Coordinator was interviewed and stated I do not have a record of 12 hours of in-services for any staff. I took over as DON recently and there are no records from the previous DON and to date, I have not held any formal in-service trainings. The DON further stated There needs to be 12 hours of in-service training annually for CNAs. Review of the Facility Assessment Tool, updated 5/4/2024, documented: Required in-service training for nurse aides must be sufficient to ensure the continuing competence of aides, but must be no less than 12 hours per year

This citation pertains to intake MI00135746. Based on interview and record review the facility failed to maintain a properly functioning alarm system for the northeast door of the facility for one cognitively impaired resident (R101) of three residents who were elopement risks. On 4/11/23, R101 left the facility without staff knowledge. The facility last saw R101 at 5:10 PM and identified R101 as missing at 7 PM during shift change. R101 was found wandering by the fire department. R101 was taken to the hospital and returned to the facility on [DATE] by relatives. This deficient practice resulted in the likelihood of serious injury, serious harm, serious impairment, or death when R101 left the facility unsupervised and without staff knowledge. The immediate jeopardy started in 4/11/23. Review of the facility report incident dated 4/12/23 revealed, Resident left safe area into community, last observed by staff at 5:10 PM on 4/11/23 .family was in earlier that day and took resident outside on the front porch, family left at 5:00 PM. Resident thought she could go back outside unattended and was seen walking down the street and was taken to Novi Providence Hospital. Resident is now safe and has returned to the facility. A review of R101's medical record revealed, R101 was admitted to the facility on [DATE] and had a medical diagnosis of Dementia. A review of R101's quarterly MDS dated [DATE] revealed, a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated severe cognitive impairment. In addition, R101 required supervision when walking. A review of R101's care plan dated 9/20/22 revealed, I am at risk of elopement, I have a history of opening the front door and going on the porch .Interventions: assist resident with navigating through the facility to ensure resident does not wander .monitor and redirect resident as necessary to ensure safety .update elopement book per policy. A review of the elopement risk assessment dated [DATE] revealed, R101 was ambulatory, had one or more predisposing diseases, was cognitively impaired, and was taking one or more medications (including psychoactive medications). R101's elopement risk score was 8 (a score of 11 or higher is considered at risk). On 4/25/23 at 10:41 AM, an attempt was made to contact Certified Nursing Assistant (CNA) B. CNA B did not return call while onsite. On 4/25/23 at 10:45 AM Licensed Practical Nurse (LPN) A was asked to describe the events when R101 eloped from the facility. LPN A said rounds (checking to make sure residents are safe and accounted for) were made toward the end of the shift. LPN A explained that at 7:30 PM CNA B asked her if R101 was observed. LPN A reported observed R101 sometime between 4 PM to 4:30 PM. At this time, LPN A and CNA B attempted to locate R101. R101 was not located within the facility and Code Pink (elopement) was initiated. During the interview, LPN A explained the fire department alerted the facility that they picked up R101 because she was walking around, and the fire department transferred R101 to the local hospital. LPN A reported CNA B heard the alarm and put the code into the door (disarming the alarm) and did not inform LPN A that the alarm sounded. LPN A reported that she was unaware the alarm sounded until rounds were made. LPN A said this incident occurred because the alarm sound on the northeast door is inaudible at a distance and, The alarm system needed to be fixed. LPN A stated, If were we aware of the alarm in the beginning, we could have jumped on the incident faster. On 4/25/23 at 11:34 AM the Director of Nursing/ Nursing Home Administrator (DON/NHA) said in an interview, the door magnet to the door that acts as a locking system was loose. There was a small gap in between the magnet and the door. Also, the door alarm sound was very low. The door alarm was loud enough to be heard by the first two resident rooms that are in vicinity of the northeast door where R101 eloped. On 4/25/23 at 11:40 AM the DON/NHA was interviewed and said that maintenance did not have an alarm/ door check section on the maintenance rounding sheets prior to and at the time the incident occurred. On 4/25/23 at 11:56 AM Maintenance Director (DM) C was interviewed. DM C reported the alarms are periodically checked, the only required checks are completed quarterly. When queried on whether there was documentation of the quarterly checks for the alarm system, DM C stated, There are no logs to show the door alarms are checked for quarterly review. On 4/25/23 at 12:10 PM, the DON/NHA was asked about the video camera footage related R101's elopement. on 4/11/23 between 4 PM and 4:30 PM R101 and her daughter rang the doorbell to get back in from the front porch. The DON/NHA unlocked door to let them in. The DON/NHA walked with R101 and her mother to the back door and saw R101's daughter leave. Around 5 PM R101 was seen out in the hallway walking around the building. 5:06 PM the resident looked outside front door and then walked around the facility again. At 5:10 PM, R101 was seen going to the northeast front porch door. R101 was able to push the door open and was seen on the porch looking into the facility through the window. R101 walked to porch gate and attempted to unlatch the gate. At 5:20 PM, R101 was seen walking up the street. During the interview, DON/NHA explained that facility staff were not aware that R101 left the facility between 5:20 PM and 7 PM. The DON/NHA said when night shift arrived, rounds were done, and R101 was discovered to be missing. She explained at 7:30 PM staff notified her that R101 was missing, and the local hospital notified the facility that the fire department transferred R101 to the hospital. On 4/25/23 at 12:40 PM the DON/NHA was asked what the expectations of facility staff are when an alarm goes off. The DON/NHA stated, My expectation is that when the staff hears any alarm, they should go to the alarm sound as soon as it is heard. On 4/25/23 at 1:48 PM R101's Family Member D was interviewed and acknowledge that R101 was missing from the facility, and R101 was picked up from the hospital and returned R101 to the facility at approximately 9 PM. A review of the Elopements policy, undated, documented the following: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. However, further review of the policy revealed there was no written procedure on what to do when the door alarm is activated. A review of the Elopement Drill Documentation Form, undated, noted Nursing/ Ancillary staff make determination that the resident is missing, and an announcement is made using facility approved protocol (e.g., internal alert code) to alert all personnel that a search is underway. However, further review of the policy revealed that there was no procedure to address alarm response. On 4/25/23 the past non-compliance was received and reviewed. Review of the past non-compliance verified the removal of the Immediate Jeopardy on 4/11/23. The facility removal plan documents the following: On 4/11/2023 resident left the building through a malfunctioning alarm and door; she was found shortly after safe and was returned to the facility with family. She was assessed by nurse for any adverse effects of resident leaving a safe area without authorization; resident was noted to be at baseline with no injuries noted. Resident was placed on 1:1 until further evaluation by IDT. Physician, responsible party, and police were notified of incident. Facility area assessed and addressed at the time of incident, resident was placed on 1:1 sitter for monitoring safety and whereabouts until further notice. Door was placed on 1:1 monitoring assignment until door Alarm Company came out to fix the door alarm, door alarm was repaired the evening of 4/11/2023. Residents identified to be at risk for elopement have been reviewed to be in the elopement book and have care plan and interventions in place. Elopement drill and in-service were started with staff on the night shift of 4/11/2023 and was completed with all shifts by 4/17/2023. Policy for elopement was reviewed by the administrator and updated appropriately. Disaster preparedness manual reviewed and deemed appropriate for plan to locate missing resident. Staff re-educated on residents that are at showing risk for elopement and how to handle and communicate resident needs to appropriate departments. Non-compliance with education will result in 1:1 education or written discipline per policy. The abatement plan included the following: * Door alarms will be monitored daily by maintenance staff as part of rounds. On weekends Charge nurse will be responsible for checking the door alarms for functioning. DON/designee to complete door alarms daily for 4 weeks then weekly for 4 weeks and then monthly for 3 months for functioning. * Elopement drills will be conducted weekly for 4 weeks then monthly until further determined. Concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. DON is responsible for sustained compliance. The facility believe that immediate jeopardy was ceased and corrected on 4/11/2023 due to immediate actions of the administrator to get the door fix and secure all residents safety, placing resident on 1:1 sitter assignment until further notice, education, and elopement code pink drills were started night shift of 4/11/2023 and all staff participated and completed task.

Based on observation, interview and record review, the facility failed to assess weight changes, nutritional interventions, and notify physician and resident representative of significant weight loss for two sampled residents (R2 and R10) of three residents reviewed for weight changes from a total sample of 14 resulting in significant weight loss and potential for further weight changes and compromised health conditions. Findings Include: Resident #2 In observations on 4/20/22 at 10:35 AM, 11:49 AM, 1:05 PM, 2:22 PM, 3:19 PM and 4:30 PM, R2 was observed ambulating in the hallways of the facility. In observations on 4/21/22 at 8:15 AM, 10:07 AM, 12:09 PM, 1:35 PM, and 3:49 PM, R2 was observed ambulating in the hallways of the facility. In observations on 4/22/22 at 8:50 AM, 11:44 AM, 1:30 PM, and 4:02 PM, R2 was observed ambulating in the hallways of the facility. In observations on 4/26/22 at 10:12 AM, 11:44 AM, 1:30 PM, and 4:02 PM, R2 was observed ambulating in the hallways of the facility. R2's shirt and pants were loosely hanging over the residents body frame in each of the observations. Review of an Admission Record face sheet revealed R2 was admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facesheet indicated R2's Responsible Party (RP) was her granddaughter. Review of a quarterly Minimum Data Set (MDS) assessment for R2, with a reference date of 2/11/22, revealed moderately impaired cognition. The MDS indicated the resident required limited assistance with all activities of daily living (ADL's). Section K (Swallowing/Nutritional Status) of the MDS indicated R2's weight reflected Loss of 5% or more in the last month or loss of 10% or more in last 6 months? Yes, not on physician-prescribed weight-loss regimen. Review of R2's documented weights included: October, 2021- 209.2 pound (lbs), November, 2021 - 208 lbs, December, 2021 - 196 lbs, January, 2022 - 195 lbs, February, 2022 - 188.3 lbs, and March, 2022 - 181 lbs. R2 demonstrated a 13.48% weight loss between October, 2021 and March, 2022. There was no comprehensive Nutritional Review/Assessment since 12/10/21(4 months earlier). Review of the 12/10/21 alteration in weight care plan had approaches of monitor weights .house supplement 4 ounces twice a day (lunch and dinner). Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order reflected a decreased frequency of supplements. During an interview with Certified Nurse Assistant (CNA C) on 4/26/22 at 12:52 PM in the dining room, when asked, CNA C stated R2 walks from the time she arrived on shift (7 AM) until the time she ends her shift (3 PM). CNA C stated that sometimes R2 will refuse or partiality eat meals all day. CNA C stated R2 will take a protein drink or protein cup sometimes. CNA C reported R2 will momentarily sit down for meals and subsequently stand back up and begin ambulating in the hallways again. Review of care conference notes dated 2/22/22 documented R2's RP was in attendance. There was no evidence that R2's weight loss was discussed with the RP. Resident #10 During a tour of the East Wing Nursing Unit on 4/20/22 at 10:40 AM, R10 was heard yelling out I'm hungry as a hippo. When asked, R10 could not recall if she ate breakfast. R10 was blind and had closed eyes. During an observation in the dining room on 4/20/22 at 1:20 PM, R10 was observed eating the facility provided meal of 2 hard boiled eggs, small bowl of potato chips and a handful of baby carrots. R2 only ate the hardboiled eggs and potato chips using her fingers. Review of an Admission Record face sheet revealed R10 was admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an quarterly Minimum Data Set (MDS) assessment for R10, with a reference date of 4/6/22, indicated moderately impaired cognition. The MDS indicated the resident required extensive one person assistance with all activities of daily living. Review of R10's documented weights included: November, 2021- 218 pound (lbs), December, 2021 - 200 lbs, January, 2022 - 207 lbs, February, 2022 - 204 lbs, (no March weight obtained) and April, 2022 - 195 lbs. R10 demonstrated a 10.55% weight loss between November, 2021 and April, 2022. There was no comprehensive Nutritional Review/Assessment since 1/9/20 (2 years and 3 months earlier). There was no nutritional/dietary care plan with approaches and interventions. There was no evidence that R10's healthcare provider was notified of the weight loss. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Registered Dietician (RD D) on 4/22/22 at 1:25 PM, she confirmed she was recently hired and works only on the weekends and has not assessed all the residents yet. RD D reported if she completed a comprehensive nutritional assessment of a resident, she would have noted it in the medical record. During an interview with the Director of Nursing (DON) on 4/22/22 at 2:44 PM when asked, the DON stated she thought the weight loss was intended, but the meals being provided to the resident were not well planned out for a healthy weight loss. Review of a Nutritional Assessment policy dated 3/16/22 revealed, 1. The Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition .7. Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that adress or minimize to the extent possible the resident's risk for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences .