Michigan Masonic Home

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide dignified care to 3 residents (R5, R11, and R87) of 4 residents reviewed for dignity.Findings include:
R5
Review of an admission Record revealed R5 admitted to the facility on [DATE] with pertinent diagnoses which included cerebral palsy and periodic limb movement disorder.
Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R5, with a reference date of 12/24/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R5 was cognitively intact. Further review of same MDS assessment revealed R5 was occasionally incontinent of urine.
Review of the current toileting Care Plan intervention for R5, with a revision date of 1/26/2022, directed staff to toilet resident for bowel and bladder on request and offer a urinal every two hours around the clock.
In an interview on 1/26/2026 at 1:36 PM, R5 reported he routinely waited for 30 minutes for his call light to be answered. R5 reported he took medication that caused him to urinate a lot, and the call light response was not always fast enough to prevent episodes of incontinence.
Review of R5's call light report from 1/20/2026 to 1/27/2026 revealed the following.1/20/2026- call light activated at 8:29 AM with 28 minutes elapsed until answered1/22/2026- call light activated at 6:14 AM with 27 minutes elapsed until answered1/22/2026- call light activated at 7:47 PM with 31 minutes elapsed until answered1/24/2026- call light activated at 7:02 AM with 59 minutes elapsed until answered1/24/2026- call light activated at 10:08 AM with 24 minutes elapsed until answered1/24/2026- call light activated at 11:54 AM with 18 minutes elapsed until answered1/24/2026- call light activated at 6:37 PM with 27 minutes elapsed until answered1/25/2026- call light activated at 4:46 PM with 28 minutes elapsed until answered1/25/2026- call light activated at 6:33 PM with 36 minutes elapsed until answered1/25/2026- call light activated at 8:15 PM with 19 minutes elapsed until answered1/26/2026- call light activated at 1:44 AM with 20 minutes elapsed until answered1/26/2026- call light activated at 10:12 PM with 26 minutes elapsed until answered
In an interview on 1/28/2026 at 10:21 AM, R5 reported the previous Saturday, 1/24/2026, he waited an extended period in bed after pressing his call light (59 minutes per call light report) that morning and was unable to hold his urine and wet himself. R5 reported this made him feel undignified.
R11
Review of an admission Record revealed R11 admitted to the facility on [DATE] with pertinent diagnoses which included Parkinson's Disease and unsteadiness on feet.
Review of a current toileting Care Plan intervention for R11, with a revision date of 9/9/2025, directed staff to toilet resident every 2 hours while awake and upon request.
In an interview on 1/26/2026 at 2:55 PM, R11 reported he often waited 30 minutes for his call light to be answered and often urinated on himself because he could not hold his urine that long. R11 reported this made him feel like he was not wanted. Review of R11's call light report from 1/20/2026 to 1/27/2026 revealed the following.1/20/2026- call light activated at 9:43 AM with 32 minutes elapsed until answered1/21/2026- call light activated at 8:24 AM with 18 minutes elapsed until answered1/21/2026- call light activated at 11:20 AM with 22 minutes elapsed until answered1/21/2026- call light activated at 2:01 PM with 27 minutes elapsed until answered1/21/2026- call light activated at 2:43 PM with 28 minutes elapsed until answered1/22/2026- call light activated at 6:32 AM with 31 minutes elapsed until answered1/22/2026- call light activated at 3:09 PM with 17 minutes elapsed until answered1/22/2026- call light activated at 6:43 PM with 19 minutes elapsed until answered1/22/2026- call light activated at 7:28 PM with 25 minutes elapsed until answered1/23/2026- call light activated at 12:50 AM with 22 minutes elapsed until answered1/23/2026- call light activated at 5:46 AM with 28 minutes elapsed until answered1/23/2026- call light activated at 7:06 AM with 29 minutes elapsed until answered1/23/2026- call light activated at 9:13 AM with 34 minutes elapsed until answered1/23/2026- call light activated at 4:21 PM with 28 minutes elapsed until answered1/23/2026- call light activated at 9:02 PM with 24 minutes elapsed until answered1/24/2026- call light activated at 5:11 AM with 18 minutes elapsed until answered1/24/2026- call light activated at 10:04 AM with 23 minutes elapsed until answered1/24/2026- call light activated at 5:20 PM with 30 minutes elapsed until answered1/24/2026- call light activated at 6:34 PM with 25 minutes elapsed until answered1/24/2026- call light activated at 9:38 PM with 21 minutes elapsed until answered1/25/2026- call light activated at 1:36 AM with 24 minutes elapsed until answered1/25/2026- call light activated at 6:48 AM with 37 minutes elapsed until answered1/25/2026- call light activated at 9:38 AM with 27 minutes elapsed until answered1/25/2026- call light activated at 9:43 PM with 61 minutes elapsed until answered1/26/2026- call light activated at 1:45 AM with 39 minutes elapsed until answered1/26/2026- call light activated at 10:15 AM with 32 minutes elapsed until answered1/26/2026- call light activated at 7:06 PM with 23 minutes elapsed until answered1/26/2026- call light activated at 11:12 PM with 26 minutes elapsed until answered
R87
Review of the Electronic Medical Record (EMR) admission Record reflected R87 admitted to the facility 8/5/24 with pertinent diagnoses that included diagnoses that included Orthostatic Hypotension (a measurable drop in blood pressure when standing from lying or sitting that may result in lightheadedness), Syncope (fainting), and Collapse.
The Minimum Data Set (MDS) (a resident assessment tool) dated 11/5/25 reflected a Brief Interview for Mental Status (BIMS) (a scale used to assist to determine a resident's cognitive status) reflected R87 had a score of 15 out of 15 which indicated the Resident was cognitively intact.
On 1/26/26 an interview was conducted with R87 in her room. R87 reported she fell about 6 months prior because she self-transferred to use the bathroom when staff did not respond timely to her call light. R87 reported she has a walker, but staff have told her to wait for assistance because she might fall and break her hip. R87 stated that scares me. R87 reported since then there have been instances of slow call light response when she wanted to use the bathroom that resulted in either soiling or wetting herself. R87 reported this makes her feel helpless and had asked staff, how it would make them feel if they had to sit in their own poop and pee. R87 reported once she soiled herself when started on bowel medication. The Resident indicated she is proud and has visitors but doesn't want people coming to see her when the room smells like poop. R87 reported it really bothers her when she voids on herself.
Review of the call light report for R87 from 1/20/26 to 1/25/26 revealed:
1/20/26 call light activated at 8:44 AM with 26 minutes elapsed until suspended.
1/21/26 call light activated at 2:19 AM with 29 minutes elapsed until suspended.
1/22/26 call light activated at 1:00 PM with 22 minutes elapsed until suspended.
1/23/26 call light activated at 8:03 AM with 37 minutes elapsed until suspended.
1/23/26 call light activated at 9:55 AM with 36 minutes elapsed until suspended.
1/23/26 call light activated at 11:20 AM with 28 minutes elapsed until suspended.
1/24/26 call light activated at 6:46 PM with 31 minutes elapsed until suspended.
1/24/26 call light activated at 8:40 PM with 36 minutes elapsed until suspended.
1/25/26 call light activated at 9:53 AM with 29 minutes elapsed until suspended.
1/25/26 call light activated at 8:11 PM with 32 minutes elapsed until suspended.
During a second interview conducted 1/28/26 at 9:22 AM R87 reported instances when staff had turned off the call light and returned later to provide the aid needed. R87 added, They are real busy. R87 reported at these times she had not re-initiated the call light but that sometimes she was unable to hold her urine until staff returned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a pressure relieving care plan for 1 Resident (R28) of 1 Resident reviewed for care plans.Findings included:R28Review of R28's admission record dated 1/28/26 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: chronic pain, dysuria (frequent urination), reduced mobility, and chronic kidney disease. R28 was her own responsible party.Review of R28's Brief Interview of Mental Status (BIMS), a mental/cognitive assessment, dated 12/2/25 revealed R28 scored 15 out of 15 (normal mental status).Review of R28's skin integrity care plan revision date of 11/06/25 revealed, I have actual impairment to skin integrity r/t (related to) hemiplegia/hemiparesis (paralysis of half of the body). Interventions included: cushion for chair dated 10/25/25. No interventions were noted for the toilet or bedpan.On 1/27/26 at 1:26 PM, R28 was observed sitting in her room in her wheelchair. R28 complained of buttock pain, pain when she sits on the toilet and bed pan for extended periods of time. Certified Nursing Assistant (CNA) H came in the room to assist R28 and R28 was agreeable to allowing the Surveyor to check the skin on her buttock. CNA H assisted R28 to stand and remove R28's pants. R28 pointed to her coccyx area when explaining where she hurt. The coccyx and sacral area were coated with a thick white substance. Some skin was observed to be darker in the sacral area than the rest of her buttock. The coccyx was not visible. R28 was sitting on a green pad. CNA H said R28 was to be sitting on a pressure relief cushion. CNA H could not locate the cushion that was normally in R28's wheelchair. CNA H obtained a different seat cushion. R28 took the disposable cover off her drink and ran her finger around the edge and said the outside of the cup was like the bed pan and explained the edge hurt her buttock when she sat on it.During an observation and interview with R28 on 1/29/26 at 10:37 AM, R28 was sitting on the toilet in her bathroom. R28's feet were several inches off the floor and R28 was complaining of the toilet seat hurting her buttock. R28's Charge Nurse, CN M was asked to come evaluate R28's buttock pain and need for assistance. CN M asked R28 if she could shift her weight off where it hurt. R28 tried but said she could not. CN M handed R28 the bed pan she uses and asked where the bedpan hurt her and R28 pointed to the narrow sides with her fingers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to prevent falls for 2 residents (R11 and R38) of 5 residents reviewed for falls.Findings include:R11
Review of an admission Record revealed R11 admitted to the facility on [DATE] with pertinent diagnoses which included Parkinson's Disease and unsteadiness on feet.
Review of a current toileting Care Plan intervention for R11, with a revision date of 9/9/2025, directed staff to toilet resident every 2 hours while awake and upon request.
In an interview on 1/26/2026 at 2:55 PM, R11 reported he often waited 30 minutes for his call light to be answered. R11 reported he was unable to hold his urine that long and often urinated on himself while waiting for assistance.
Review of R11's Note Text in the Electronic Medical Record (EMR), dated 1/13/2026 at 2:04 PM revealed .This writer was called into resident's room by CNA, who stated that resident was noted to be sitting on the floor of his bathroom. Resident stated that he needed to use the bathroom and could not wait so he tried getting on the toilet but was unable to make it onto the toilet, and he had to sit down on the floor. Review of R11's Note Text in the EMR, dated 1/27/26 at 2:38 PM, revealed .IDT (Inter-Disciplinary Team) post fall huddle and Root-Cause Analysis performed. On 1/13/26 at 1250 (R11) was observed to be seated on the floor of his bathroom. He reported to the staff that he was trying to get on the toilet but was unable to make it onto the toilet and he sat down on the floor. He had urinated on the bathroom floor. He had his call light on prior to self-transferring, but (R11) is not patient and. tries to transfer without being strong enough to complete the transfer safely. Root causes of irritability and impulsiveness were discussed by IDT. Further review of the report revealed it did not state how long R11's call light had been activated prior to staff finding him on the bathroom floor and it did not identify the length of the call light wait time as part of the root cause of this fall.
In an interview on 1/28/2025 at 3:47 PM, the Nursing Home Administrator (NHA) reported she would provide the call light report for R11 on 1/13/2025. The NHA did not know why this information was not reviewed in the post fall huddle Root-Cause Analysis.
Review of R11's Past Calls report, dated 1/13/2026, revealed his bathroom pull station call light was activated at 12:25 PM with 28 minutes elapsed until staff turned the call light off at 12:53 PM.
In an interview on 1/29/2026 at 10:22 AM, Registered Nurse (RN) Charge Nurse M discussed the 28-minute wait time in between when R11 activated the bathroom call light at 12:25 PM and the staff response at 12:50 PM. RN Charge Nurse M reported 28 minutes was longer than a resident should be required to wait for assistance using the bathroom.
In an interview on 1/29/2026 at 10:42 AM, the NHA did not have a reason that the call light wait time was not included in the post fall Huddle and Root Cause Analysis performed for this fall. Review of the facility policy/procedure Incidents & Accidents Policy, revised 11/2023, revealed .The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Conducting a root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences.
R38
Review of an admission Record revealed R38 admitted to the facility on [DATE] with pertinent diagnoses which included Parkinson's disease, dementia, psychotic disorder with hallucinations, delusional disorder, and major depressive disorder.
In an observation on 01/29/2026 at 8:19 AM, R38 ambulated into the hallway from his room utilizing a two-wheeled walker. R38 walked down the opposite hallway from his room (closed rooms) and observed a lighted sign on the wall. R38 was without staff presence at the end of this hallway. R38 attempted to enter another resident room in the hallway as he ambulated toward the nurse's station. Staff members walked through the hallway past R38 and did not attempt to approach. R38 then ambulated to the common area where the television played an Elvis video. R38 stepped backward multiple steps tipping his front walker legs off from the floor. Staff noted to be in another hall and in other resident rooms. One staff member was observed with a breakfast hall tray that she returned to the kitchen; another staff member was observed in the dirty linen room. R38 ambulated back to the end of the same hallway (closed rooms) and proceeded to turn around when he reached the end of the hallway. R38 ambulated without his walker back from the hallway to lean against the nurse's station. There were no staff present at the nursing station or within sight.
Review of a current activities of daily living Care Plan intervention for R38, initiated 04/17/2025, directed staff that R38 required supervision with a two-wheeled walker for ambulation.
In an interview on 01/29/2026 at 8:49 AM, Licensed Practical Nurse (LPN) K was queried what supervision with ambulation would mean in the care plan. LPN K replied that supervision with ambulation means that staff keep visual eyeline at all times with the resident. LPN K observed during response that R38 was standing at the nursing station without his walker. LPN K assisted R38 to obtain his walker and redirected him to his room.
In an interview on 01/29/2026 at 8:59 AM, Certified Nursing Assistant (CNA) E was queried what supervision with ambulation would mean in the care plan. CNA E stated it meant staff were supposed to keep R38 visually in sight.
In an interview on 1/29/26 at 9:06 AM, CNA F was queried what supervision with ambulation would mean in the care plan. CNA F stated you have to watch them when they walk. When asked which residents on the unit required supervision with ambulation CNA F was unable to identify which residents required supervision with ambulation.
In an interview on 1/29/26 at 9:13 AM, Registered Nurse (RN) Charge Nurse N was queried what supervision with ambulation would mean in the care plan. RN Charge Nurse N stated you would be with that resident; you are supervising them. RN Charge Nurse N reported that supervision is when staff always has that resident in their line of sight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently provide clear and concise medical records for 2 residents (R9 and R12) of 20 residents reviewed.R9Review of a resident admission Record revealed R9 admitted to the facility on [DATE] with pertinent diagnoses which included parkinsonism, bipolar disorder, anxiety disorder, and heart failure. Review of R9's electronic medical records (EMR) revealed (Facility Name) Interdisciplinary Conference Report Sheets dated 02/11/25, 5/13/25, and 8/12/25 were marked as the Quarterly option with an X. Further review revealed Resident in attendance: Yes or No all sheets presented with a check mark beside No. Resident family/legal representative in attendance? Yes or No the sheets presented with a check mark beside No. Further review revealed check mark stating completion of a baseline care plan summary encompassing updates to goals, medications, dietary information, and treatments since the last care plan summary had been completed with Resident and/or Resident family/legal representative although Resident and Resident family/legal representative were both marked as not in attendance. Review of R9's EMR revealed (Facility Name) Interdisciplinary Conference Report Sheet dated 10/21/25, with the Quarterly option check marked. Further review revealed Resident in attendance: Yes or No presented a check mark beside No. Resident family/legal representative in attendance? Yes or no presented blank. Further review revealed check mark stating completion of a baseline care plan summary encompassing updates to goals, medications, dietary information, and treatments since the last care plan summary had been completed with Resident and/or Resident family/legal representative although Resident and Resident family/legal representative were both marked as not in attendance. R12Review of a resident admission Record revealed R12 admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease and major depressive disorder.Review of R12's EMR revealed (Facility Name) Interdisciplinary Conference Report Sheet dated 10/16/25, with the Quarterly option checked yes. Further review revealed Resident in attendance: Yes: or No: presented blank. Resident family/legal representative in attendance? Yes: or No: presented blank. Further review revealed check mark stating completion of a baseline care plan summary encompassing updates to goals, medications, dietary information, and treatments since the last care plan summary had been completed with Resident and/or Resident family/legal representative although Resident and Resident family/legal representative were both marked as not in attendance. Review of R12's electronic medical record on 01/27/2026 revealed (Facility Name) Interdisciplinary Conference Report Sheet dated 01/13/2026, with Annual option checked yes. Report Sheet requested Resident in attendance: Yes: or No: presented a check mark beside No. Resident family/legal representative in attendance? Yes: or No: presented blank. Further review revealed check mark stating completion of a baseline care plan summary encompassing updates to goals, medications, dietary information, and treatments since the last care plan summary had been completed with Resident and/or Resident family/legal representative although Resident and Resident family/legal representative were both marked as not in attendance. In an interview and record review on 01/28/2026 at 9:00 AM the Social Service Designee (SSD) R reported that care conferences were completed on paper and when the care conference was completed the paper was taken to be signed by the resident's physician and after the physician signed the care conference was uploaded into the resident's chart. SSD R reported the care conference paperwork should be filled out in its entirety to assist with family involvement.In an interview on 01/28/2026 at 1:00 PM, questioned the Registered Nurse (RN) Charge Nurse N if the expectation would be to have resident/representative involvement for the section that states Baseline Care Plan summary completed with resident/representative including to updates to goals, medications, and dietary information, services, and treatments since initial baseline care plan, RN Charge Nurse N responded yes. Review of facility policy/procedure Nursing Documentation Policy, updated 03/2023, revealed .each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation .

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility. Findings include: On 01/27 at 9:13AM, a drinking fountain was observed that appears to be used inconsistently, located in the unused Boardroom wing on the Ground Level. The basin of the drinking fountain was dry at time of observation. Director of Environmental Services (DES) U was asked about use of the drinking fountain and the flushing schedule for the fountain at that time. DES U indicated they were unsure about the flushing schedule or use of the drinking fountain due to the area being used mainly for storage and that sometimes the restroom facilities are used by facility personnel. Record review of the facility's policy, Michigan Masonic Home, Water Management Program Policy MN-D 153 Procedure 2, states A risk assessment will be conducted by the water management team annually., indicating the drinking fountain would have been assessed annually and status of flushing schedule known.

Based on interview and record review the facility failed to monitor lab results and promote communication between health care providers to maintain an effective antibiotic stewardship program to ensure timely identification and treatment of an infection for one Resident (R103) of six residents reviewed for medications. Findings include:Review of the Electronic Medical Record (EMR) reflected R103 admitted to the facility 8/18/16 with pertinent diagnoses that included a history of urinary tract infections (UTI).Review of the EMR Progress Note entry on 1/2/26 at 4:31 PM reflected a urinalysis was ordered by a physician.Review of the EMR Progress Note entry on 1/4/26 at 2:49 PM reflected the urine specimen had been obtained and sent to the laboratory for analysis.Review of the EMR revealed abnormal urine lab results on 1/4/26 and that a culture and sensitivity (C and S) was to be completed. The document included a physician note dated 1/7/26 at 9:31 AM, UA positive for kleb penumoniae (sic) (a bacterial urinary tract infection), will start 7-day course of Ceftin (antibiotic). Extended course due to hematuria (blood in urine) as well. Called (name of facility) to update result.Review of the EMR revealed documentation of Culture and Sensitivity results Last Resulted 1/6/26 at 7:47 AM. The result reflected the culture result of >100000 col/ml Klebsiella Pneumoniae. The document included the same note from the physician that (name of facility) had been contacted and that the 7-day course of an antibiotic would be started.Review of the EMR did not reflect documentation of the positive lab result for UTI or the need for an antibiotic until 1/16/26 at 15:28 when an antibiotic was ordered. ) No documentation was found in the EMR of monitoring for the results of the urine specimen submitted by facility 1/4/26.Review of the January 2026 Medication Admisnistration Record (MAR) for R103 reflected antibiotic therapy was initiated the evening of 1/16/26.On 1/28/26 at 11:38 AM, an interview was conducted with Infection Preventionist (IP) G. IP G reported that the charge nurses will inform her of residents with suspected infections, if a urine sample was sent to the lab, or if a physician wanted to start an antibiotic. The IP reported that she would follow up to make sure a note was entered into the medical record. IP G reported that the Medical Director follows most of the facility residents but that another Physician at the facility was responsible for a small number of residents. IP G reported that this Physician was following R103. The IP reported that the documentation of the lab results and the order for an antibiotic were placed in a separate hospital EMR and not the facility EMR. The IP indicated there was a miscommunication despite documentation in the facility EMR that a urine sample had been sent to the lab and was without monitoring for the results. The policy provided by the facility titled Infection Surveillance Policy last revised 9/2025 was reviewed. The policy reflected It is the policy of (name of facility) to have a system of infection surveillance services as a core activity of the (facility's) infection prevention and control program's purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices . And Procedure: .2. The nurses participate in surveillance through assessment of residents and reporting changes in condition to the resident's physicians and management staff, per protocol for notification of changes and in-house reporting of communicable disease and infections. Examples of notification triggers include, but not limited to: a. Resident develops signs and symptoms of infection.c. A microbiology test is ordered.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises. Findings include: On 01/27/2026 at 8:30AM, a patch of black mold-like substance was observed, 2 feet long by 1 foot wide, at eye level, on the wall in the Water room, located in Maintenance and Laundry wing of Ground Level. Director of Facilities (DF) T confirmed the observation at the time of walk through. There was no visible explanation at time of observation, as the wall was dry and there were no notable high humidity issues in the room.

Based on observation, interview and record review, the facility failed to maintain self-esteem, honor preferences and ensure care was given in a dignified manner for one resident (R47) out of 22 residents reviewed for dignity.
Findings:
Review of an admission Record reflects R47 admitted to the facility with diagnosis that included Parkinsonism (a group of movement disorders that share similar symptoms to Parkinson's disease), difficulty walking, unspecified mood disorder, anxiety and agoraphobia (fear of places and situations that might cause panic, helplessness and embarrassment) with panic disorder.
During an observation and interview on 12/16/24 at 10:31 AM, R47 was in a maroon-colored t-shirt and athletic shorts. The t-shirt was soiled with what appeared to be food spills, a crucifix around his neck was caked with an unknown substance. R47 reported his breakfast spilled the day before and no one came to help him clean it up.
During an observation and interview on 12/17/24 at 9:07 AM, R47 was wearing the same soiled clothes he had on the day before. R47 reported that he does not like his showers because he does not like showers given to him by women. R47 said that he would be more willing to shower if a male attendant helped him. R47 repeated that women showering him was not appropriate and embarrassed him.
During an interview on 12/17/24 at 9:13 AM, Registered Nurse (RN) N reported she was aware R47 did not like women showering him. RN N said R47's preference to have male caregivers is not care planned, but there is a male Certified Nurse Aide (CNA) who could help if needed and the facility should be able to accommodate this need.
Review of a Task Monitor for showering and bathing for the last 30 days (11/22/2024-12/16/2024) reflected R47 had one shower on 11/22/2024 with Set-up or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. The report showed that R47 refused a shower on 11/25/2024 and 12/10/2024. The report showed Not Applicable on 12/2/2024 and 12/16/2024.
Review of a Care Plan initiated on 2/25/2021 reflected R47 required assistance with ADL (activities of daily living), mobility and toileting. Interventions and tasks related to this focus included BATHING supervision x 1 (one assist) as I allow. The care plan did not specify R47's preference for male caregivers. Further review of the entire care plan revealed R47 was taking psychotropic medications for depression, anxiety and agoraphobia with fluctuating symptoms of anxiousness. The care plan did not include interventions to address R47's reported embarrassment with female caregivers and preference for male caregivers for showers.
During an interview on 12/18/2024 at 11:54 AM, Registered Nurse (RN)/Assistance Director of Nursing (ADON) O reported that she was very familiar with R47 and knew he did not like women giving him showers. RN/ADON O said the staff needed to do a better job of documenting R47's refusal to shower and attempts to reapproach when needed. RN/ADON O said there is a male CNA who could accommodate R47's preference for male caregivers when showering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed implement interventions to prevent falls for three residents (R12, R38, and R87) of 6 residents reviewed for falls.
Finding include:
Resident #87 (R87)
Review of R87's face sheet dated 12/18/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: Dementia, pain and edema. He was not his own responsible party.
Review of his Brief Interview of Mental Status (BIMS) score dated 9/24/24 revealed a score of 2/15, indicating he is severely cognitively impaired.
R87 was observed on12/16/24 at 11:01 AM in his room in a recliner chair with his feet up and not supervised. A couple minutes later, R87 was observed walking by himself in his room to the bathroom with no assistive device. A few minutes later, he was observed walking back to his recliner alone.
During an observation and an interview on 12/17/24 at 3:00 PM, R87 was in his room in a recliner alone with his feet up. No walker was observed in his room. Registered Nurse (RN) C came to the resident's room and was asked about how much assistance R87 needed for ambulation. RN C reported he required a walker with one person to assist for ambulation.
Review of R87's incident report dated 12/6/24 at 5:50 AM revealed he had a witnessed fall in his room. The CNA (Certified Nursing Assistant) was in his room at the time to take him to the bathroom.
Review of R87's Fall Root Cause Summary dated 12/10/24 at 14:40 (2:40 PM), for the fall that occurred on 12/9/24, revealed he was last observed in bed at midnight and was dry at that time. (3 hours and 17 minutes prior to being found on the floor in the hallway). Interventions included: assist to the bathroom every 2 hours while awake (standard of care), gripper strips to the floor by the bed, gripper strips to the floor in front of recliner, keep in supervised area while up and therapy to screen due to weakness. There was no indication that supervision when awake was implemented.
Review of the Fall Root Cause Summary dated 12/9/24 at 17:07, for the 12/6/24 fall for R87 revealed he was last observed at 5:50 AM, last time toileted 2:00 AM. Summary of incident. Resident was standing up from recliner to go to the bathroom with staff in room at the time. Resident became weak and went to his knees. Resident did not hit his head. Abrasion LT (left) knee. Intervention: Remind and encourage me to use my call light as needed during acute illness.
Review of R 87's incident report dated 12/9/24 at 3:17 AM revealed R87 had an unwitnessed fall in the hallway. Interviews revealed he was confused but did not indicate other behaviors or give details about amount of sleep or any routine patterns of care that were the same or different that night.
Review of R87's fall care plan revealed he is at high risk for falls due to dementia, pain, history of falls, incontinence, poor safety awareness and self-transfers often, dated 9/19/24. The fall interventions included keep in supervised area while up, initiated on 12/9/24. (Which is not reflected on the [NAME]).
Review of R87's [NAME] dated 12/18/24 revealed that he was to be assisted to the bathroom every 2 hours while awake, he was not to be left unattended in the bathroom, he was to use a front wheeled walker with limited assistance of one person to walk. There was no intervention for him to be in a supervised area while he is awake. (This intervention was on the care plan).
Resident #12 (R12)
Review of R12's face sheet dated 12/18/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Vascular dementia, sleep apnea, and unsteady on feet. She was not her own responsible party.
During an observation and an interview with Registered Nurse (RN) C on 12/17/24 at 2:49 PM she pointed out R12 in the main dining area on the unit playing bingo at that time. She confirmed that R12 was a fall risk, and they try to keep her in supervised activities.
Review of R12's incident and accident report dated 9/27/24 at 11:12 AM revealed R12 had a witnessed fall in the day room. The Certified Nurse aide reported R12 was self-transferring and noticed R12's knee was shaking. The report said R12 used the toilet at 8:30 AM and was last seen in the day room [ROOM NUMBER] minutes prior to the fall. The report did not indicate any activity was happening at the time of the fall or provide any details of care provided or behaviors.
Review of R12's Fall Root Cause Summary dated 10/1/24 at 16:13 (4:13 PM) for the fall that occurred on 9/27/24 revealed R38 was seen sitting in a chair in the sunroom [ROOM NUMBER] minutes prior to being found on the floor. The summary of incident revealed, Resident was self-transferring to the bathroom in the day room when her leg knee gave out. Staff had observed her transferring and not asking for help. Due to her cognition resident does not always remember to ask for assistance. Intervention placed was a bell provided in day room when sitting in day room to ring for help.
Review of R12's incident report dated 10/7/24 at 10:58 AM revealed R12 had an unwitnessed fall in the sunroom. R12 indicated that she needed to use the bathroom. She was last observed at 10:30 AM sitting in the sunroom with her eyes closed. R12 did not use the bell. The report did not indicate when she was last assisted to the toilet. The report did not indicate any activity, or supervision was being provided at the time of the fall. No interventions placed.
Review of R12's Fall Root Cause Summary dated 10/15/24 for the fall that occurred on10/7/24, revealed R12 was observed sitting in a recliner in the sunroom with her eyes closed at 10:30 AM, she had tennis shoes with grip and had a walker in use at that time. Summary of incident, Resident observed on the floor in sunroom in front of sunroom chair. Resident stated she was attempting to get up and use the bathroom when her right leg gave out. Resident did not use her bell provided to ask for assistance. Resident does have a history of self-transfers and d/t cognition does not always ask for help. Interventions placed, assist to common area when up, dycem placed in in chair in sunroom, Therapy to focus on transfers for the chairs in the sunroom. One person assists on and off the unit. Previous intervention was to provide a bell in the sunroom. Previous fall was also in sunroom, providing a call bell was not effective for a severely cognitively impaired resident. There was no indication that the dycem would prevent self-transfer and no indication of how they would be addressing the unsafe transfers or meeting her toilet needs.
Review of R12's fall care plan dated 4/23/24 revealed that R12 was high risk for falls related to dementia, history of falls, unsteady on feet, poor safety awareness, and history of self-transfers. She has been noted to rush when she is walking and needs to be reminded to slow down. She is on diuretic, seizure and psychotropic medications. She has seizure like activity. She uses a walker to walk. She has occasional incontinence and sometimes takes herself to the bathroom. Interventions included: assist me to common area when up 10/7/24, Dycem (nonskid material) in chair in the sunroom where she enjoys sitting most days. Provide bell in day room when I am sitting in there 9/27/24, Therapy to focus on transfers from the chair in the sunroom.
Resident #38 (R38)
Review of R38's face sheet dated 12/18/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Alzheimer's disease, chronic kidney disease with heart failure. She was not her own responsible party.
Review of R38's Minimum Data Set (MDS) nursing assessment dated [DATE] revealed she was severely cognitively impaired.
Review of R38's incident report dated 7/14/24 at 15:30 (3:30 PM) revealed she had an un-witnessed fall in the dining room near her wheelchair. Review of R38 fall care plan revealed no new fall intervention was placed after this fall.
Review of R38's Root Cause Summary dated 7/16/24 at 13:34 (1:34 PM) for the fall on 7/14/24 revealed the same information that was on the incident report dated 7/14/24 at 3:30 PM. The new intervention placed was pain cream was discontinued, and a pain patch started, therapy screen for strengthening and she was referred to a physician for increased behaviors. No documentation was located that indicated R38 had signs/symptoms of pain prior to the fall. The documentation did not include any behaviors prior to the fall. It was not clear why pain and behaviors were determined to be the root cause of her fall.
Review of R38's incident and accident report dated 7/30/24 at 17:30 (5:30 PM) revealed she had an unwitnessed fall in the hallway. Staff statements revealed she had been in bed at 4:00 PM and she refused to use the bathroom at that time. She had shoes on. When R38 was asked what she was doing she said she slid out of bed and scooted in the hallway. There was no indication how long she had been in bed, when was the last time she used the toilet, or how she had responding to care earlier that day. (or when her needs were last met).
R38's Fall Root Cause documentation for fall on 7/30/24 dated 8/6/24 at (7 days after the fall). New interventions were blood sugar checks before meals for 1-day, orthostatic blood pressures for 3 days and bowel and bladder monitoring for 3 days. There were no meaningful or sensical interventions to address or prevent future falls based on investigation.
Review of R38's incident and accident report dated 10/11/24 at 20:25 (9:25 PM) revealed R38 had an unwitnessed fall in her room. Staff statements revealed R38 was watching TV at 19:30 (8:30 PM) in an unknown location. No information was documented that provided to indicate what R38's behaviors were that day, when she went to bed, how long she slept or the last time she had used the toilet. New interventions work order for gripper strips in front of the recliner and bed.
Review of R38's Fall Root Cause dated 10/17/24 at 17:03 (5:03 PM) regarding the fall on 10/11/24 revealed that R38 was in her recliner watching TV at 19:30 (approximately 1 hour prior to her fall). There was no indication of the last time she used the bathroom, behaviors prior to the fall, when she slept last. There was no indication of any changes in condition or behavior noted. The new intervention placed was gripper strips in front of the recliner and side of bed. Not enough information provided to show a thorough investigation of a fall to show gripper strips as an appropriate intervention.
Review of R38's incident and accident report dated 11/14/24 at 2:45 AM revealed she had an un-witnessed fall in her room, she was on the floor in front of the bathroom, her walker was in the bathroom and her shoes were on the opposite feet. They moved her closer to the nurse's station for observation. Staff statements revealed R38 was seen 45 minutes prior to the fall, sleeping in bed. No indication of how long R38 had been sleeping prior to the fall.
Review of R38's Fall Root Cause dated 11/18/24 at 17:00 (5:00 PM) for the 11/14/24 fall revealed R38 used the toilet at 12:31 AM. No indication of behaviors, sleep pattern or amount of time resident had been sleeping was found. Under interventions was offer, encourage an assist me to the bathroom every 4 hours (old intervention and according to the root cause was provided that night.) No new interventions were located.
Review of R38's [NAME] (care giver instructions) dated 12/18/24 (date of this survey) included the following information in the safety section: do not leave me unattended in my bathroom, offer, encourage and assist me as need to the bathroom every 4 hours, and when I am awake in the night and ambulating, assist me to the common area. Mobility included: ambulation extensive assist x 1 using 4 wheeled walker, bed mobility independent, toilet use extensive assist of 1 encourage, offer, and assist with toileting before and after meals and at bedtime. Transfer extensive assist of 1 with 4 wheeled walker.
Review of R38's Activities of Daily Living (ADL) care plan dated revision on 11/19/24 revealed, I will frequently attempt to self-transfer and ambulate on my own. I have poor safety awareness and do not utilize my call light consistently. I have a history of declining the use of a gait belt. I choose not to consistently us my walker in my room. I prefer to sleep in at times and may yell at staff and become combative with cares.
Review of R38's fall care plan dated revision on 12/17/24 revealed that R38 has had a history of falls, frequently does not use her walker and takes medications that can alter her balance. She had poor safety awareness and is impulsive. She had a history of using furniture in her room to walk, laying on the floor in her room. She is taking diuretic medication (causing urination). She can be resistive and combative with care. On 3/23/23 the intervention to take R38 to the common area when she is awake and at night when walking was added.
During an interview with Unit Manager A on 12/18/24 at 9:00 AM, Unit Manager A was asked about the process of coming up with new interventions and what were the new interventions placed for R38 on 7/14/24 and 7/30/24. Unit Manager A used the electronic medical record to review R38's care plan and fall documents. She could not locate new interventions or information on how they determine the interventions.
Unit Manager A called the Assistant Director or Nursing (ADON) and the ADON came and started reviewing the record for resolved care plans as she could not locate a new intervention in the current care plan. The Director of Nursing joined the interview and explained that they do an initial meeting with staff and document what happens. They take that information and do a Root Cause Analysis. They are to place interventions at the time and add interventions based on the Root Cause Analysis.
The surveyor requested the Root Cause Analysis documentation of this process for: R38, R13 and R87. It was not clear how the faciltiy was going to improve safety or supervision of these residents as they were all severely cognitively impaired, were known to not use call lights, known to self-transfer and had poor safety awareness.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the residents in the facility. Findings include:
During a tour of the main dry storage area for the kitchen, at 11:38 AM on 12/16/24, an interview with Life Safety Emergency Manager (LSEM) K and Director of Dining Services (DDS) M found that this area is no longer used for its intended purpose of being a serving kitchenette. Observation found multiple water fixtures including a preparation sink, a hand sink, a steam table fill, and pot fill fixture on the cook line, that had been stagnant and not under any routine flushing schedule. Sink compartments were found covered, dry and dusty. The hot and cold water lines for the kitchenette hand sink was turned on and brown water came out momentarily before turning clear.
During a tour of the first floor North Kitchenette, starting at 11:54 AM on 12/16/24, an interview with DDS M found that dietary staff don't use the back dish room portion of the first-floor kitchenette. When asked if this area is on a regular flushing schedule for removing stagnant water, LSEM K stated that they will add this area to the list.
During a review of the facilities Water Management Plan (WMP), starting at 1:40 PM on 12/16/24, with DDS M, LSEM K, Director of Facilities (DOF) J, and Director of Environmental Services (DES) I, an interview with staff found that they do regular flushing of water as part of their risk prevention. When asked if the facility currently sent anything to a lab for testing or if they did any testing in house, DOF J stated that they currently do not. When asked if there was any other control measures or limits the facility was using to decrease the risk of Legionella or other OPPP, staff were unsure.
During a tour of the facility, at 3:10 PM on 12/16/24, it was observed that a janitors closet on the second floor North hall, was found with a faucet and no chemical pre dispense. When asked if staff use this sink, DES I asked EVS Aide L and he stated, nobody ever uses that sink. When asked if this was a fixture that is routinely flushed, LSEM K stated they would add it to the list.
During a tour of the Ventilation Unit, at 3:10 PM on 12/16/24, it was observed that a water line that used to service the flush valve of a hopper, was protruding from the wall with crusted debris residue on the outside indicating it was still servicing water and was a stagnant line. An interview with DOF J found that he was unsure if the water line had been disconnected or if it was a stagnant line.
A record review found an Infection Control Risk Assessment, dated 11/30/17, with no facility layout or instructions on how water flows through the facility.
A review of the Michigan Masonic Home Water Management Program Procedure, revised 09/2024, found that .3. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the Homes water system. The risk assessment will consider the following elements: a. Premises plumbing: This includes water system components as described in the documentation of the Homes water system .
A review of the Michigan Masonic Home Water Management Program Policy, revised 9/2024, found that 3. Based on the risk assessment, control points (locations in the water systems where a control measure can be applied) will be identified. 4. Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical controls, temperature management, disinfection level control, visual inspections, or environmental testing for pathogens. 5. Testing protocols and acceptable ranges (control limits) will be established for each control measure.

Based on observation and interview the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination, affecting residents, staff, and the public. Findings Include:
During a tour of the kitchen, at 11:15 AM on 12/6/24, observation of the dish machine area found that the dirty side of the machine had a roughly 10 foot long built in rinse stream, that drains into the garbage disposal. The rinse stream had multiple submerged inlets that hang below the overflow rim of the rinse table and was not observed with an atmospheric vacuum breaker (AVB) that would protect the potable water supply from potential back siphonage (due to the submerged inlets). An interview with Director of Facilities (DOF) J found that he has only been here a couple months and was not sure if the submerged inlets were protected with an AVB. When asked if he could see an AVB anywhere in line of the submerged inlets, DOF J sated he could not.
During a tour of the first floor North clean holding room, at 2:18 PM on 12/16/24, it was observed that a mop sink faucet was found left on and connected to a chemical pre-dispense. No wasting tee or sidekick device was present to remove constant back pressure from the faucet's internal AVB. An interview with Director of Environmental Services (DES) I found that the faucet should be shut off between use.
During a tour of the second floor North spa room, at 2:40 PM on 12/16/24, it was observed that a stack of towels and wash cloths were found stored open and exposed next to the shower. An interview with Life Safety Emergency Manager K found that linens should not be stored open and exposed.
During a tour of second floor North, at 2:45 PM on 12/16/24, it was observed that the tabletop ice machine was found directly connected to the wastewater drain. Food contact equipment must be air gapped in order to remove the risk of contamination due to wastewater back flow.
During a tour of the Ventilation Unit spa room, at 2:55 PM on 12/16/24, it was observed that four towels and six wash cloths were found stored open and exposed next to the shower.
During a tour of the Ventilation Unit soiled utility room, at 3:09 PM on 12/16/24, it was observed that a mop sink faucet was found installed over an area where a hopper used to be installed. At this time, no wastewater access was available for this water fixture and water would run down onto the floor.
During a tour of the laundry room, at 3:30 PM on 12/16/24, it was observed that one of the clean laundry carts was found with an accumulation of paper trash and debris under the carts false bottom.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to safely transport one resident (R25) in a wheelchair, resulting in the potential for serious injury.
Findings include:
A review of R25's admission Record, dated 10/26/23, revealed R25 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R25's admission Record revealed multiple diagnoses that included chronic respiratory failure with hypoxia, anxiety, depression, and post-traumatic stress disorder.
A review of R25's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 9/27/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R25 was cognitively intact. In addition, R25's MDS revealed she could propel herself in a wheelchair with supervision or touching assistance (helper provides verbal cues or touching/steadying assistance as the resident completes the activity) for distances of at least 50 feet and partial/moderate assistance (helper does less than half the effort) for distance of at least 150 feet in a corridor or similar space.
During an observation on 10/25/23 at 1:15 PM, R25 told Registered Nurse (RN) B that she wanted to go to the dining area to participate in an activity. RN B pushed R25 in her wheelchair without foot pedals from R25's room to the dining area. R25 had her legs extended straight out in front of her and raised at approximately a 90-degree angle while she was being pushed.
During an interview on 10/26/23 at 10:30 AM, RN E stated staff are not supposed to push residents in their wheelchairs without foot pedals, because the resident could put their feet down and fall on their face.
During an interview on 10/26/23 at 10:35 AM, RN D stated staff are not supposed to push residents in their wheelchairs without foot pedals, even if the resident can hold their feet up. She stated their feet could fall to the floor and get caught under the wheelchair. She also stated the resident could fall out of their wheelchair if their feet becomes caught under the wheelchair.
A review of the facility's Personnel Vehicle Wheelchair Transportation Policy, dated 4/15/20, revealed, Identification of hazards and risks is the process through which the interdisciplinary team becomes aware of potential hazards in the positioning and transportation of a resident in a wheelchair and the risk of a resident having an avoidable accident . Caregiver staff should make a reasonable effort to identify the hazards and risk factors for each resident before beginning transportation of that resident . Considerations . Are their feet resting flat on the foot plates (foot pedals)? . Quick Check (after resident is transferred into the wheelchair) - buttocks to the back of the chair - Pelvis level - Feet appropriately supported on footplates .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a monthly pharmacy drug regimen review recommendation was reviewed by the physician in a timely manner for 1 of 5 residents reviewed (R35), resulting in R35 receiving a medication over an extended period of time that had insufficient evidence for its use, the potential for the physician not knowing of a pharmacy recommendation, the potential for a delay in implementing a pharmacy recommendation, and the potential for adverse effects from a medication that the pharmacy identified as potential medication issue.
Findings include:
A review of R35's admission Record, dated 10/26/23, revealed R35 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included dementia, diabetes, and urinary incontinence.
A review of R35's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 8/23/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 5 which revealed R35 was severely cognitively impaired.
A review of R35's Pharmacy Consultation Report, dated 8/24/23, revealed to the pharmacist recommended that the physician discontinue R35's cranberry supplement due to insufficient evidence to promote using cranberry supplements to decrease Urinary Tract Infection (UTI) reoccurrence in older adults. R35's physician accepted the recommendation and signed it on 10/5/23 (42 days after the pharmacist made the recommendation).
A reviewed of R35's medication administration records (MAR's), dated 8/24/23 to 10/26/23, revealed R35 received cranberry oral capsules (an unnecessary medication/supplement) from 8/24/23 to 10/6/23 (43 days after the pharmacist's recommendation to discontinue it).
A review of the facility's Medication Regimen Review Policy, revised 8/10/17, revealed, 7. Upon completion of the MRR (Medication Regimen Review), the facility designee and/or physician, will respond to the recommendations in a timely manner . 10. Each residents' drug regimen remains free of unnecessary drugs. An unnecessary drug is any drug when used . b. For excessive duration . d. Without adequate indications for its use .
During an interview on 10/26/23 at 03:30 PM, Assistant Director of Nursing (ADON) A stated the pharmacist usually sends their recommendations to the facility within a day or two of when they see the resident. She stated the physician will usually see the recommendation within a week of the facility receiving the recommendation.
During an interview on 10/26/23 at 04:11 PM, the Director of Nursing (DON) stated the physician should address a pharmacy recommendation within a week or two. She stated the physician rounds weekly. The DON stated six weeks is a bit too long (not timely) for the physician to address a recommendation. She stated in the case of R35's cranberry supplement recommendation, it appeared she (the DON) had to re-issue the pharmacy recommendation for the physician to review because the copy that they have on file for R35 had a fax number on the top of the page, dated 10/5/23 at 9:10 AM. The DON stated that would indicate that she had to request another copy of R35's 8/24/23 pharmacy recommendation. The DON stated the original pharmacy recommendations do not have the fax number at the top of the page. The DON stated she did not know why the pharmacy recommendation had to be re-issued. She stated the system she uses to keep track of pharmacy recommendations just indicates that she received the recommendation, not the date it was received or if it had to be requested again.