Michigan Veterans Home Of Chesterfield Township

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to apply and/or document refusals of a palm protector for one resident (R82) out of one reviewed for range of motion, resulting in the potential for contractures and/or delay in treatment. Findings include:
On 1/30/2023 at 9:55 AM, an interview was conducted with R82 regarding their stay in the facility. R82 stated that they enjoyed being in the facility, however they would like their therapy to be a little more intense. R82 stated that they would like to work more on their hands and sitting up. Nothing was noted on R82's hands.
A review of the medical record revealed that R82 admitted into the facility on 8/23/2022 with the following diagnoses, Muscle Wasting and Atrophy and Unspecified Injury at Unspecified Level of Cervical Spinal Cord. A review of the most recent Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R82 also required total two-person assistance with bed mobility and transfers.
A review of the physician orders noted the following, Order: Remove Palm Protectors and evaluate skin integrity of bilateral hands, replace palm protectors, notify provider of any skin issues. Directions: Every Evening Shift. Status: Active. Start Date:9/7/2022 15:00 (3:00 PM). Further review of the Treatment Administration Record for the month of January did not reveal any refusals of palm protector application.
A review of the task noted the following, Wash bilateral hands, ensure care between fingers, dry thoroughly and replace palm protectors. Notify Nurse of any skin issues observed. Further review of the task list for the last thirty days did not reveal any refusals of palm protector application.
On 1/31/2023 at 9:41 AM, R82 was observed in the bed with no palm protectors on. R82 stated that they have not worn them 'in a while' and that no one has tried to put them on. R82 stated that sometimes they will use a towel because the current splint they have is uncomfortable.
On 1/31/2023 at 10:32 AM, an interview was conducted with Therapy A regarding R82 not being observed wearing palm protectors. Therapy A stated that R82 refused them all the time and Occupational Therapy (OT) has tried three different type of hand splints. Therapy A stated that they have asked the nursing staff to be sure they document refusals.
On 1/31/2023 at 12:54 PM, an interview was conducted with the Director of Nursing (DON) regarding R82's palm protectors. The DON stated that their expectation is that if R82 is in fact refusing to wear the palm protectors then that should be documented in the medical record.
A review of a facility policy titled, Assistive Devices and Equipment noted the following, Policy: The home maintains and supervises the use of assistive devices and equipment for members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to don a gown for a contact precaution room for one resident (R82) out of one reviewed for isolation precautions, resulting in the potential for the spread of infection. Findings include:
A review of the medical record revealed that R82 admitted into the facility on 8/23/2022 with the following diagnoses, Muscle Wasting and Atrophy and Unspecified Injury at Unspecified Level of Cervical Spinal Cord. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R82 also required total two-person assistance with bed mobility and transfers.
A review of the physician orders noted the following, Order: Contact Precautions r/t (related to)continuing symptoms of ESBL(infection resistant to antibiotics)-post contact precautions sign outside the room and ensure visible (not on door)-PPE cart outside room with donning (putting on) sign-minimum of touchless trash can inside room with doffing (removal of) sign (may choose to use 3 bin cart .Status: Active.
On 1/31/2023 at 9:40 AM, A contact precautions sign was observed in front of the room, as well as a Personal Protective Equipment (PPE) bin.
On 1/31/2023 at 9:41 AM, Certified Nursing Assistant (CNA) D was observed at R82's bedside with gloves and no gown on. R82 stated that they were being cleaned up.
On 1/31/2023 at 11:54 AM, an interview was conducted with Infection Control Preventionist (ICP) C regarding the observation. ICP C stated that if they are changing R82's (name of catheter) catheter then they should be wearing a gown, gloves, and goggles. ICP C stated that if they are going in to give care, they should be wearing a gown and gloves.
A review of a facility policy titled, Isolation Precautions noted the following, Contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the member or the member's environment.