Michigan Veteran Homes At Grand Rapids

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain complete and accurate medical records for 1 resident (Resident#25) of a total sample of 25, resulting in a potential for missed wound care and worsening of a wound going unrecognized.
Findings include:
Review of an admission Record revealed Resident #25 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: atherosclerosis (condition causing a narrowing of blood vessels due to the build up of plaque, pressure ulcer of the sacral region (lower back, base of spine, pelvic area), diabetes (condition resulting in elevated blood sugar levels), and chronic pain.
Review of a Minimum Data Set (MDS) assessment for Resident #25 with a reference date of 2/25/25, revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #25 was moderately cognitively impaired.
Review of a Care Plan for Resident # 25 with a reference date of 10/5/22, revealed a problem/goal/interventions of: (Resident #25) has .presence of actual pressure wounds .Goal: Intact skin will remain free of redness, blisters, or discoloration .Interventions .Notify the medical provider and wound nurse of any new skin issues, injuries or other skin related concerns .
In an interview on 4/28/25 at 2:01pm, Resident #25 reported he had multiple wounds and that the staff changed the bandages once a week.
In an interview on 4/29/25 at 12:54pm, Registered Nurse (RN) BB reported Resident #25 had multiple wounds, and the treatment was painful, so the resident only wanted it done once a week.
In an interview on 4/30/25 at 9:35am, RN BB reported the Treatment Administration Record (TAR) for Resident #25 had no document of wound treatment being completed on 4/21/25 for Resident #25, which was the day the dressing change to his coccyx (base of the spinal column) was due. RN BB reported she would speak with the hospice nurse, who was responsible for completing wound care for Resident #25, and review documentation to determine if Resident #25 received wound care on 4/21/25.
In an interview on 4/30/25 at 9:45am, Licensed Practical Nurse (LPN) ZZ reported Resident #25 did not refuse dressing changes to his wound on his coccyx. LPN ZZ reported if a treatment was not documented in the TAR, it would be documented in nursing progress notes. LPN ZZ also reported any refusals for dressing changes should be documented in nursing progress notes.
Review of an email received from RN BB on 4/30/25 at 10:30am revealed I spoke with hospice and LPN ZZ. Hospice RN did not come in on 4/21 and they (hospice services) did not notify us until late in the day. LPN ZZ did the dressings (dressing changes for Resident #25) on 4/22.
In an interview on 4/30/25 at 11:50am, RN BB reported documentation of weekly wound measurements, as well as evaluations of wounds was expected to be completed week. When further queried, RN BB reported the electronic medical record reflected the last measurements of Resident #25's wounds were dated 4/7/25.
In an interview on 4/30/25 at 12:08pm, Wound Nurse/RN(WNRN) AA reported she tracked the completion of weekly wound evaluations and documentation of wound measurements at the facility. WNRN AA said the hospice RN was responsible for documenting the evaluation, treatments and condition of Resident #25's wounds. WNRN reported Resident #25 had recently received wound evaluations and wound care from hospice nurses that were filling in and not actually assigned to him. WNRN AA reported she had been gone for several days, and another nurse covered her responsibilities, but that nurse was still learning the role. WNRN AA reported she thought the lack of appropriate documentation regarding Resident #25's wound care and wound evaluations may have been overlooked and not corrected in her absence. WNRN AA confirmed Resident #25 had no documentation of wound measurements since 4/7/25 in his medical record. When further queried, WNRN AA reported it was important to have documentation of weekly wound care and wound measurements to determine if the wound was improving or worsening.
Review of Principles for Nursing Documentation published by the American Nurses Association, 2010, revealed Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice.
Review of a Pressure Injury Prevention and Management facility policy with a reference date of 4/11/25 revealed Policy: (Facility name omitted) is committed to .provide treatment and services to heal the pressure ulcer .5. Monitoring: The RN (Registered Nurse) .or designee, will review all relevant documentation regarding skin assessments .progression towards healing, compliance at least weekly .and document a summary of finding the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #100:
Review of an admission Record revealed Resident #100 was a male with pertinent diagnoses which included cholecystectomy drain (thin tube inserted into the gallbladder to drain excess bile), pressure ulcer right heel, and deep tissue injury to left medial bunion near great toe.
Review of Order dated 2/4/25, revealed, .Enhanced Barrier Precautions (EBP) related to: Chole drain - Ensure the precaution sign is posted and visible outside of member room (not on member door). - PPE supplies are available outside the room. - Touchless trash receptacle inside room near doorway for PPE disposal prior to exit .
During an observation on 04/28/25 at 12:10 PM, Resident #100 was brought to his room to transfer him into bed. Certified Nursing Assistant (CNA) N was observed making Resident #100's bed. She grabbed the pillows off his bed and placed them in the chair. CNA N grabbed his personal blanket and quilt off the chair and placed them on his bed. There was no signage on the door to indicate he was on EBP.
In an interview and observation on 04/28/25 at 12:13 PM, CNA N reported Resident #100 had a wound on his bottom. CNA N reported personal protective equipment (PPE) would be worn while bathing him and changing his brief as she was making his bed.
During an observation on 04/28/25 at 12:15 PM, CNA N folded the blankets down and CNA M brought the hoyer in the room to transfer Resident #100 to his bed. CNA M reported Resident #100 had on the blue boots to protect his heels as he had a wound on his right heel. Both CNAs hooked the resident's sling up to the hoyer machine, rolled Resident #100 over to his bed, guiding him over the bed and stabilizing him while the hoyer was slowly lowered to the bed. CNA N had placed her hands on Resident 100's feet while he was slowly lowered to the bed. Both CNAs were on each side of him and removed the loops from the sling off the hoyer arm. CNA M removed the hoyer from under the bed and moved it out of the way. CNA M came back to Resident #100 had him roll towards her as she removed the sling and then had him roll to the other side to remove the sling from that side while she supported him and removed the sling from under Resident #100. CNA M then adjusted him in the bed so he was more centered and checked his brief to determine if he needed care. CNA N removed her gloves, cleaned the hoyer, performed hand hygiene and exited the room. Neither CNA wore a gown during cares.
In an interview on 04/28/25 at 12:20 PM, CNA M reported the only time the staff would wear EBP PPE was when they were providing care to the resident when Resident #100's wounds were exposed.
In an interview on 04/30/25 at 12:31 PM, Registered Nurse (RN) YY reported the staff would wear a gown and gloves while providing care to a resident who was under enhanced barrier precautions (EBP) as your clothes could spread whatever you had come into contact with to the resident you were providing care to.
In an interview on 04/30/25 at 01:25 PM, Nursing Home Admininstrator (NHA) A reported when staff were providing hands on care to a resident under EBP, the staff were required to wear what the guidance was on the sign posted outside of the resident's door indicated.
Review of the facility's Enhanced Barrier Precautions policy last revised 4/1/24 revealed, POLICY
It is the policy of MVH to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs) . 2. Initiation of Enhanced Barrier Precautions .
b. An order for enhanced barrier precautions will be obtained for members with any of the following:
i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy tubes) even if the member is not known to be infected or colonized with a MDRO .3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the member's room .4. High-contact member care activities include: a. Dressing. b. Bathing. c. Transferring. d. Providing hygiene. e. Changing linens. f. Changing briefs or assisting with toileting. g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy tubes. h. Wound care: any skin opening requiring a dressing .
Based on observation, interview, and record review, the facility failed to implement and follow enhanced barrier precautions for 2 (Resident #419 and #100) of 25 sampled residents reviewed for infection prevention and control resulting in the potential for the development and transmission of communicable diseases and infections.
Findings include:
Resident #419
Review of an admission Record revealed Resident #419 was originally admitted to the facility on [DATE] with pertinent diagnoses which included unstageable pressure ulcer of right heel.
Review of Resident #419's Treatment Administration Orders (TAR) revealed, Order: Enhanced Barrier Precautions related to: unstageable ulcer to right heel/ dialysis access site. Ensure the precaution sign is posted and visible outside of member room (not on member door). PPE (personal protective equipment) supplies are available outside the room. Touchless trash receptacle inside room near doorway for PPE disposal prior to exit. every shift for transmission based precautions. Start date: 4/24/25. It was noted that nursing staff had documented this treatment order as completed each shift from 4/24/25 to 4/29/25.
In an observation on 4/28/25 at 10:39 AM, Resident #419's room was noted to not have an Enhanced Barrier Precautions sign near the door or a cart with PPE for staff to wear for high contact care with Resident #419.
In an observation on 4/29/25 at Licensed Practical Nurse (LPN) II and Certified Nursing Assistant (CNA) VV and CNA D entered Resident #419's room. LPN II administered oral medications to Resident #419 and then applied gloves and began to remove the dressing bandage on Resident #419's right foot. It was noted that LPN II was not wearing a gown. After LPN II completed Resident #419's medication administration, CNA VV and CNA D placed a hoyer sling (piece of equipment used with a hoyer lift to transfer patients with limited mobility) underneath Resident #419 and then attached the sling to the hoyer to transfer Resident #419 to his wheelchair. It was noted that CNA VV and CNA D did not wear gloves or gowns while assisting Resident #419.
In an interview on 4/30/25 at 9:38 AM, Nursing Supervisor (NS) CC reported that Resident #419 had an order in place for Enhanced Barrier Precautions because of the open wound on his right foot. NS CC reported that Resident #419 should have had a sign near his door indicating that he was on Enhanced Barrier Precautions, and a cart outside of his room with PPE for staff to use. NS CC reported that she was unaware that Resident #419 did not have Enhanced Barrier Precautions in place.
In an interview on 4/30/25 at 10:25 AM, CNA D confirmed that Resident #419 was not in Enhanced Barrier Precautions until the afternoon of 4/29/25. CNA D confirmed that staff had not been using PPE when providing care for Resident #419.
In an interview on 4/30/25 at 12:28 PM, LPN II reported that she was unaware that Resident #419 was supposed to be on Enhanced Barrier Precautions. LPN II confirmed that the facility did not initiate Enhanced Barrier Precautions for Resident #419 until the afternoon of 4/29/25.
In an interview on 4/30/25 at 1:57 PM, Infection Preventionist (IP) FF reported that Resident #419 was supposed to be on Enhanced Barrier Precautions because he had a wound. IP FF confirmed that the order for Enhanced Barrier Precautions was not placed until 4/24/25. IP FF confirmed that there was a breakdown in communication among the staff that placed the order and the staff that were supposed to follow the order and set Resident #419's room up for Enhanced Barrier Precautions, and that the facility missed this. IP FF confirmed that nursing staff were documenting that Resident #419's Enhanced Barrier Precautions orders were in place between 4/24/25 through 4/29/25, but that was inaccurate, as the facility had not placed Resident #419 into Enhanced Barrier Precautions until the afternoon of 4/29/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent accidents for 1 (Resident #48) of 5 residents reviewed for accidents and hazards, resulting in Resident #48 sustaining a fall and the potential for residents to not meet their highest practicable physical, mental, and psycho-social well-being.
Findings include:
Review of a Transfer/Discharge Report revealed Resident #48 admitted to the facility on [DATE] with pertinent diagnoses which included weakness and unsteadiness on his feet.
Review of a Minimum Data Set (MDS) assessment for Resident #48, with a reference date of 1/10/2024 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #48 was cognitively intact.
In an interview on 4/3/2024 at 9:50 AM, Resident #48 reported he fell from his wheelchair when a staff member was pushing him without foot pedals and his feet caught on the floor making him fall forward out of the chair. Resident #48 reported staff now use foot pedals any time they push him in his wheelchair.
In an interview on 4/4/2024 at 1:19 PM, Director of Nursing (DON) B reported Resident #48 fell out of his wheelchair as a result of Competency Evaluated Nursing Assistant (CENA) F pushing him in his wheelchair without using foot pedals.
Review of Resident #48's Progress Notes, dated 10/21/2023 at 2:19 PM, revealed .Member was being pushed in wheelchair without foot pedals on. Member dropped his feet down got caught on the carpet, member fell forward out of wheelchair. He sustained no injury .
Review of Resident #48's Witnessed Fall report, dated 10/21/2023 at 12:20 PM, revealed .Root Cause analysis: Member was being pushed in the wheelchair without footrests. Members have to have footrests on their chair when being pushed in the (wheelchair). Education completed with the staff involved .
Review of CENA F's (agency) Healthcare Services Documented Counseling, dated 10/26/2023, revealed .Summary of violation: . (CENA F) transported a member to the dining room without foot pedals . Corrective Action taken . (CENA F) will take the time to make sure all foot pedals are on for members when they are being transported by her in their wheelchairs .
In an interview on 4/4/2024 at 2:27 PM, Licensed Practical Nurse (LPN) U reported staff are required to use foot pedals when pushing a resident in a wheelchair for resident safety. LPN U reported the facility has provided training for this.
In an interview on 4/4/2024 at 2:30 PM, CENA BB reported he always used foot pedals if pushing someone in a wheelchair. CENA BB reported he remembered recent training for this.
In an interview on 4/4/2024 at 2:31 PM, CENA G reported she used foot pedals when pushing residents in wheelchairs. CENA G stated, I have for 38 years.
Review of facility education Transporting Members in Wheelchairs Safely, dated 10/26/2023, revealed .NEVER PUSH MEMBERS WITHOUT FOOT PEDALS!!! Foot pedals are required when transporting members in wheelchairs . This is a huge safety concern. Member's feet can get caught and they can fall from their wheelchair .
During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included individual and facility wide staff education. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00139911.
Based on interview and record review, the facility failed to ensure the safety and prevent elopement of 1 resident (Resident #106) of 4 residents reviewed for accidents and hazards, resulting in the elopement of Resident #106 and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.
Findings include:
Review of an admission Record revealed Resident #106 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and delusional disorders.
Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 9/11/2023 revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated Resident #106 was severely cognitively impaired.
Review of an Elopement Evaluation assessment for Resident #106, dated 8/26/2023, revealed Resident #106 was identified to be at high risk for elopement.
Review of a current wandering and elopement Care Plan intervention for Resident #106, initiated 8/26/2023, revealed resident wore a wander guard on his right ankle.
Review of a Facility Reported Incident (FRI) report received by the State Agency on 9/22/2023 at 12:59 PM revealed Resident #106 eloped from the facility when on 9/21/2023 at approximately 7:05 PM he left the household courtyard unsupervised and was later found by staff on facility grounds at approximately 7:17 PM.
In an interview on 10/18/2023 at 8:16 AM, Licensed Practical Nurse (LPN) N reported he allowed Resident #106 to go out on the courtyard the evening of 9/21/2023, not realizing that the courtyard was not secured. LPN N reported the gate was supposed to alarm when opened, but it did not alarm when Resident #106 exited the courtyard unbeknownst to staff. LPN N reported facility staff escorted Resident #106 back to the unit after finding him in the parking lot. LPN N reported maintenance staff were contacted and secured all of the courtyard gates at that time.
In an interview on 10/18/2023 at 8:55 AM, Certified Nursing Assistant (CNA) M reported CNA Scheduler H asked her to check on Resident #106 as she was leaving the facility the evening of 9/21/2023 as she had seen him go by the front of the building in the parking lot in his wheelchair. CNA M reported she found Resident #106 sitting in his wheelchair in front of the main entrance of the old building watching the park across the road. CNA M reported Resident #106 told her that he just wanted to get out for a while and stated, I can't leave the grounds.
In a telephone interview on 10/18/2023 at 11:44 AM, CNA Scheduler H reported she noticed Resident #106 rolling by the front of the building in his wheelchair the evening of 9/21/2023 and asked CNA M to check on him as she was getting ready to clock out for the night. CNA Scheduler H reported she was not aware Resident #106 was at risk for elopement but knew he had been on the decline and wanted to make sure he was all right. CNA Scheduler H reported CNA M returned with Resident #106 and stated, He had not left the property.
In an interview on 10/18/2023 at 8:35 AM, Registered Nurse (RN) Unit Manager Y reported Resident #106 was allowed to be on the courtyard without supervision on 9/21/2023 as the courtyard was part of the secured facility.
In an interview on 10/18/2023 at 10:00 AM, Licensed Master Social Worker (LMSW) R reported Resident #106's care plan was updated on 8/28/2023 to prevent him from being outside of the secured facility without supervision. LMSW R reported Resident #106 was allowed to be in the secured courtyard alone as it was considered part of the secured complex.
In an interview on 10/17/2023 at 12:41 PM, Facility Manager T reported the courtyard gates were not being checked prior to Resident #106's elopement on 9/21/2023. Facility Manager T reported the courtyard gates are now being checked every shift to ensure that they are closed and every day to ensure that they are alarming properly.
In an interview on 10/18/2023 at 9:34 AM, Nursing Home Administrator (NHA) A reported Resident #106 required supervision while on facility grounds but was allowed to be unsupervised within the secured facility when the elopement occurred on 9/21/2023. NHA A reported maintenance staff secured the courtyard gates after the elopement on 9/21/2023 and the gates are now being checked daily to ensure that they are functioning. NHA A reported staff were educated on 9/22/2023 regarding the function and rounding of courtyard gates.
Review of facility policy/procedure Elopements and Wandering Members, reviewed 12/27/2022, revealed .The purpose of this policy is to ensure that members who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents . Elopement occurs when a member leaves the premises or a safe area without authorization and/or necessary supervision to do so . The home is equipped with door locks/alarms to help avoid elopements . Alarms are not a replacement for necessary supervision .
During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included audits, education, and training. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to properly date mark and discard food product. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected all residents who consume food from the kitchen.
Findings Include:
During the initial tour of the kitchen, starting at 9:18 AM on 2/6/23, an interview with Culinary Supervisor (CS) D, found that potentially hazardous foods are labeled with a preparation date to keep track of date marking. Observation of the walk-in cooler found an opened bag of lettuce with a use by date of 2/4/23.
During a tour of the two-door continental refrigeration unit in the main kitchen, at 9:25 AM on 2/6/23, it was observed that nutritional drinks and shakes were found stored in the unit, not dated. When asked if these are ever frozen, or if they arrive and get put directly under refrigeration, CS D stated they go into refrigeration upon arrival. A review of the product information on the nutritional drink and shakes found that they can be kept for up to 14 days under refrigeration. Twenty-five cranberry apple nutritional juices found in their box stated it was delivered on 1/14/23, twelve orange nutritional juices with a label stating they were delivered on 1/19/23, and 8 nutritional shakes with no date to indicate discard.
During a tour of the Sunset kitchen, starting at 10:08 AM on 2/6/23, it was observed that four orange nutritional juices and five nutritional shakes were found in the single door refrigeration unit, not dated.
During a tour of the Pier [NAME] front kitchen, at 10:18 AM on 2/6/23, it was observed that 10 nutritional shakes and three nutritional juices were found not dated.
During a tour of the Lake Michigan front kitchen, at 10:25 AM on 2/6/23, it was observed that eight nutritional shakes and an open container of thickened water were found with no date to indicate proper discard. A review of the thickened water stated it was good for ten days under refrigeration once opened.
During a tour of the Downtown kitchen, starting at 10:35 AM on 2/6/23, it was observed that 17 nutritional juices and six shakes were found with no dates in the single door unit. Further observation of the unit found a bag of sliced ham dated 1/29, sliced turkey dated 1/23, applesauce dated 1/5, and an open container of thickened cranberry dated 1/26.
During a tour of the Grand River front kitchen, at 10:50 AM on 2/6/23, it was observed that three nutritional shakes were found with no date to indicate discard.
During a tour of the Skyline front kitchen, at 10:55 AM on 2/6/23, it was observed that five nutritional juices and two shakes were found with no date to indicate discard.
According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 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 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .
According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .