Pilgrim Manor

F-F677.

47659

Resident #18

Review of an Minimum Data Set (MDS) assessment revealed Resident #18 was originally admitted to the facility on [DATE REDACTED] with pertinent diagnoses which included heart failure.

Review of a Minimum Data Set for Resident #18, with a reference date of 4/21/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #18 was cognitively intact.

Review of a Minimum Data Set for Resident #18, with a reference date of 4/21/24 revealed that Resident #18 was dependent on staff for toileting, showering, and dressing.

During an interview on 7/23/24 at 12:31 PM, Resident #18 reported that she had to frequently waited for long periods of time for staff assistance. Resident #18 reported that there were multiple occasions where she had to lay in soiled briefs while she waited for staff assistance. Resident #18 reported that the facility staff seemed short staffed and unable to complete care or answer call lights promptly nearly every day.

Resident #35

Review of an Admission Record revealed Resident #35 was originally admitted to the facility on [DATE REDACTED] with pertinent diagnoses which included adult failure to thrive.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 40 235038 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235038 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Grand Rapids 2000 Leonard N E Grand Rapids, MI 49505

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Review of a Minimum Data Set (MDS) assessment for Resident #35, with a reference date of 6/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #35 was Level of Harm - Minimal harm or cognitively intact. potential for actual harm

During an interview on 7/23/24 at 1:18 PM, Resident #35 reported that she had gone 11 days without a Residents Affected - Some shower. Resident #35 reported that the facility staff were unable to assist her with showers because they did not have the staff to assist with showers.

During an interview on 7/25/24 at 10:06 AM, Certified Nursing Assistant (CNA) K reported that residents were frequently missing their showers because the facility did not have the staff to provide showers. CNA K reported that the facility often had one CNA on each unit, and when there was only one CNA on each unit,

they were unable to assist residents with showers.

During an interview on 7/24/24 at 8:17 AM, Registered Nurse (RN) H reported that the staffing ratios at the facility were often challenging. RN H reported that the facility would frequently work with only two nurses for three units. RN H reported that when nursing had to split the third unit, it would make completing any tasks difficult, especially administering medications on time.

During an interview on 7/24/24 at 12:43 PM, CNA M reported that the facility often scheduled one CNA per unit, which made caring for residents that required two person assistance difficult. CNA M reported that CNA's often struggled to complete their tasks, and residents were frequently left to wait for the CNA's to find someone to assist them with completing care.

During an interview on 7/25/24 at 10:14 AM, Medical Doctor (MD) EE reported that the facility was often short staffed. MD EE reported that she had witnessed several staff members in tears due to being overwhelmed with their work load.

48637

During a confidential resident council meeting held on 7/25/2024 at 10:00 AM, seven of nine residents reported that they waited for a long time for help. These residents stated that sometimes they have to wait 1 hour to 1 and 1/2 hours for help. Two residents stated that if they complain to an aide, they will take a longer time to help. Another resident stated that sometimes staff goes in the room and turns off the call light without meeting their needs. One resident stated that sometimes they have to change the shower day when they are shorthanded. They all agreed that it is harder to get help on third shift.

Review of the Resident Council minutes dated 1/23/2024 under the clinical department revealed (Resident name omitted) says he asks for something and is told to wait a sec (second). He says he has to keep asking as the time goes by.

Review of the Resident Council minutes dated 3/19/2024 under the clinical department revealed (Resident name omitted) says he has given up on the light and just yells for help until he is answered.

Review of the Resident Council minutes dated 4/24/2024 under the clinical department revealed (Resident name omitted) commented that she had to wait 40-45 minutes before anyone comes to help her use the bathroom.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 40 235038 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235038 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Grand Rapids 2000 Leonard N E Grand Rapids, MI 49505

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Review of the Resident Council minutes dated 6/26/2024 under the clinical department revealed (Resident name omitted) said she sat on the toilet with the string pulled for 2 hours recently with no help. She says at Level of Harm - Minimal harm or times, there is no help. potential for actual harm

During another interview on 7/25/2024 at 12:57 PM, AD E stated that she was aware that concerns regarding Residents Affected - Some long call light wait times was brought up several times in Resident Council meetings and she gave these concerns to the appropriate department head.

41982

Resident #12

Review of an Admission Record revealed Resident #12 was a female, with pertinent diagnoses which included: unsteadiness on feet and need for assistance with personal care.

Review of a Minimum Data Set (MDS) assessment for Resident #12, with a reference date of 6/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #12 was cognitively intact.

Review of Resident #12's current Care Plan revealed a focus of Resident has an ADL (activities of daily living) self-care performance deficit . last revised 2/7/24 with pertinent care planned interventions which included: TOILETING: 1 person assist PERSONAL HYGIENE: 1 person assist and TRANSFERS: 1 person assist all of which had a date initiated of 8/7/23.

In an interview on 7/23/24 at 10:19 AM, Resident #12 reported she sometimes had to wait 1/2 hour to get on

the toilet because of staff call offs and less staff available to assist. Resident #12 went on to report that she has a bowel condition and when she has waited that long for assistance and held her bowel movement in too long, it was uncomfortable and she felt constipated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 40 235038 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235038 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Grand Rapids 2000 Leonard N E Grand Rapids, MI 49505

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or 47659 potential for actual harm Based on interview and record review, the facility failed to ensure physician ordered laboratory diagnostic Residents Affected - Few services were obtained and completed in a timely manner in 1 (Resident #35) of 1 residents reviewed for laboratory services, resulting in delayed treatment/intervention related to lab results, increased pain/discomfort, and impaired coordination of care.

Findings include:

Review of Resident #35's Orders revealed, . UA (urinalysis) w/reflex to C&S (culture and sensitivity) if appropriate. Start date: 7/12/24 .

Review of Resident #35's electronic health record (EHR) did not reveal any notes related to the delayed results of Resident #35's urinalysis that was ordered on 7/12/24.

During an interview on 7/23/24 at 1:18 PM, Resident #35 reported that she had been experiencing pain with urination for over two weeks. Resident #35 reported that the facility had taken a urine sample to check for a urinary tract infection on 7/12/24, but the facility did not get results from that urine sample. Resident #35 reported that she had learned on 7/19/24 that the facility never received the results from the first urine sample when she was asked to provide another sample.

During an interview on 7/24/24 at 4:08 PM, Registered Nurse (RN) HH reported that reported that she believed that Resident #35's urine sample that was obtained on 7/12/24 was sent to the wrong lab. RN HH reported that the facility had recently switched lab providers and the nurses were unclear on the new process was for obtaining labs. RN HH could not report how the facility tracked and monitored lab orders to ensure that they were completed and reviewed.

During an interview on 7/25/24 at 10:14 AM, Medical Doctor (MD) EE reported that Resident #35's urine sample was first ordered on 7/12/24. MD EE reported that the facility had recently switched lab providers and there was a delay in orders being processed. MD EE reported that there was a lot of confusion among the nursing staff with the new lab ordering process. MD EE was not able to report how the facility was tracking and monitoring pending lab orders to ensure that they were completed. MD EE confirmed that Resident #35 experienced a delay in treatment and care due to the facility not ensuring the urine sample was sent to correct lab and following up on the urinalysis results.

During an interview on 7/25/24 at 12:40 PM, Director of Nursing (DON) B reported that the facility had switched lab providers on 7/1/24. DON B reported that the facility was still working out the kinks and miscommunication on the new lab ordering process. DON B confirmed that education and training had not yet been provided to all nursing staff that were responsible for lab orders. DON B reported that she was currently responsible for monitoring all lab orders to ensure that they were completed. DON B could not confirm if she had followed Resident #35's lab order from 7/12/24, and she was unable to explain why Resident #35's lab order on 7/12/24 was not completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 40 235038 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235038 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Grand Rapids 2000 Leonard N E Grand Rapids, MI 49505

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Review of the Facility's Laboratory and Diagnostic Guidelines policy last revised 10/26/23 revealed, Policy:This guideline is set up to track the timely completion, reporting and monitoring of laboratory and Level of Harm - Minimal harm or diagnostic tests, results, and notifications which are used to monitor resident status and/or therapeutic potential for actual harm medication levels .10. The physician should be notified if the lab/diagnostic test is unable to be completed, reason why, and request for new orders .12. All notifications, attempts at notifications, and response should Residents Affected - Few be noted in the resident ' s medical record .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 40 235038 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235038 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Grand Rapids 2000 Leonard N E Grand Rapids, MI 49505

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38905 potential for actual harm Based on observation, interview, and record review the facility failed to provide food at a palatable Residents Affected - Some temperature to 9 of 9 residents interviewed during resident council and 2 of 2 resident (Resident #15 and Resident #27) reviewed for food palatability, resulting in the potential for decreased food consumption and potential nutritional decline.

Findings include:

During a tour of lunch service, at 11:38 AM on 7/23/24, an interview with [NAME] QQ found that hot food on

the steam table should be around 165F to stay hot for residents.

At 11:48 AM on 7/23/24, a test stray of the regular meal was plated for the surveyor and placed on the health center one cart.

At 11:52 on 7/23/24, the cart and test tray made it to the floor of Health Center one.

At 12:07 PM on 7/23/24, all trays were passed from the health center one cart and the surveyor brought the test tray back to the conference room. At this time the following temperatures were found, Pasta/Meat was 122F and the peas were 121F.

A revisit to the kitchen, at 8:03 AM on 7/24/24, found that the last breakfast cart of trays was sent out five minutes ago to health center one. A visit to Health Center one, with dietitian PP, found that a resident who had denied their breakfast tray and had their tray sitting on the meal cart. When asked when the cart came down to Health Center one, D PP stated that she timed stamped it at 7:58 AM.

Once all the trays were taken from the Health Center one cart, the surveyor took the test tray back to the conference room and arrived at 8:10 AM and found the following temperatures of hot food: Scrambled egg was 124F, Sausage Links 103F and oatmeal was 125F.

A revisit to the kitchen, at 8:23 AM on 7/24/24, found staff still plating assisted living residents for breakfast. At this time a temperature of the sausage links in the steam table were taken and found to be between 130F-140F.

48637

During a confidential resident council meeting held on 7/25/2024 at 10:00 AM, nine of nine residents reported that their food was cold whether they received it in their room or the main dining room. The residents agreed that drinks such as coffee and hot water were cold too. The residents stated that cold foods has been an issue for a while and it's not getting resolved.

Review of the Resident Council minutes dated 1/23/2024 under the dietary department revealed, Many times food temp (temperature) is still an issue, being too cold.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 235038 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235038 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Grand Rapids 2000 Leonard N E Grand Rapids, MI 49505

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Review of the Resident Council minutes dated 2/20/2024 under the dietary department revealed Most all residents at this meeting said 75% of the time all the food is cold. Level of Harm - Minimal harm or potential for actual harm Resident #15 (Resident R15)

Residents Affected - Some Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident R15 admitted to the facility

on [DATE REDACTED] with diagnoses of type 1 diabetes, anxiety, and depression. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated Resident R15 was cognitively intact (13 to 15 cognitively intact).

During an interview on 7/23/2024 at 11:21 AM, Resident R15 stated that his food is almost always cold when he gets it

in his room. Resident R15 said he goes to the dining room at times and it is cold there too.

Resident #27(Resident R27)

Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident R27 admitted to the facility

on [DATE REDACTED] with diagnoses of End Stage Renal Disease, Type 2 diabetes, and depression. Brief Interview for Mental Status (BIMS) reflected a score of 10 out of 15 which indicated Resident R27 was cognitively impaired (8-12 moderately impaired).

During an interview on 7/24/202 at 8:42 AM, Resident R27 stated that he eats in his room and the food is always cold. Resident R27 also stated that the coffee is cold.

During an interview on 7/25/2024 at 12:57 PM, AD E stated that she was aware that concerns regarding cold food was brought up several times in Resident Council meetings and she gave these concerns to the appropriate department head.

During an interview on 7/25/2024 at 1:10 PM, Regional Dietitian (RD) W stated that sometimes residents aren't in their rooms when the tray is delivered and it sits there and when they get back to their room it's cold. RD W said that another tray should be requested at this time or nursing staff should notify the kitchen to deliver it later.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 235038 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235038 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Grand Rapids 2000 Leonard N E Grand Rapids, MI 49505

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 48637 Residents Affected - Some Based on interview and record review, the facility failed to consistently provide a nourishing nighttime snack to eight of nine residents who attended a confidential Resident Council meeting resulted in the potential for residents to have more than 14 hours between a substantial evening meal and breakfast the following day, decreased oral intake, and the potential for weight loss.

Findings include:

During a confidential resident council meeting held on 7/25/2024 at 10:00 AM, eight of nine residents reported that they don't get snacks at bedtime and if they ask for it, they are often given only one choice. One resident stated that there weren't any healthy choices, the snacks are salty and not diabetic friendly and there weren't choices in what they get at night. Another resident said that she thinks staff is eating resident snacks.

Review of the document Mealtimes revealed that breakfast is served 7:30-8:30 AM and dinner is from 5:30-6:30 PM. The time from the end of dinner to breakfast the next morning is approximately 13- 14 hours.

Review of the Resident Council minutes dated 6/26/2024 under the dietary department revealed (Resident name omitted) said she watches CNAs (Certified Nursing Assistants) take pocketful of snacks for the residents and eat them all. She has confronted a few CNAs, but nothing changes.

During an interview on 7/25/2024 at 12:15 PM, Registered Dietitian (RD) W stated that the dietary staff stock

the nourishment room and fridge with a variety of snacks: cheez-its, creme pies, chips, pudding, cottage cheese, beverages, milk, ice cream, sandwiches-tuna, egg salad and turkey every day. RD W said that nursing staff hands out the snacks during the day and at night.

During an interview on 7/25/2024 at 12:21 PM, Nursing Home Administrator (NHA) 'A stated that dietary stocks the nourishment room every day and CNAs are supposed to pass them out.

Review of the Offering/Serving Bedtime Snacks Policy with an implementation date of 10/20/2020 and a review/revision date of 1/01/2022 revealed, Policy Explanation and Compliance Guidelines: 1. The nursing staff offers bedtime snacks to all residents in accordance with the resident's needs, preferences and requests on a daily basis. 2. All diabetic or special diet bedtime snacks are labeled and dated. Each label contains the resident's name and room number. 4. Nursing staff delivers and serve snacks to residents. 5. Intake of bedtime snacks is documented in the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 235038 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235038 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Grand Rapids 2000 Leonard N E Grand Rapids, MI 49505

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38905

Residents Affected - Many Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.

Findings include:

During the initial tour of the facility, starting at 9:40 AM 7/23/24, a tour of the walk in cooler found a container of breakfast sausage tightly covered with saran wrap that was warm to the touch. At this time a temperature of the sausage links was taken and found to be 109F.

An interview with [NAME] QQ, at 9:55 AM on 7/23/24, found that the sausage links were pulled from the breakfast line about an hour ago and placed in the walk-in cooler.

An interview with Assistant Kitchen Manager OO, at 10:08 AM on 7/23/24, found that staff log cooling on a sheet on the cabinet. A review of the Cooling Temperature Log dated 2024, found that on 5/2 and 6/11 cooling for sausage was logged. Both items were stated to start cooling at 9:00 AM and by 11:00 AM both items were logged above 70F.

During a revisit to the kitchen, at 10:58 AM on 7/23/24, an observation of the sausage links found them still tightly wrapped and covered in saran wrap. A temperature of the sausage links was found to be 78F at this time. An interview with Dietitian PP, found that the item will be discarded and the cook will be educated on proper cooling.

According to the 2017 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less .

According to the 2017 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.

During the initial tour of the facility, at 9:42 AM on 7/23/24, observation of the walk in freezer found a box of raw hamburgers stored open and exposed to the elements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 235038 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235038 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Grand Rapids 2000 Leonard N E Grand Rapids, MI 49505

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (4) Except as Level of Harm - Minimal harm or specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, potential for actual harm covered containers, or wrappings;

Residents Affected - Many During the initial tour of the kitchen, at 10:01 AM on 7/23/24, it was observed that one 14 inch sauce pan and two 12 inch sauce pans were found heavily encrusted with black carbon accumulation on the inside of the pans cooking surface. It was also noted that the surface of the pans were textured with an accumulation of encrusted carbon.

An observation of the dish machine area, at 10:05 AM on 7/23/24, found the drain directly before trays into

the dish machine was found to be loose and leaking water on the floor near the floor drain.

According to the 2017 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.

An observation of the dish machines data plate, at 10:06 AM on 7/23/24, found that it requires a minimum wash temperature of 160F. An observation of the wash temperature gauge at this time found it was reading 156F while Assistant Kitchen Manager OO was doing dishes.

A record review of the facilities Dish Machine Temperature Log, dated July 2024, found that the majority of

the 67 logged wash temps were logged below the 160F required minimum stated on the dish machines data plate.

According to the 2017 FDA Food Code section 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); (2) For a stationary rack, dual temperature machine, 66oC (150oF); (3) For a single tank, conveyor, dual temperature machine, 71oC (160oF); or (4) For a multitank, conveyor, multitemperature machine, 66oC (150oF). (B) The temperature of the wash solution in spray-type warewashers that use chemicals to SANITIZE may not be less than 49oC (120oF).

According to the 2017 FDA Food Code section 4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions. (B) A WAREWASHING machine's conveyor speed or automatic cycle times shall be maintained accurately timed in accordance with manufacturer's specifications.

During the initial tour of the kitchen, at 10:10 AM on 7/23/24, observation of the two door [NAME] cooler found open containers of thickened apple, orange, and cranberry juices. A review of the containers state the items are only good for 7 days after opening.

During a tour of Health Center 1 pantry, at 11:19 AM on 7/23/24, it was observed that one open container of Vanilla Med Pass 2.0 was found with no date to indicate discard. Review of the product label found it is good for three days after opening. Further review of the unit found a nutritional chocolate shake with no date and manufactures directions that state the item is good 14 from thaw.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 235038 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235038 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Grand Rapids 2000 Leonard N E Grand Rapids, MI 49505

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a tour of the Health Center 2 Pantry, at 11:25 AM on 7/23/24, it was observed that an open container of thickened cranberry and a nutritional chocolate shake were found without dates to indicate discard. Level of Harm - Minimal harm or potential for actual harm 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 Residents Affected - Many 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) .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 235038