Portagepointe

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49735

Residents Affected - Few Based on interview and record review, the facility failed to ensure physician orders were in place for a resident with a foley catheter (a tube inserted through the urethra to drain urine out of the body from the bladder) for one Resident (#26) of two residents reviewed for catheter care resulting in the potential for unnecessary catheter usage and increased potential for urinary tract infection.

Findings include:

Resident #26 (Resident R26)

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], revealed admission to the facility on [DATE REDACTED], with active diagnoses that included: history of Urinary Tract Infections (UTI), Alzheimer's Disease, dementia, and anxiety disorder. MDS Section C revealed Resident R26's cognitive skills were severely impaired and Resident R26 rarely or never made decisions.

During a phone interview on 5/27/25 at 2:09 p.m., Family Member (FM) B reported she was the responsible party for Resident R26 and the facility did not call her to obtain permission for the foley catheter to be placed in Resident R26's bladder. FM B stated, I want to call the facility right away to find out why (Resident R26) has a catheter.

During an interview on 5/29/25 at 8:33 a.m., the Director of Nursing (DON) acknowledged the physician was not called to obtain doctors orders to insert a catheter into Resident R26, and conceded there was no diagnosis that would necessitate the use of a urinary catheter. The DON acknowledged the responsible party for Resident R26 was not notified. The DON reported Registered Nurse (RN) A had inserted the catheter into Resident R26 and should have called the physician to obtain an order for the insertion of the catheter.

During a phone interview on 5/29/25 at 8:53 a.m., RN A reported, Resident R26 was seeping urine, and I decided to put the catheter into the resident. RN A acknowledged she did not call the physician and did not call the responsible party.

Review of facility policy titled Long Term Care (LTC) Indwelling Catheter Maintenance and Care last revised 3/5/24, read in part .These guidelines are related to .appropriate use of indwelling catheters .insert catheters only for appropriate indications. Avoid use of urinary catheters in elders for management of incontinence . confirm provider's (physician) order. Confirm appropriate diagnosis for insertion of foley catheter .

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 6 235624 Department of Health & Human Services Printed: 08/26/2025 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 235624 B. Wing 05/29/2025

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

Portagepointe 500 Campus Drive Hancock, MI 49930

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 0801 2-102.20 Food Protection Manager Certification. (A) A PERSON IN CHARGE who demonstrates knowledge by being a FOOD protection manager that is certified by a FOOD protection manager certification program Level of Harm - Minimal harm or that is evaluated and listed by a Conference for Food Protection-recognized accrediting agency as potential for actual harm conforming to the Conference for Food Protection Standards for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with 2-102.11(B). (B) A FOOD ESTABLISHMENT that has a Residents Affected - Many PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection recognized accrediting agency as conforming to the Conference for FOOD Protection Standards for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2 102.12.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 6 235624 Department of Health & Human Services Printed: 08/26/2025 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 235624 B. Wing 05/29/2025

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

Portagepointe 500 Campus Drive Hancock, MI 49930

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 (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 Level of Harm - Minimal harm or clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is potential for actual harm 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 Residents Affected - Many section and:

(1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1;

(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.

On [DATE REDACTED] at 7:15 a.m., the high-temperature dishwasher in the Pewabic Kitchen was observed for appropriate sanitation temperatures. KM C stated that this dishwasher does not get to the correct wash temperature, Our [Company Name] representative said if this strip turns black then it was fine despite the temperature it is saying on the dish machine.

A sanitization strip was placed on a clean plate and KM C began a cycle. The final rinse temperature was 137 degrees Fahrenheit ( F), and the sanitization strip did not turn black to indicate that the dishes was properly sanitized.

On [DATE REDACTED] at 12:15 p.m. Dietary Aide (DA) D was observed using the Pewabic dish machine. DA A was first observed taking a pitcher and scooping out water in the bottom of the dish machine. Then placing dishes into

the machine, closing the door and having to hold the door shut so the dish machine would run. A towel was observed near the bottom of the dish machine to collect water. The final rinse temperature of the dish machine was 117 F.

The FDA 2022 Food Code states:

,d+[DATE REDACTED].11 Hot Water and Chemical. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: (A) Hot water manual operations by immersion for at least 30 seconds and as specified under S ,d+[DATE REDACTED].111; P (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS ,d+[DATE REDACTED].15, ,d+[DATE REDACTED].112, and ,d+[DATE REDACTED].113 and achieving a UTENSIL surface temperature of 71 C (160 F) as measured by an irreversible registering temperature indicator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 235624 Department of Health & Human Services Printed: 08/26/2025 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 235624 B. Wing 05/29/2025

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

Portagepointe 500 Campus Drive Hancock, MI 49930

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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or 34568 potential for actual harm Based on observation, interview and record review, the facility failed to implement its policy and procedure Residents Affected - Many related to monitoring food brought in by visitors for residents and stored in refrigerators. This failure allowed unmarked and out dated food to be present in the refrigerator units potentially contributing to illness of any or all 56 residents using the units to store food. Findings include:

On 5/27/25 at 3:50 p.m. an initial kitchen tour was conducted with Kitchen Manager (KM) C. The following items were observed throughout the tour:

A. A glass pickle jar containing pickles and no label with a name, date, or any other identifying information

B. Two health shakes, not purchased by the facility and no label with a name, date, or any other identifying information.

An interview was conducted with KM C who confirmed that items brought into the facility should contain the residents name and date they were brought into the facility.

Review of the facility's LTC (long term care) Food Brought in from Outside Sources Revised 1/13/23 read, in part, .Family/friends are to inform the nurse and/or elder associates of any food or beverages brought into

the House for elder consumption .Perishable food from outside sources should be stored in the refrigerator.

The items is to be labeled with the Elder's name, and date. Prepared food items are to be discarded within 72 hours if not consumed. Shelf stable food items will be stored for up to 7 days .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 235624