Medilodge Of Rochester Hills, Inc

F-F686.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41415 potential for actual harm Based on observation, interviews and record reviews the facility failed to ensure infection control standards Residents Affected - Many and practices were consistently implemented (Resident R58) and ensure an effective infection control prevention and control program was consistently implemented for 62 of 62 residents residing at the facility during the time of

the survey. Findings include:

A review of the facility's Infection Control Surveillance program provided by the Infection Control Nurse (ICN) J who also served as the facility's Infection Preventionist was conducted and revealed the following:

- No monthly Infection Control Analysis report for May, June or July 2024

- No surveillance log for July 2024

Further review of the program revealed inaccurate mapping of infections. Review of the July 2024 antibiotic audit revealed three residents treated with antibiotics for a urinary tract infection and only one resident was identified on the facility's mapping.

On 8/28/24 at 11:12 AM, a meeting to review the facility's infection control program was conducted with ICN J. ICN J explained how they were hired three months prior and took responsibility of the facility's infection control program at that time. When asked, ICN J stated they also had the responsibility of being the facility's staff development coordinator, unit manager and cart nurse when needed. When asked how many hours out of the week they devoted to the Infection Control Program, ICN J stated . four hours out of every eight hour shift . ICN J was asked about the missing monthly analysis reports that are generated to oversee the facility's infections and present to the facility's QAPI (Quality Assurance Performance Improvement) program. ICN J stated they were unaware of what the analysis report was. April 2024's analysis report was reviewed with ICN J and ICN J stated they had questions regarding the math and determining the infections for the report. ICN J stated they had not completed a report since resuming the role. ICN J stated the new corporation is implementing a new system for them to complete the infection surveillance and monthly analysis. ICN J was then asked how many QAPI meetings they attended since employment and ICN J replied they attended one meeting. ICN J stated the meetings are held monthly, however the facility had recently transitioned to a different corporation and had not been held monthly. ICN J was then asked about the inaccurate mapping of infections for July 2024. ICN J reviewed the program and stated they must have missed it.

Review of the facility's policy titled Infection Prevention and Control Program Overview last dated 8/1/24, documented in part . The infection prevention and control program is comprehensive in that it addresses the prevention, identification, reporting, investigation and controlling of infections and communicable diseases among residents, employees, volunteers and visitors . There is on-going monitoring for infections among residents . Infection prevention and control is a component of the facility's quality assessment and assurance program and infection prevention and control reports are made to the QAA (quality assurance) committee .

No further explanation or documentation was provided by the end of the survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0880 32568

Level of Harm - Minimal harm or Resident #58 (Resident R58) potential for actual harm

On 8/26/24 at 10:34 AM, Resident R58 was observed positioned on his back in bed with a tracheostomy tube (trach) Residents Affected - Many (a tube inserted into the windpipe to provide breathing assistance) and a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube inserted into the stomach to directly provide nutrition). When spoken to, Resident R58 did not make eye contact and did not verbally respond to questions.

A review of Resident R58's clinical record revealed Resident R58 was admitted into the facility on [DATE REDACTED], and readmitted on [DATE REDACTED] with diagnoses that included: diffuse traumatic brain injury with loss of consciousness, acute respiratory failure with hypoxia, type 2 diabetes, and seizures. A review of an admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident R58 had severely impaired cognition, was dependent on staff all activities of daily living, received all nutrition via a PEG tube, and had a tracheostomy tube to assist with breathing.

On 8/27/24 at 11:06 AM, the skin underneath Resident R58's foam trach collar tie was observed with Licensed Practical Nurse (LPN) 'A'. Upon lifting up the trach tie, a large amount of secretions was observed on Resident R58's neck. At that time, LPN 'A' reported he was going to clean the secretions from Resident R58's neck. LPN 'A' donned gloves located outside of the room and a sterile trach kit was opened that contained supplies and sterile gloves. LPN 'A' removed the gloves he was wearing and donned the gloves in the sterile kit without performing hand hygiene in between the glove change. LPN 'A' then used the gauze in the kit to wipe the secretions from Resident R58's neck and underneath the trach mask. After the secretions were cleaned, LPN 'A' proceeded to apply clean gauze under the trach mask without changing gloves and performing hand hygiene.

On 8/27/24 at approximately 2:45 PM, an interview was conducted with the Director of Nursing (DON). When queried about when hand hygiene and gloves changes should occur during trach care, the DON reported whenever you are going from dirty to clean. The above observation was shared with the DON. The DON reported LPN 'A' should have removed his gloves, performed hand hygiene, and donned clean gloves between cleaning the secretions and applying clean gauze.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 41415 potential for actual harm Based on interview and record reviews the facility failed to maintain and implement an effective antibiotic Residents Affected - Some stewardship program for five (Resident R1, Resident R11, Resident R23, Resident R58, Resident R212) of five residents identified, however this deficient practice had the ability to affect multiple residents that were prescribed and administered antibiotics while residing in the facility. Findings include:

A review of the April, May, and June 2024 Infection Surveillance logs revealed no documentation of any of

the documented infections to have met or not met the criteria of an infection.

Review of the Surveillance logs revealed the following:

- April 2024- Resident R23 was prescribed and administered Cephalexin 500 mg (milligram) three times a day for a right arm selling/pain from an IV (intravenous) site from the hospital. Review of the April 2024 infection log documented in part . Started on ATB (antibiotic) as prophy (prophylaxis). Sent to hospital and found to have

a GI (gastroenterology) bleed and no infection so DCed (discontinued) ). The antibiotic was signed off until completed, however the resident was sent and admitted to the hospital prior to its completion.

Further review of April 2024 surveillance documented Resident R212 was . Readmit from hospital with ATB (antibiotic) therapy for pneumonia . Doxycycline 100 mg every 12 hrs.(hours) for Pneumonia was started on 4/17/24.

Review of the medical record revealed no documentation of the review of the antibiotic or appropriateness.

- June 2024- Resident R58 was documented as . Infection- Other . Levaquin 500 mg . there was no documentation of

the type of infection identified or if the infection met criteria. Review of the physician orders and June 2024 Medication Administration Record (MAR) documented the antibiotic to have been administered once daily for Infection for seven days. Review of the program and Resident R58's record revealed no documentation of the appropriateness of the antibiotic. Further review revealed Resident R1 was prescribed Amoxicillin-Pot Clavulanate 875/125 mg for a urinary tract infection (uti). The surveillance log did not identify if the infection met criteria.

Review of Resident R1's June 2024 MAR documented the antibiotic was administered twice a day for . bacterial infection for 10 days .

Review of Resident R1's medical record revealed no documentation of signs/symptoms that met criteria for a uti and no documentation of the appropriateness of the antibiotic.

- July 2024- Resident R11 was identified on an antibiotic audit due to no surveillance log to have been completed for

the month of July 2024. The audit document Macrobid 100 mg twice a day for a uti. Review of the program revealed no documentation of the infection to have met criteria or the appropriateness of the antibiotic.

Review of the medical record revealed documentation of a urinalysis to have been completed, however Resident R11's record did not contain results of a urinalysis or culture report.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0881 On 8/28/24 at approximately 11:22 AM, the Infection Control Nurse (ICN) J who also served as the facility's Infection Preventionist was interviewed and asked the criteria the facility utilized and ICN J replied McGeers Level of Harm - Minimal harm or criteria. ICN J was then asked how they identified if the infection met criteria and what tool they utilized to potential for actual harm determine if it met or not. ICN J stated there was a new program that the new corporation was implementing for their infection control program. Once transitioned, ICN J stated the software would inform them if it met Residents Affected - Some criteria. ICN J was then asked how they confirm the appropriateness, length and time of an antibiotic and ICN J stated they would review the physician orders and notes. ICN J was asked where they or the physician document if an infection met criteria and the appropriateness of prescribed antibiotics and ICN J replied they had not document it in the past, however, will implement it moving forward.

Additional documentation was provided by ICN J and reviewed, however the concerns of infections meeting criteria and concern of the appropriateness of antibiotics remained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41415 potential for actual harm Based on interview and record review the facility failed to provide education and offer the pneumococcal Residents Affected - Few immunization for two R's 26 & 58 of five residents reviewed for the Pneumococcal immunization. Findings include:

Resident R26

Review of Resident R26's medical record revealed no documentation of the resident and/or representative to have been educated and offered the pneumococcal immunization. Further review of the medical record revealed no documentation of the immunization to be medical contraindicated or noted the resident to already be immunized. Resident R26 was admitted to the facility on [DATE REDACTED].

Resident R58

Review of 58's medical record revealed no documentation of the resident and/or representative to have been educated and offered the pneumococcal immunization. Further review of the medical record revealed no documentation of the immunization to be medical contraindicated or noted the resident to already be immunized. Resident R58 was admitted to the facility on [DATE REDACTED] and had a readmitted [DATE REDACTED].

Review of the facility's policy titled Pneumococcal Vaccine dated 8/1/24, documented in part . It is the policy of this facility that all residents will be offered the pneumococcal vaccines to aid in preventing pneumonia . Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccines and when indicated, will be offered the vaccinations, unless medically contraindicated or the resident has already been vaccinated . Before receiving the pneumococcal vaccines, the resident or responsible party shall receive information and education regarding the benefits and potential side effects of pneumococcal vaccines .

On 8/28/24 at 11:37 AM, the Infection Control Nurse (ICN) J who oversees the Pneumococcal vaccinations

in the facility was interviewed and asked the facility's process on educating and the administration of the Pneumococcal vaccine. ICN J stated the vaccine is offered upon admission. ICN J stated they have a new process in place under the new ownership that will bundle the education and consents for all immunizations. ICN J was asked to provide the education and consents provided to the R's 26 & 58 and/or their representatives. ICN J stated they would look into it and follow up. A short time later ICN J returned and stated they were unable to find the requested documentation, however both residents/representatives will be educated and offered today 8/28/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41415

Residents Affected - Few Based on interview and record review the facility failed to provide education and offer the Covid-19 vaccine and/or booster for two R's 26 & 58 of five residents reviewed for the Covid-19 vaccine. Findings include:

Resident R26

Review of Resident R26's medical record revealed no documentation of the resident and/or representative to have been educated and offered the Covid-19 Vaccine. Further review of the medical record revealed no documentation of the vaccine to be medical contraindicated or noted the resident to have already received

the vaccine and/or booster. Resident R26 was admitted to the facility on [DATE REDACTED].

Resident R58

Review of 58's medical record revealed no documentation of the resident and/or representative to have been educated and offered the Covid-19 Vaccine. Further review of the medical record revealed no documentation of the vaccine to be medical contraindicated or noted the resident to have already received the vaccine and/or booster. Resident R58 was admitted to the facility on [DATE REDACTED] and had a readmitted [DATE REDACTED].

Review of a facility policy titled COVID-19 Vaccine dated 9/23/23, documented in part . It is the policy of this facility that all residents will be offered the COVID19 vaccines to aide in preventing COVID19 infections and outbreaks . Residents will be assessed for eligibility to receive COVID19 vaccines and when indicated, will be offered the vaccinations, unless medically contraindicated or the resident is up to date with vaccination, as recommended by CDC (Centers for Disease Control and Prevention) . Before receiving the COVID19 vaccines, residents or responsible parties shall receive information and education regarding the benefits and potential side effects .

On 8/28/24 at 11:37 AM, the Infection Control Nurse (ICN) J who oversees the COVID-19 vaccinations in the facility was interviewed and asked the facility's process on educating and the administration of the COVID-19 vaccinations and/or boosters. ICN J stated the vaccine is offered upon admission. ICN J stated they have a new process in place under the new ownership that will bundle the education and consents for all immunizations. ICN J was asked to provide the education and consents provided to the R's 26 & 58 and/or their representatives. ICN J stated they would look into it and follow up. A short time later ICN J returned and stated they were unable to find the requested documentation, however both residents/representatives will be educated and offered today 8/28/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 54 235036

F-F791

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 34208

Residents Affected - Few Based on interview and record review the facility failed to establish an effective Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) plan that identified issues of harm. This deficient practice had the potential to affect all 59 residents in the facility. Findings include:

A review of a facility provided policy titled, Quality Assessment & Assurance Program revised 9/18/29 was conducted and read, .Quality Assurance is a continuous process towards quality management .Each person's effort contributes to improving resident outcomes .The Quality Assessment and Assurance (QAA) Committee provides leadership and guidance for ongoing continuous quality and performance improvement .

On 10/9/24 at 12:27 PM, an interview was conducted with the facility's Director of Nursing regarding concerns identified with pressure ulcers. The DON acknowledged the concerns and the facility's ongoing audits that indicated no concerns despite concerns identified during the re-visit survey.

On 10/9/24 at 1:00 PM, an interview with the facility's Administrator was conducted regarding the facility's Quality Assurance process and they acknowledged the concerns with pressure ulcers.

Cross-reference

F-F850.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0745 On 8/28/24 a facility document titled Social Services-Director was reviewed and revealed the following: Position Summary: The Social Service Director is responsible to provide medically related social work Level of Harm - Minimal harm or services so that each Resident may attain or maintain the highest practicable level of physical, mental, and potential for actual harm psychosocial well-being. This position assesses and treats emotional and behavioral problems related to patient illness. Participates as a member of interdisciplinary team and may assist patients in treatment Residents Affected - Some planning Principal Duties and Responsibilities: Responsible for operating the Social Services department within budgetary guidelines and limitations. Completes annual performance reviews of all subordinate staff; provides guidance and education to staff in relation to their performance. Provides counseling and disciplinary action to subordinate staff as needed. Responsible for training and educating staff in the Social Services department. Assesses and evaluates each Resident ' s psychosocial needs and develops goals for providing the necessary services and takes part in the admissions process as needed. Incorporates the Social Service goals in the Resident ' s Plan of Care and attends care planning conferences. Assists the Residents in adjusting to the facility and promotes a positive environment for the continuity of relationship with family and community. Assists Residents and families to utilize the community resources when not provided directly by the facility. Maintains confidential records and interviews with Residents and families as appropriate. Assists in the development, supervision, and education of staff. Serves as the team lead or assigns team lead to a staff in the department in discharge planning. Ensures completion of any required components of DPOA (durable power of attorney) or guardianship paperwork. Coordinates services with psychiatric providers. Coordinate services with OBRA (Omnibus Budget Reconciliation Act) including overseeing proper completion and management of the PASARR (Pre-admission screening annual resident review) program. Assists the Clinical IDT (interdisciplinary team) in resident room management. Assists Residents and families in resolving grievances as assigned. Attend Clinical IDT Meetings and serves as an advocate for Resident Rights. Reports all hazardous conditions, damaged equipment, and supply issues to appropriate persons. Assure that established infection control and standard precaution practices are maintained at all times. Follow established safety precautions when performing tasks and using equipment and supplies. Maintains the comfort, privacy and dignity of Residents and interacts with them in a manner that displays warmth, respect and promotes a caring environment. Communicates and interacts effectively and tactfully with Residents, visitors, families, peers, and supervisors. Answers and respond to call lights promptly and courteously when working in Resident care areas. Reports all Resident concerns to the appropriate department head. Attend and participate in departmental meetings and in-services as directed. Attends in-service and education programs and attends continuing education required for maintenance of professional certification or licensure. Understands Infection Control and follows the Company ' s Infection Control guidelines, such as hand washing principles. Maintains a high level of confidentiality in accordance with HIPAA (Health Insurance Portability and Accountability Act) guidelines at all times and protects confidential information by only providing information on a need-to-know basis. Promotes and Protects Resident Rights by assisting Residents to make informed decisions, treating Residents with dignity and respect, protecting Residents ' personal belongings, reporting suspected abuse or neglect, avoiding the need for physical restraints in accordance with current professional standards; and supporting independent expression, choice and decision-making consistent with applicable laws and regulations. Perform Related duties as assigned .Supervisory Responsibilities: Supervises employees in the department and others for whom they are administratively or professionally responsible (if applicable) by following policies and applicable laws. Uses independent judgment and discretion on behalf of the organization in the performance of these duties

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 41415

Residents Affected - Few Based on observation, interview and record review the facility failed to establish and implement an effective system to receive, dispense, administer and disposition of controlled medications account for two (R's 59 & 315) of five residents reviewed for medications, this deficient practice resulted in the inaccurate documentation of a controlled medication and had the ability to result in the diversion of medication not accounted for. Findings include:

On 8/27/24 at 8:24 AM, Licensed Practical Nurse (LPN) A was observed preparing the morning medications for Resident R315. LPN A was observed to obtain a morphine sulfate bottle, inside of a plastic bag with a folded controlled form for the morphine medication. The form was reviewed with LPN A and was observed to be blank. LPN A was asked how they were accounting for the unopened morphine medication if the document was blank. LPN A stated they don't account for the medication until they open the bottle. LPN A was asked to provide the current Morphine controlled form in use. Review of the Morphine controlled form that was in use revealed the facility staff was only counting the opened morphine bottle and not accounting for the unopened Morphine bottle, creating opportunity for diversion. LPN A was then asked to provide the opened Morphine bottle and when compared to the Morphine controlled form in use, confirmed the facility staff were failing to account for all of the Morphine medication on hand for Resident R315. LPN A was asked how they count each controlled medication with the off going or incoming nurse and LPN A replied they don't account for each controlled pill or liquid, they only count full and half cards of medications and document it as such. LPN

A stated this is how they were trained to do it at the facility.

On 8/27/24 at 9:03 AM, the Administrator and Director of Nursing (DON) were asked to provide the facility's policy on the receipt, processing, count and maintenance of controlled medications.

Review of the facility's policy provided revealed the following:

Accepting Medication Delivery dated 8/1/24, was reviewed and contained no documentation for the receipt of controlled medications.

Medication Access and Storage dated 8/1/24, was reviewed and documented in part . Schedule III and IV controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose .

At 2:35 PM, the Administrator and DON were again asked to provide the policy for their protocol on receiving, disposition and reconciliation of the facility's-controlled medications in detail.

Review of the policy provided titled Controlled Medication - Ordering & Receipt dated 2/2024 documented in part . A controlled medication accountability record is prepared when receiving or checking in a controlled substance medication for a resident. The following information is completed: Name of the resident, Prescription number, Drug name, strength . and dosage form of medication, Date received, Quantity received, Name of the person receiving the medication .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0755 Review of an additional policy provided titled Controlled Medication Storage dated 01/24 documented in part . At each shift change or when keys are surrendered, a physical inventory of all controlled substances, Level of Harm - Minimal harm or including refrigerated items, is conducted by two licensed nurses or approved individuals per state regulation potential for actual harm and is documented on the controlled substances accountability record or verification of controlled substances count report . Residents Affected - Few

The facility failed to implement a system for their controlled medications.

On 8/27/24 at 2:49 PM, the DON was interviewed, informed of the observation of LPN A and the incident with the Morphine medication and the DON replied they were trained under the previous corporation (the facility had recently been taken over by a new corporation) that they don't specific non controlled medications from controlled medications and count the cards as full or halves. The DON stated the new corporation had a better system in place which would be implemented.

No further explanation or documentation was provided by the end of the survey.

32568

Resident #59 (Resident R59)

On 8/27/24 at 11:06 AM, LPN 'A' was observed at the medication cart located on the North East Unit. LPN 'A' was observed going through the double locked box that contained controlled substance medications and comparing the number of pills with what was written on the controlled substance count sheet. LPN 'A' was observed writing on the count sheet without removing a tablet from the supply.

At that time, LPN 'A' was interviewed and the controlled substance count sheet was observed. It was for Resident R59 (klonopin - an antianxiety medication). LPN 'A' dated the entry 8/27/24 at 9:00 AM (two hours earlier) and documented that he removed one pill from the supply with a total count of 13 pills. When queried about why

he documented that a pill was removed when it was not, LPN 'A' reported he gave the medication earlier in

the morning but did not document it on the count sheet. When queried about the appropriate process for accounting for controlled substances, LPN 'A' reported he should have documented the removal of the pill at

the time it was removed and administered.

On 8/27/24 at approximately 3:00 PM, the DON was interviewed. The DON reported that any controlled substance that was removed from the supply should be documented on the associated count sheet for that medication at the time it was removed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 41415 Residents Affected - Few Based on observation, interview and record review the facility failed to follow the facility's policy on the maintenance and storage of medications and foods for one of one medication storage rooms observed. Findings include:

On 8/27/24 at 8:20 AM, an observation of the medication back up storage room refrigerator was conducted.

A refrigerator temperature check list was observed with the date of 8/20/24 to have been the last date staff had checked the temperature of the refrigerator. Two applesauce containers were found in the refrigerator next to medications and insulins that were also stored in the refrigerator. The Director of Nursing (DON) was asked to confirm the findings and stated the nightshift nurses are responsible for checking the refrigerator temperature. The DON stated they would start education with their staff. The DON also stated there should be no food stored in the refrigerator with the residents medications and if so, should be separated.

Review of a facility policy titled Medication Access and Storage review date of 8/1/24, documented in part . It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls . Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated, and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods (e.g., employee lunches, activity department refreshments) are not stored in this refrigerator .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38271 potential for actual harm Based on observation, interview and record review, the facility failed to ensure a dental oral surgery referral Residents Affected - Few was made for one resident (Resident R20) of one residents reviewed for dental services. Findings include:

On 8/27/24 at approximately 11:03 a.m., Resident R20 was observed in the group meeting and indicated that they were supposed to have their tooth taken out in January but had no assistance from the facility in getting the procedure completed.

On 8/27/24 at approximately 3:04 p.m., Resident R20 was observed in the hallway, up in their wheelchair and expressed concerns about their tooth hurting and needing to be pulled. Resident R20 indicated again that nobody was going to do anything about it.

On 8/27/24 the medical record for Resident R20 was reviewed and revealed the following: Resident R20 was initially admitted to

the facility on [DATE REDACTED] and had diagnoses including Pain and Dysphagia. A review of Resident R20's MDS (minimum data set) with an ARD (assessment reference date) of 7/20/24 revealed Resident R20 needed assistance from facility staff with most of their activities of daily living. Resident R20's BIMS score (brief interview for mental status) was 15 indicating intact cognition.

A Dental evaluation dated 2/15/24 revealed the following: Confirmed with facility patient is Covid-19 negative and afebrile.; Reviewed Medical History; Patient has plaque and calculus build-up, recommend cleaning and exam every 6 months; Patient masticating well.; Stressed brushing twice per day to maintain health of teeth and tissues.; Patient has discomfort from fractured teeth #2, #19. Refer to oral surgeon for extractions due to need for surgical extractions and health issues. Tooth #8 DFL caries .Action required by Nursing home staff: Referral to oral surgeon for extraction of teeth #2, #19 surgical extractions .

A second dental evaluation dated 4/26/24 revealed the following: Treatment notes: Patient complains of pain

in lower left and upper right .#19 is non-restorable and causing the patient pain, irreversible pulpitis and/or symptomatic apical periodontitis. Both #2 and #3 have fractures with caries in them, and due to the communication issues with the patient, it is not possible at this moment to discern which tooth is bothering him. He gives no concrete answer to the presence of cold in his mouth on these teeth and percussion and palpation do not yield anything useful. Patient unable to effectively communicate. Note to hygiene: please take PA (posterior-anterior) of #2 and #3, so that it may be possible to find out which tooth is causing the patient discomfort .Action required by Nursing home staff: Refer to MD/OS (medical doctor/oral surgeon) for extraction of tooth; Please refer for extraction of #19 .

A progress note dated 7/8/202410:00 Nurses' Notes: Resident LOA (leave of absence) to dentist appt (appointment) via harmony transportation accompanied by cena (certified educated nurse assistant).

A second progress note dated 7/8/2024 revealed the following: Resident returned back to the facility. Unable to be seen without guardian present with him. Appointment needs to be rescheduled.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0791 On 8/27/24 at approximately 3:25 p.m., during a conversation with the Administrator (providing social service oversight) the Administrator was queried regarding the lack of oral surgeon referral being made and they Level of Harm - Minimal harm or indicated that they have been without a social worker who would usually make those referrals and had potential for actual harm recently hired a new one. The Administrator indicated that they would have to make Resident R20 a dental appointment to get their tooth extracted. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 22960

Residents Affected - Many Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include:

On 8/26/24 at 9:10 AM, there was raw chicken observed under running water directly inside the sink basin of

the 2 compartment sink. The internal temperature of the chicken was measured to be 67 degrees Fahrenheit. When queried, Dietary Staff M stated the chicken was in the walk-in cooler, but was still frozen, so it was placed in the sink to thaw. No explanation was given as to why the chicken was still in the sink basin with an internal temperature of 67 degrees Fahrenheit.

According to the 2017 FDA Food Code section 3-501.13 Thawing Except as specified in (D) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be thawed: 1. (A) Under refrigeration that maintains the FOOD temperature at 5 C (41 F ) or less; or

2. (B) Completely submerged under running water: 1. (1) At a water temperature of 21 C (70 F ) or below, 3. (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5 C (41 F ).

On 8/26/24 at 9:20 AM, in the walk-in cooler, there was an undated pan of leftover enchiladas, an undated pan of white sauce, an undated pan of gravy, an opened undated package of bologna, an opened undated 1 gallon container of Italian dressing and ranch dressing, and a 1 gallon container of creamy Caesar dressing dated 6/17-7/17. Dietary Staff M confirmed the items should have been dated when opened.

According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous 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 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed 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, 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm 48680

Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure a plan of care for hospice services being provided was coordinated and documented in the resident's clinical record for one (Resident R315) of one sampled resident reviewed for hospice services, resulting in a lack of coordination of comprehensive services and incorrect code status. Findings include:

On 8/25/24 at 10:20 AM, Resident R315 was observed lying in bed with a family member present. An interview was held with Resident R315. Resident R315 was then asked how the care was received at the facility and stated that they were only here for a short period of time because they were a hospice respite patient (at the facility for a short period of time).

On 8/27/24 at 3:00 PM, the Director of Nursing (DON) was interviewed and asked how the facility communicated with the hospice company for Resident R315. DON replied that we have been doing everything verbally, there is no actual book or log (to communicate with hospice) at this moment. The DON continued by stating , I have told the administrator (about the communication concern), and they will communicate to the hospice company about our requirements and expectations.

There was no additional information provided by the exit of the survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 54 235036 Department of Health & Human Services Printed: 09/11/2025 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 235036 B. Wing 08/28/2024

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

The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309

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 0850 Hire a qualified full-time social worker in a facility with more than 120 beds.

Level of Harm - Minimal harm or 32568 potential for actual harm Based on interview and record review, the facility licensed failed to employ a full-time qualified social worker Residents Affected - Many when certified for 126 residents, resulting in multiple deficient practices including the following areas, advance directives, ancillary services, completing Social Service assessments, discharge planning, and Preadmission Screening and Resident Review (PASRR). This deficient practice had the potential to affect all 62 residents who resided in the facility. Findings include:

During an onsite annual recertification survey conducted from 8/26/24 through 8/28/24 deficient practices were identified in multiple areas of social services, including the failure to provide the following: effective coordination of advance directives to ensure the residents' desired code status was properly documented in

the clinical record, discharge planning resulting in an unsafe discharge without home health care services, completion of PASRR, and facilitation of ancillary services including dental and audiology, and assessment of residents for their social service needs.

A review of a Facility Assessment Tool provided by the facility revealed the facility was licensed to provide care to 126 residents.

On 8/27/24 at 9:44 AM, an interview was conducted with Human Resources Director (HR) 'E' and Corporate HR 'F'. According to HR 'F', the facility had a change in ownership on 8/1/24 and there was no qualified social worker employed at that time. HR 'F' reported the facility did hire a social worker who was starting on 9/4/24. At that time, documentation of the last day the previous social worker worked in the facility was requested. When queried about whether there are anyone providing full-time social services in the facility

after the previous social worker resigned, HR 'F' reported various people were helping out since 8/1/24, but not onsite and not full time.

A review of Termination Information for the former social worker, SW 'G', revealed SW 'G' last day worked in

the facility was 3/28/24 with a termination date of 4/17/24.

Cross-Reference