Accolade Healthcare of Pontiac

Inspectors wroteBased on observation, interview and record review the facility failed to use foot pedals when transporting a resident in a wheelchair and failed to follow a care plan intervention to utilize a mechanical lift to transfer a resident for two (R2 and R7) of three residents reviewed for accidents in the sample of eight residents. These failures resulted in R2 falling from the wheelchair and suffering a head laceration requiring sutures and R7 suffering a fractured rib when staff transferred R7 without using the mechanical lift. Findings Include:1. According to the current Electronic Health Record (EHR), R2 has diagnoses including unspecified hydronephrosis, weakness, repeated falls, muscle wasting and atrophy of the bilateral thighs, lack of coordination, abnormal posture, cognitive communication deficit, chronic fatigue, osteoarthritis, obesity, anemia, lymphedema, and hypertension. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents' rights to dignity, respect, and timely assistance were maintained by failing to respond to call lights in a timely manner for three (R3, R4 and R8) of four residents reviewed for call light response time in the sample list of eight. Findings Include: The facility's grievance logs for April, May, and June 2026 document concerns related to delayed call light response times, including complaints that call lights were not monitored, and response times exceeded acceptable limits. The facility Resident Privacy and Dignity Policy revised 1/26, documents the facility is responsible for ensuring all residents are provided dignity and respect at all times. [...]

Inspectors wroteBased on interview and record review, the facility repeatedly failed to follow physician's orders to utilize a Bilevel Positive Airway Pressure (BiPAP) machine and failed to notify the physician when the BiPAP was not administered for one (R1) out of three residents reviewed for quality of care on a sample list of eight. R1's Administration Record dated April of 2026 documents an order, with a start date of 4/4/26, for R1 to wear a BIPAP every night. A Resident/Family Concern Grievance Form dated 4/6/26 at 9:00AM, documents R1 was concerned that his BiPAP was not at the facility when he admitted to the facility. An email exchange from V13 (Admissions/Marketing Coordinator) with the equipment company, dated 4/10/26, documents V13 notified the equipment company of an issue with R1's BiPAP tubing. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure resident records were accurate for one of two residents (R7) reviewed for documentation accuracy on a sample list of eight. Findings Include:1. R7's Nursing Note dated 6/11/26 at 2:31 PM documents, (V21 Medical Director) also assessed resident, resident had no pain or discomfort in the rib area. No signs of fracture of the area. (V21) stated it looked like a noddle (sic) or legion. (Xray Company) called to re-review Xray and call back with findings. On 6/16/26 at 11:30AM, V5 (Assistant Director of Nursing) stated V21 (Medical Director) physically assessed R7 for a fracture. On 6/16/2026 at 11:16AM, V21, (Medical Director), stated he reviewed radiographs for R7 at the request of facility administration and referred to the radiologist. V21 stated he did not physically assess or see R7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident from physical abuse by another resident. This failure affects two residents (R1 and R2) out of twelve residents reviewed for abuse on the sample list of 26.

Inspectors wroteBased on record review and interview the facility failed to ensure safe transfer techniques were implemented for one (R1) of three residents reviewed for accidents. The resident sustained a fracture of the left knee when a mechanical lift transfer requiring two staff members was performed by only one staff member. Findings Include The Facilities Hydraulic Lift (Hoyer) Policy revised on 1/26 documents all nursing staff will be trained on the proper use of the hydraulic (hoyer) lifts that are used within the facility, to ensure safe transfer for residents. This Policy also documents that the staff is to obtain assistance from a second staff member. On 11/29/26 at 3:04AM, the Nursing Progress notes documents: R1was sent to the hospital after complaining of pain in the area above her left knee. R1 received Norco (pain medication) just before leaving for the hospital. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an incident resulting in a fracture was reported to the State Agency within the required timeframe for one (R1) of three residents reviewed for Accidents. Findings IncludeThe Facilities Accidents and Incidents policy revised on 1/26 documents that reporting accidents and incidents, including injuries of an unknown origin, must be reported to the department supervisor and an Accident/Incident Report form must be completed on the shift that the accident or incident occurred. This document also states that the Director of Nursing (DON)/Designee will report any accident/incident of major injury to the State Agency within 24 hours. On 11/29/26 at 3:04AM, R1's Nursing Progress note documents R1 was sent to the hospital after complaining of pain in the area above R1's left knee. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation of the required transfer/discharge process for one (R3) of three residents reviewed for transfer/discharge. The facility discharged R3 without documentation of the required discharge notice and required elements in the medical record. The Facility Discharge/Transfer Policy revised 1/25 documents the facility is to provide guidelines for appropriate discharge and transfer procedures. The facility also documents that the facility will have a written or telephone order from the attending physician for the transfer or discharge of a resident. R3 was admitted to the facility on [DATE] per R3's nursing progress notes. Per R3's Hospital notes dated 2/23/26, R3 was dropped off at the Emergency Department (ED) from the facility with complaints of social concern. [...]

Inspectors wroteBased on Interview, Observation and Record Review the facility failed to follow admission orders for c-collar care for one (R1) out three residents reviewed on a sample list of three. Findings Include:On 7/18/2025, R1 had a fall that resulted in a C2 fracture of the neck. R1 was sent to the emergency room for evaluation due to pain in the left shoulder and returned on 7/19/25 with an Aspen C-Collar (Cervical Collar) and orders for care of the C-Collar. On 8/2/25 at 8:05AM, V8 (Certified Nursing Assistant) stated V8 put resident (R1) to bed on 7/18/25, there was no recliner in the room, which V8 stated that R1 usually sleeps in recliner. On 7/18/25, V8 found resident (R1) had rolled out of bed and was complaining of shoulder pain and with the assistance of V9 (Certified Nursing Aide) and V10 (Registered Nurse) resident (R1) was put back to bed via Hoyer lift. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for two (R1, R2) of three residents reviewed for infection control in the sample list of three.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident and their representative in writing about a hospital transfer and failed to provide a bed hold notice for five of five residents (R9, R26, R50, R63 and R74) reviewed for hospitalizations on the sample list of 35. The facility's Bed Reserve Policy Notification no date, documents this bed reserve policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. 1. R9's Nursing Notes document R9 was transferred to the emergency room on 3/29 and 5/25/25. R9's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R9's representative for R9's hospitalizations on 3/29 and 5/25/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide numerous showers as scheduled for dependent residents. These failures affect two residents (R34 and R63) of six reviewed for activities of daily living in the sample list of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan. This failure affects one (R50) of 19 residents reviewed for care plans in the sample list of 35.

Inspectors wroteBased on observation, interview and record review the facility staff failed to provide complete incontinence care for R18. R18 is one of one resident sampled for incontinence care in a total sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to have an order for the provision of dialysis treatments for two (R13 and R46) of two residents reviewed for dialysis in the sample list of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for two (R2 and R275) of seven residents reviewed for EBP on the sample list of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement an ordered nutritional supplement and failed to notify a resident representative of the significant weight loss for one of two residents (R379) reviewed for nutrition in the sample list of 26. These failures resulted in R1's severe weight loss of 10.8% in 12 days.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the facility kitchen food service areas, and equipment in a clean, sanitary condition to prevent potential cross-contamination and food-borne illness to residents. This failure has the potential to affect all 76 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents medications, including Schedule II controlled substances, were stored appropriately within visual control of the nurse. This failure affects four of 22 residents (R2, R31, R35, R25) reviewed for medication storage for the sample list of 26.

Inspectors wroteFailures at this level require more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to respect a resident's right to have a visitor with a service support animal present during meal service for one of 18 residents (R377) reviewed for resident rights in the sample list of 26. B. Based on observation, interview, and record review the facility failed to ensure a resident's right of dignity by failing to cover a resident's exposed abdomen in the dining room where other residents were present. This failure affected one of eighteen residents (R24) reviewed for dignity on the sample list of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain an order for a therapy recommended arm sling and failed to assist in applying the arm sling for one of one resident (R377) reviewed for Limited Range of Motion in the sample list of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate pain management was provided for one of two residents (R29) reviewed for pain on the sample list of 26. Findings Include: The facility's Pain Management Policy dated August 2017 documents the facility's mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of the policy is to accomplish that mission through an effective pain management program, providing residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The same policy documents pain is defined as whatever the experiencing person says it is, existing whenever the experiencing person says it does. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to dispose of discontinued medications for one (R9) of 22 residents reviewed for physician orders in the sample list of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a call light was within reach for one of five residents (R1) reviewed for call lights on the sample list of seven. Findings Include: R1's ongoing and undated Medical Diagnosis Listing documents the following diagnoses: Quadriplegia, Multiple Sclerosis, Anxiety Disorder, and Neuromuscular Dysfunction of the Bladder. On 4/15/24 at 9:15 am, R1 was sitting up in a motorized wheelchair in R1's room and stated, R1 was needing R1's incontinence brief changed but that R1 can't even call them to tell them because R1's call light is hanging on the wall {behind the bed} and R1 can't reach it. At this time, R1's call light was secured to the wall, behind the head of R1's bed, out of reach and next to R1's bed was an end table, which prevented R1 from getting close enough to the wall to reach the call light. [...]

Inspectors wroteBased on observation and record review, the facility failed to prevent possible cross contamination during incontinence care for one of four residents (R1) reviewed for toileting on the sample list of seven. Findings Include: On 4/15/24 at 9:35 am, V4 CNA (Certified Nursing Assistant) and V7 RN (Registered Nurse) were changing R1's incontinence brief. R1 had been incontinent of urine and stool and R1's brief was saturated. V4 donned gloves and provided incontinence cares using disposable wipes, then proceeded to grab a clean incontinence brief and placed it under R1 without removing the potentially contaminated gloves or performing hand hygiene. R1 then urinated again, onto the new incontinence brief. V4 changed gloves at this time but did not perform hand hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store a frozen food item to protect from freezer damage, failed to maintain the range hood in a manner to protect foods being prepared, and failed to protect serving wares from cross contamination during meal services. These failures have the potential to affect all 79 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete and submit a comprehensive Minimum Data Set within the 14-day requirement after determining a significant change in a resident's health status. This failure affects one resident (R28) out of three reviewed for pressure ulcers on the sample list of 28.

Inspectors wroteBased on interview and record review, the facility failed to revise a resident's care plan to reflect the actual level of assistance required to accomplish activities of daily living. This failure affects one resident (R37) out of three reviewed for activities of daily living on the sample list of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal hygiene or grooming services to remove facial hair from a female resident. This failure affects one resident (R37) out of three reviewed for activities of daily living on the sample list of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize basic infection control procedures by failing to wear gloves during the administration of a finger puncture blood glucose check and administration of an insulin injection. This failure affects one resident (R39) out of one observed for glucose checks and insulin administration on the sample list of 28.