Highpointe on Michigan Health Care Facility

Inspectors wroteBased on observation, interview, and record review conducted during a survey the facility did not ensure the resident's right to be free from neglect for twenty two (22) (Residents #1, 2, 3, 7, 8 ,9 ,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25) of twenty two (22) residents reviewed. Specifically, on 08/18/2025, 08/27/2025, 08/28/2025, and 12/04/2025 staff did not provide incontinent rounds and/or care every two (2) to three (3) hours per the residents' plan of care and safety checks.

Inspectors wroteBased on interview, observation, and record review conducted during a survey, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for two (2) (Residents #4 and #5) of three (3) resident reviewed for accidents. Specifically, the facility did not ensure that Resident #4, who was severely cognitively impaired and at risk for elopement, was adequately supervised to prevent them from exiting through a stairwell door and they were found in the stairwell; the facility did not ensure Resident #5 was reassessed for elopement risk or had interventions in place to prevent/address exit seeking behavior when they had improvement in their functional levels and the resident was found on the sidewalk next to the building by staff.

Inspectors wroteBased on interview, and record review conducted during the Abbreviated Survey (Complaint #NY00376929) the facility did not ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one (1) (Resident #1) of three (3) reviewed. Specifically, a BiPAP machine (Bilevel Positive Airway Pressure machine used as a non-invasive respiratory support) was not provided until five days after admission to the facility. The finding is: The policy and procedure titled Resident Assessment Process revised 12/2022 documented the external data collection of medical documents begins at the time of admission from transferring institutions. These documents will assist the interdisciplinary team in the development of the comprehensive assessment. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during a complaint investigation (#NY00330798 and #NY00325133) during an extended standard re-certification survey from 9/3/2024 to 9/16/2024, the facility failed to protect the residents' right to be free from sexual abuse by a resident for three (Residents #33, #50, #208) of ten residents reviewed. Specifically, the facility failed to implement safeguards that resulted in repeated instances of sexual abuse with residents that had impaired cognitive status and lacked the ability to consent. This resulted in and had the likelihood for psychosocial harm that is Immediate Jeopardy and Substandard Quality of Care for Residents #33, #50, #208 with the likelihood to affect all residents (census 265) in the facility.

Inspectors wroteBased on observations, interviews, and record review completed during complaint investigations (Complaint #NY00345300 and #NY00324827) during an extended recertification survey, the facility failed to ensure that each resident received adequate supervision to prevent accidents and elopement for two (Resident #20 and #228) of ten residents reviewed. Specifically, Resident #228 required 1:1 (one to one) supervision for safety and had an unwitnessed fall, sustaining a right hip fracture. In addition, on 9/24/2023 at 1:25 PM Resident #189 eloped through the front door of the facility. This resulted in actual harm to Resident #228 that was not Immediate Jeopardy.

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (#NY00330798 and #NY00325133) during an extended standard survey on 9/16/24, the facility did not ensure that all alleged violations of abuse were thoroughly investigated for four (Resident #33, Resident #50, Resident #208, Resident #226) of ten residents reviewed. Specifically, facility investigations lacked interviews with potential witnesses and other potential victims (Resident #50, Resident #208, and Resident #226). Also, there was lack of an investigation when Resident #226 exposed their genitals in front of Resident #33 and Resident #50 in a common area.

Inspectors wroteBased on interview and record review conducted during an extended standard survey completed from 9/3/2024 to 9/16/2024, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; [...]

Inspectors wroteBased on interview and record review conducted during an extended survey completed on 9/16/24, the facility did not ensure a quality assurance and performance improvement (QAPI) program did not ensure the committee developed and implemented appropriate plans of action to correct quality deficiencies and regularly reviewed, analyzed and acted on available data to make improvements. Specifically, the facility quality assurance and improvement program did not identify, develop, and implement an appropriate plan to prevent and protect all residents from sexual abuse when repeated patterns of sexually inappropriate behaviors occurred. Additionally, when there was a change in the facilities processes for addressing hospital transfer/discharge notifications and bed hold policy notices; [...]

Inspectors wroteBased on observation, interview and record review conducted during an Extended survey completed on 9/16/24, the facility did not ensure the resident's representative was notified immediately of a change of condition for one (Resident #267) of two residents reviewed for notification of change. Specifically, Resident #267's representative was not notified of the resident's tracheostomy (opening into the trachea) tube being removed. The finding is: Resident #267 had diagnoses that included traumatic subdural hemorrhage (bleeding in the brain), acute kidney failure, and depression. The Minimum Data Set (a resident assessment tool) dated 8/11/24 documented Resident #267 was moderately cognitively impaired, usually understood and sometimes understands. The comprehensive care plan dated 5/11/24 documented Resident #267 had a tracheostomy related to impaired breathing mechanics. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a complaint investigation (#NY00324941) during an Extended survey completed on 9/16/24, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (Residents #20) of two residents reviewed. Specifically, Resident #20 had greasy, disheveled hair, with matting and knots to the back of their head. The finding is: Resident #20 had diagnoses that included multiple sclerosis (disease central nervous system), age-related physical debility, and epilepsy (seizure disorder). The Minimum Data Set (a resident assessment tool) dated 7/7/24 documented the resident was understood, understands, and had severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review conducted during an extended standard survey completed on 9/16/24, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtained informed consent prior to the installation of bed rails for one (Resident # 20) of one resident reviewed for bed rails. Specifically, Resident #20 was not assessed for risk of entrapment from bed rails, there was no documented evidence the risks and benefits of bed rails were reviewed and that consents were obtained prior to bed rail use. Additionally, there was lack of maintaining the bed rails in proper working order. The finding is: [...]

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (#NY00336618) during an Extended survey completed on 9/16/24, the facility did not ensure that residents are free of significant medication errors for one (Resident #250) of three residents reviewed. Specifically, on 3/20/24 Registered Nurse #3 erroneously administered Resident #247's morning medications to Resident #250 which resulted in a significant medication error. The finding is: The policy and procedure titled Medication Ordering, Interpretation and Administration Guidelines revised 10/3/22 documented prior to all medication administration, scanning both the patient's wristband and the medication barcode are required. [...]

Inspectors wroteBased on record review and interview conducted during an extended standard survey completed on 9/16/24, the facility did not ensure that the resident or resident representative was notified in writing, of the transfer and the reason for hospitalization for three (Resident #91, #222 and #250) of three residents reviewed. Specifically, Resident #91 was sent to the hospital on 8/30/24 and Resident #222 had multiple hospitalizations (4/14/24, 5/16/24, 5/23/24 and 8/13/24) with no written notification to the resident or their representative of the Notice of Transfer or Discharge. Resident #250 was transferred to the hospital on 3/20/24 with no written notification to the resident or their representative of the Notice of Transfer or Discharge and facility did not send a copy of the Transfer or Discharge notice to the Office of the State Long Term Care Ombudsman.

Inspectors wroteBased on record review and interview conducted during an extended standard survey completed on 9/16/24, the facility did not ensure that the resident or resident representative was notified in writing of the bed hold policy for three (Resident #91, #222 and #250) of three residents reviewed for hospitalization. Specifically, Resident #91 was sent to the hospital on 8/30/24, Resident #222 had multiple hospitalizations (4/14/24, 5/16/24, 5/23/24 and 8/13/24) and Resident #250 was transferred to the hospital on 3/20/24 with no written notification to the resident or their representative of the facility's bed hold policy.

Inspectors wroteBased on interview and record review conducted during an Abbreviated survey (Complaint #NY00342510) completed on 5/22/24, the facility did not ensure that all alleged violations including abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation is made. If the events that caused the allegation do not involve abuse or result in seriously bodily injury not later than 24 hours to the facility's Administrator and to other officials (including to the State Survey Agency) for one (Resident #1) of three residents reviewed. Specifically, facility staff did not report an allegation of resident neglect to the Director of Nursing or the Administrator which resulted not reporting to the State Survey Agency as required. The finding is: [...]

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey (Complaints NY00295560 and NY00289847) completed 8/23/22 through 8/30/22, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for three of four residents reviewed. [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey started on 8/23/22 and completed on 8/30/22, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #29) of six residents reviewed for quality of care during activities of daily living. Specifically, Resident #29 was observed to have a bilateral axillary (underarm) rash on 8/26/22 and a treatment was not ordered until 8/29/22. Additionally, a nurse applied a medicated powder to Resident #29's bilateral axillary rash without a physician's order on 8/26/22. The finding is: [...]

Inspectors wroteBased on observation, record review, and interview conducted during the Standard survey started 8/23/22 and completed on 8/30/22, the facility did not ensure that a resident with limited range of motion (ROM) received appropriate treatment and equipment to prevent further decrease in range of motion for two (Resident #100 and #138) of four residents reviewed for range of motion (ROM) services. Specifically, Resident #100 was not provided ROM according to therapy recommendations and plan of care and Resident #138 was not provided a palm posey (assistive device that positions the fingers away from the palm) to their right and left hand as planned by Occupational Therapy (OT).

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey started 8/23/22 and completed on 8/30/22, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one (Resident #56) of four residents reviewed for respiratory care. Specifically, there was not an order for oxygen (O2) or humidification since 12/10/21. The finding is: The facility policy and procedure (P&P) titled Oxygen Therapy, O2 revised 11/10 documented a written physician order was necessary to initiate oxygen therapy, with exception for emergency short term use only. All oxygen therapy orders must include parameters, flow rate or percent FIO2 (fraction of inspired oxygen). [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey started on 8/23/22 and completed on 8/30/22, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and Director of Nursing (DON), and that these reports were acted upon for one (Resident #159) of five residents reviewed for Drug Regimen Reviews. Specifically, the Consultant Pharmacist's did not identify the continued use of a PRN (as needed) Ativan (psychotropic antianxiety medication) in use for six months, and the physician did not act upon the recommendations in a timely manner. Additionally, there was lack of identifying and reporting that the medication was not administered per the physician's order. The finding is: [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey started on 8/23/22 and completed on 8/30/22, the facility did not ensure that PRN (as needed) orders for psychotropic drugs were limited to fourteen days and if the attending physician believes that it was appropriate for the PRN order to be extended beyond fourteen days, they should document the rationale in the medical record and indicate the duration of the PRN order for one (Resident #159) of five residents reviewed for unnecessary medications. Specifically, there was lack of physician documentation indicating the duration of use for a PRN psychotropic medication (Ativan - medication used to treat anxiety) used beyond fourteen days. The finding is: [...]

Inspectors wroteBased on observation, interview and record review during a Standard survey beginning on 8/23/22 and ending on 8/30/22, the facility did not maintain an infection prevention and control program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility had no documented evidence that three (Certified Nursing Assistant (CNA) #1, #2, and Dietary Service Worker #4) out of four staff reviewed for COVID-19 testing, who were not up to date with their COVID-19 vaccination, were tested for COVID-19 as required.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey (Complaint # NY00241999) completed on 1/22/20 the facility did not meet the nutritional needs of residents in accordance with established national guidelines and follow the prepared menus. Four (Unit 1, Unit 2, Unit 3, and Unit 4) of four-unit serveries did not serve proper portion sizes. Specifically, Unit 1 and Unit 3 at lunch on 1/15/20 and Unit 2 and Unit 4 at lunch on 1/17/20. In addition, on 1/15/20 menu read garlic toast and puree consistencies did not receive garlic toast or any type of similar substitution.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 1/22/20, it was determined the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for three (Units Kensington Heights, Elmwood Village and Cold Springs) of nine units observed for the environment. Specifically, the shower gurney mats were soiled and in disrepair. Underneath the mats, extending the full length of the shower gurney, the mesh beds were heavily soiled with garbage and unknown substances.

Inspectors wroteBased on observation, interview and record review conducted during a Standard Survey completed on 1/22/20, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for one (Resident #29) of three residents reviewed for abuse. Specifically, there was a lack of a thorough investigation into verbal abuse allegations from 11/22/19. The finding is: Review of the policy and procedure titled Identification and Reporting of Abuse, Neglect or Mistreatment of a Skilled Nursing Facility Resident with review date of 7/17 documented the facility begins an investigation immediately upon discovery of an incident. The investigation is the process used to try to determine what happened. When an incident or suspected incident of abuse is reported, the administrator or designee will investigate the incident with the assistance of the appropriate personnel. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 1/22/20, the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for two (Resident #16 and # 243) of five residents observed for ADL's. Specifically, residents who were dependent on staff for ADL's, had long, jagged fingernails (#16 and #243) with brown debris under multiple fingernails (#16). In addition, the lack of proper incontinent care ( #243).

Inspectors wroteBased on observation, record review, and interview completed during the Standard survey completed 1/22/20, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and equipment to prevent further decrease in range of motion. Specifically, one (Resident #243) of four residents reviewed for range of motion (ROM) services was not provided with a palm posey (assistive device that positions the fingers away from the palm) to their right hand as planned by Occupational Therapy (OT). The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 1/22/20 the facility did not ensure that residents who had an indwelling Foley catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #511) of two residents reviewed for catheter care. Specifically, the lack of maintaining infection control practices, improper Foley care. Additionally, the lack of care plan development to address a history of urinary tract infections (UTI). The finding is: Review of the undated document titled Urinary Catheter: Indwelling (Foley) Catheter Care -CE Quick Sheet documented instructions for catheter care for males: Retract the skin if the patient is not circumcised. Hold the genitalia at the shaft just below the glans. [...]

Inspectors wroteBased on observation, record review, and interview conducted during a Complaint investigation (Complaint #NY00241999) during the Standard survey completed on 1/22/20, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, two (Cold Springs Village, Kensington) of three resident units reviewed for food temperatures during meals had issues involving food items that were not at safe and appetizing temperatures. Residents #A, B, family representative C, D, E, and F were involved.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard Survey (Complaint # NY00241999) completed on 1/22/20, the facility did not store and distribute food in accordance with professional standards for food service safety. Specifically, one of one main kitchen and five (Cold Springs B POD, Elmwood A Pod, [NAME] B Pod, Kensington A and B Pods) of fifteen-unit nourishment pods had issues with unclean equipment, wet and dirty stacked pots and pans and outdated and undated food. The finding is: Review of a policy and procedure (P&P) titled Cleanliness & Sanitation dated 1/2015 revealed purpose to achieve a clean, sanitary environment. Procedure: follow the guidelines given to define the standard of clean for kitchen equipment, food preparation, storage, dining, and ware washing areas. Pots and pans: free of grease and air dried. Hoods/ Hood Filters: [...]