& suarcormestcan re oer DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS SHELLY EDGERTON March 12, 2018 In the Matter of License No: AH490353181 Cedar Ridge LLC Docket #: 18-001970 255 § Airport Ra ‘St Ignace, MI 4u/’s1 EMERGENCY ORDER OF SUMMARY SUSPENSION Procedural History: On March 12, 2018, the Bureau of Community and Health Systems issued a Notice of Intent fo Revoke the license of Cedar Ridge LLC. This notice alleges statutory and licensing rule violations that are the result of two. special investigations concluded in 2018 (Special Investigation Reports: 201840233002 ‘and 2018A0233008). The March 2018 Notice of Intent fo Revoke is included as ‘Attachment A ofthis order. ‘An administrative hearing regarding the revocation of Cedar Ridge LLC's license fo operate a home for the aged is currently pending with the Michigan ‘Administrative Hearing System (Docket #16-001970), Finding (On January 22, 2018, the Bureau of Community and Health Systems concluded ‘Special Investigation Report 2018A0233002, which is included as Attachment B of this order. On March 7, 2018, the Bureau of Community and Health Systems concluded Special Investigation Report 2018A0233009, which is included as ‘Attachment C of this order. These reports determined violations of the Public Health Code, 1978 PA 368, MCL 323.20101 et cog, as amonded, and the Licensing Rules for Homes for the Aged, 2005-068 HS, R925.1901 et seq, that seriously affect the health, safety and welfare of residents in the care of Cedar Ridge LLC. These violations include: + MCL 333.21311(3)(a)b)(c): The facility admited Resident N in January 2017 and did not request an age waiver. Resident N would have been 48 ‘year's old when he was edmited to Cedar Ridge. +R 325.1921(1)a)(b): The facliy does not have an organized program for providing, supervision, protection and personal care. The fire alarm was shut of, thero is not enough staff and they are allowing the maintenance eae rane msanase sosmmasene se ae pon equ ose [TW Oana oP. BOX Stee» LANSING, HCHIGAN 8903» wma» (87) 306-180,man to provide personal care to residents. Admitting residents under 60 years of age without a waiver, preselting medication, not recording as- heeded medications and not initiating a review process for scheduling as- needed medications. + R 325,1931(2): The facility was not using the safety precautions of the ‘alarm system that was installed due to Resident B leaving without stafh knowedge. + R 325.1931(5): This facilty continues to be noncompliant with regard to adequate staffing to meet the needs oftheir residents, +R 325.1932(3)(cXa}(e): The staff are not following the medication training that the facity has provided. The staff are not documenting the as-needed medication to indicate the reason it was administered. The facily did not have Resident O's medication available for her to take. Resident O did not Taceive her medication from January 4, 2018, to January 9, 2078, * R 325.1932(6): The home was presetting medications to be passed at later time in multiple medication cups. + $33.20462(6)(a){)(iyiiiv)(b): The facility admitted Resident Q on February 28, 2018, 2 direct violation of the Correction Notice Order issued to Liconsee on January 23, 2018. +R 325.1922(1): The facility doos not have a service plan for Residents R and Q. # R 326.1924(1)(a)(b)(c)(a)(e): The facility has not submitted incident reports ssince August 2017. On February 28, 2018, the facilty could not produce ‘an incident report for any of the 21 911 calls made between January 4, 2018, and February 24, 2018. +R 325.1931(2): The facility faled to protect Resident R from hypothermia when he left the faclity and did not retun all day. The facility did not protect Resident K from being outside in the snow without proper clathing ‘or supervision, +R 325.1934(6): The facilty continues to operate with short staff. On February 25, 2018, and March 5, 2018, there was only one staff member ‘on shift for a period of time. + R 325.1932(2): Resident R does not have a complete service pian that includes a physician order stating he can administer his own medications. + R 325.1951: The facility did not have the food available to meet the nutritional needs of the residents “Special investigation Report 2018A0233002 and Special Investigation Report 20180283000 completed by Licensing Staff Laura Mohrman establishes failures by Licensee to assure appropriate protection and supervision of residents, ‘multiple employee violations, resident medication violations, fallure to comply with the Correction Notice Order, reporting of incidents, accidents and elopements and nutitional needs of residents. Due to these deficiencies, which demonstrate ongoing and repeated failures to protect the health, safety, and welfare of those receiving care, the residents of Cedar Ridge, LLC, remain at substantial riskOrde The Bureau of Community and Health Systems has determined that Cedar Ridge LLC, has committed statutory and rule violations that seriously affect the health, safely, and welfare of individuals receiving care, Therefore, the provision of MCL 333.20168 of the Public Health Code of 1978, as amended, is invoked. It is ordered that the license of Cedar Ridge LLC, is hereby suspended. Cedar Ridge LLC is ordered to do the following: = Immediately discharge all remaining residents of the facility located at 255 S. Aiport Road, St. Ignace, Michigan, 49781 Inform case managers or guardians of adults in care that the license has been suspended and that Cedar Ridge LLC, can no longer provide care, * Cooperate with the case managers and/or guardians, and representatives of the Department of Licensing and Regulatory Affairs and Michigan Department of Health and Human Services - Adult Protective Services to assure that residents are immediately relocated, and that the care, treatment, and supervision of residents are not jeopardized during the relocation process, + Cedar Ridge LLC is not to receive any further adults for care following the discharge of residents and is not to provide care to residents at this location, Conclusion: This order is issued in accordance with MCL 333.20168(1), which provides that the facilty shall be given an opportunity for a hearing on this matter within 5 working days after receipt of the order. An Administrative Law Judge will be available at tho Michigan Administrative Hearing System, Ottawa Stato Office Building, 611 West Ottawa Street, 2"! Floor, Lansing, Michigan 48933 at 9:00 a.m. on Thursday, March 44th, 2018, to conduct a hearing in accordance with the Administrative Procedures Act, 1962 PA 306, as amended, MCL 24.271-87. You may appear personally or be represented by counsel ‘This Order is made and dated on this 12th day of March, 2018, in Lansing, Michigan. ‘Adult Foster Care and Camps Licensing Division Bureau of Community and Health Systems.ATTACHMENT ASTATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF COMMUNITY AND HEALTH SYSTEMS In the Matter of: Docket #: 18-001970 Cedar Ridge LLC ‘Agency Case #: AH4903531841 v Case Type: Adult Foster Care Licensing/Home for the Aged LARA — Bureau of Community and He ith Systems/Adult Foster Caro Licensing NOTICE OF INTENT TO REVOKE LICENSE ‘The Michigan Department of Licensing and Regulatory AVfairs, by Jay Calewarts, Division Director, Aduit Foster Care, HFA and Camps Licensing Division, Bureau of ‘Community and Health Systems, provides notice of the intent to revoke the license of Licensee, Cedar Ridge LLC, to operate a home for the aged pursuant to the authority of the Public Health Code, 368 PA 1978, MCL 33320101 et seq., as amended, and the licensing rules for the Homes for the Aged, R 925.1901 et seq., forthe following reasons: 1 (On or about September 30, 2014, Licensee was issued a license to operate a hhome for the aged with a licensed capacity of 54 at 255 S. Almport Rd, St Ignace, MI 49781 Prior tothe issuance ofthe license, and during subsequent medifcations ofthe statutes and rues, Licensee recsived copies of the Public Health Code and the licensing rules for homes for the aged. The Act and rules are posted and avaliable for download at vww.nichigan.covilar.Previous ing Rule Violations 3. On of about July 10, 2015, Licensing Consultant Leura Dupras completed ‘Special Investigation Report (SIR) #2015A0233010 and cited Licensee with eight licensing rule violations including rules R 326.1924(1)(a)(b\(c)(d)(e), R 325.1931(2), R 325.1931(5) and R 325.1932(5). Licensee submitted an ‘acceptable corrective action plan (CAP) to show compliance with the cited licensing rule violations and the status of the license remain unchanged, 4, On or about January 5, 2076, Licensing Consultant Laura Mohrman completed SIR #2016A0233003 and cited Licensee with five licensing rule violations, Including R 325,1924(a)(b\(e)(¢) and R 325.1931(6). Licensee submitted an acceptable CAP to show compliance with the cited licensing rule violations and the status ofthe license remain unchanged, 5. On or about February 16, 2016, Ms. Mohrman completed SIR #201640233006, land cited Licensee with four licensing rule violations, including licensing rule R 325.1931(6). Licensee submitted an acceptable CAP to show compliance with the cited licensing rule violations and the status of the license remain unchanged. 8. On or about June 9, 2016, Licansing Consultant Theresa Norton completed SIR #2016A0221016 and cited Licensee with nine licensing rule violations, Including licensing rules R 325.1931(2), R 325.1931(6). On or about July 5, 2016, Licensee submitted a Correction Notice Order to show compliance with the cited licensing rule violations.7. On or about September 28, 2017, Ms. Mohiman completed SIR +#2017A0233017 and cited License wit three lensing rue violations, including R.325,1981(2) and R 325.1981(5). As. resultof these licensing rue violations Licensee submitted an acceptable CAP to show compliance with the cited licensing rule violations and the license to operate Cedar Ridge (hereafter referred {0 29 “the facility?) was placed under enhanced supervision for six months. Investigation Rey 10233002, 8. On November 6, 2017, Ms. Mohiman received an incident report that stated thatthe ie lam system at the facility has not been working for approximately four months. Ms. Mohrman called Administrator Melissa Hammers who confimed that the fr alarm system at tho factty was curenty under repair 9. On November 21, 2017, Ms. Mohrman spoke with Ms. Hammers and asked if maintenance man Conrad Oakly is heping wih personal care of residents Ms. Hammers confimed that Mr, Oakley does help with personal care of residents on occasion, 410.0n November 28, 2017, Ms. Mohiman made an unannounced visit to the faciity and observed that the facilty was caring for 24 residents, including two residents that required a two person assist and two residents that have dementia and are elopement risks. Ms. Mokrman spoke with staff members Kimberly Keyes, Kim Wartella and Lynn Bares, Ms. Barnes stated that she has been employed atthe facity since the facity has been licensed and further stated that when staff members callin sick the facility has no one to cover theemployee shifts. Ms. Bames confirmed that Mr. Oakley does provide care to residents when the facility s short-statfed. Ms. Barnes stated that many staff members have quit because they do not want to work with so few staff 1 During the November 29, 2017, visit Ms. Mobrman spoke with Ms. Keyes who ‘was the medication passer on duty. Ms. Mohrman asked Ms. Keyes about resident medications and procedures. Ms. Keyes stated that sometimes staff are forced to work longer because there are not enough medication passers to cover the employee shifts. Ms. Mohrman and Ms. Keyes reviewed the medication cart and Ms. Mohrman observed that resident medications were preset in cups to be passed at lunch. Ms. Keyes acknowledged that many of ‘the medication passers set the medications in cups just as Ms. Mohrman had observed, 12, During the November 29, 2017, visit Ms. Mohrman interviewed Ms. Wartella ‘who stated that she had been employed at the facility for approximately three months. Ms. Mohrman asked Ms. Wartellaif she had participated in any fire ills at the facity during her employment and Ms. Wartella admitted that she had not. 13, On December 29, 2017, Ms. Mohrman received a phone call from Resident N informing her that there was only one staff member on duty because the other staff member on duty quit 14.0n December 30, 2017, Ms. Mohrman spoke with authorized Representative Luke Zhang who stated that on December 29, 2017, an additional staff member came to the facilly to cover for the staff member who quit. Ms, Mohrmanreviewed the staff schedule which confirmed tha there were two staf members fon duty on December 29, 2017, but the requirement forthe faclity isto have three staff members on duty due to the level of needs ofthe residents. The facity has two residents that require a two-person transfer and an additional {wo residents with dementia that are elopement risks. When the two staff members are tending to one ofthe two-person transfer residents there are no staff members present to supervise the remaining residents. 46.0n January 9, 2018, Ms. Mohrman made an unannounced visit tothe facity and when she opened the door at the main entrance the facity alarm did not sound, There were no staff members in the commen area and Ms. Mohrman waited five minutes before Ms, Bames entered the commen area. Ms Mohrman inetructod Me. Barnes to tur the alarm back on to monitor the doors for Resident B and Resident K 16, During the January 9, 2018, visto the actly Ms. Mohrman reviewed Resident N's fla and observed that his birthdate is February 10, 1967. Ms. Mohrman spoke wth Ms. Hammers and informed Ms. Hammers that since Resident Nis 50 years of age she would need to request an age waiver to adit anyone Under the age of 60 years. Ms. Mohrman spoke with Resident N and asked him ithe facility had been conducting fie dis and Resident N stated that they had just completed the fist one in several months due to the fe alam being broken, 417.During the January 8, 2018, vist othe facity there were 33 residents atthe facity with only two staff members scheduled. Ms, Mohrman confirmed thatMs, Hammers was hited as the administrator ofthe facilty which requires her ‘to Work two 12 hours shits per week as a care aide/medication passer, These responsibilties take away her abity to properly train and supervise the staff in the facilty. 18,During the January 9, 2018, visit to the facility Ms. Mohrman reviewed the resident medications and observed as-needed medications that had not been administered. Resident P's clonapin was required to be administered on January 4, 2018, but staff failed to do so. There was no documentation to explain why the clonapin had not been administered to Resident P. Resident Q's acetaminophen was administered on January 1, 2018, and again on January 2, 2018, but there was no documentation explaining when it was ‘administered or for what reason. It was discovered that Ms, Ballard was the staff person that consistently was not recording the reason for the as-needed medications. Resident O has not had her lorazepam available to her since January 4, 2018, This is a medication that should not be stopped being administered without physician approval 19.0n January 23, 2018, as a result ofthe findings of Special Investigation Report 1#2018A0233002 the Bureau of Community and Health Systems (hereafter referred to @8 “the bureau’) issued a Correction Notice Order to Licensee. Pursuant to MCL 333.20162 Licensee is banned from new admission of residents until the bureau has confirmed in writing that the requirements imposed by the bureau have been met by Licensee.‘Special Investigation Report #2018A0233009 20,0n February 26, 2018, Ms, Mohman received a telephone call from Ms. Barnes informing her thatthe facity has admitted anew resident, Resident Q who resides in room E18 of the facily. This is in direct violation of MCL 335.20162, as explained to Licensee in the Correction Notice Order issued by the bureau on January 23, 2018 21.0n February 27, 2018, Ms. Mohrman received a telephone call from staff member Natali Kuhn who stated that on February 25, 2018, there were only {wo staff members on the 7:00 pm. to 7:00 am. shift, Ms. Kuhn stated that dlring this shi staff member Shyanne Rickley let eay, leaving only sta member Ervin Malas on duty. During this shit Resident S had a seizure, was on the floor and was holped by another resident. 22.0n February 27, 2018, Ms. Mehrman received a telephone call fom Chief ks of local aw enforcement who informed Ms. Mohiman of an incident that ‘occurred at the facility on February 25, 2018, in which they responded to a call cof an unresponsive female, Resident S. When law enforcement arrived it was very chaotic at the facily and law enforcement id not transport Resident S from the facility. Chief Wiks also reported an incident that occurred approximately three weeks prior involving Resident R being found downtown at approximately 6:00 a.m. Resident R was taken tothe hospta for frostbite ang hypothermia 23,0n February 28, 2018, Ms. Mohrman received from Chief Wiks @ copy ofall 911 calls made from the facility since January 1, 2018. Ms. Mohrman reviewedthe list which revealed that between January 4, 2016, to February 25, 2018, there had been 21 calls to 911 made from the facility. Of these 21 incidents only one incident report had been issued to the bureau from the facilly. The ‘one incident that was reported was the November 2017 incident involving the fire alarm system, 24.0n February 28, 2018, Ms. Mohrman made an unannounced visit tothe facity ‘and confirmed that Resident Q had been admited to the facility after the Issuance of the Correction Notice Order. While Ms. Mohrman was atthe facility Resident Q was being verbally aggressive with facilty staff and swinging her cane at them, Ms. Mohman reviewed the facilty resident fles for Resident Q land Resident R and discovered that the facility did nat have a service pian available for ether resident and there was no assessment plan for Resident Q. Ms, Mohrman asked Ms. Hammers where the service plans and assessments ‘were for Resident Q and Resident R and Ms. Hammers replied that she does nothave time to complete these required documents due to the other tasks she has to complete. Ms. Mohrman confirmed that Resident Q was admitted to the ‘facility on February 28, 2018, and Resident Q is diagnosed with dementia, 25. During the February 28, 2018, facility visit Ms, Mohrman reviewed Resident R's file and observed that there was no medical discharge information from his hospital stay on February 9, 2018. Ms. Mohrman noticed that the fle did not have information regarding the needs of Resident F’s medications. When asked about this Ms. Hammers stated that Resident R insisted that he administer his own medications. Ms, Hammers showed Ms. Mohrman thebriefcase thet ReskdentR stores his medications in. Ms. Hammers informed MMs, Mohrman that she knows that Resident Ris not taking his medications. Ms, Mohrman asked Ms, Hammers i she had met with the doctor and obtained a writen order stating that Resident R is capable of handling his own medications and Ms. Hammers admited that she has not. Adeltionall, there was no documentation avelable to confim why the faiity was administering medications and why they no longer are 26, During the February 28, 2078, facity vist Ms, Mohrman reviewed the stat og and found a note from the 7.00 p.m. to 7:00 am. shit on February 8, 2018, stating that Resident R was not atthe facility when they arrived on shit. The resident sign out indicates that Resident Ref the faciity on February 7, 2018 4 11:30 am. Ms, Mohtman asked Ms. Hammers at what point does she call land check on Resident R's whereabouts and Ms. Hammers stated that she did not know. Ms, Mohrman asked to review the incident reports from August 2017 to this date but Ms. Hammers could not find them and Ms. Hammers stated that she did not know where they were. When asked about the February 25, 2018, incident Ms, Hammers stated that she did not receive an incident report 27.During the February 28, 2018, facilily visit Ms. Mohan spoke with Aaron Huskey, the facltyktshen manager. Wr. Huskey stated thatthe facity owes ‘$13,000.00 to Reinhart foods and he has concems regarding the food available atthe fact. Mr. Huskey stated that he has been buying bread and mik for the residents out of his own pocket. Mr. Huskey stated that he was cookingsloppy joes to "stretch" the food. Mr. Huskey identified a box of turkey burger that was donated by a local food pantry. There was no milk, very litle juice, very litle fruit and the only meat was hamburger and the turkey meat that was donated. Mr. Huskey stated that he cannot continue to try and feed 31 residents with this amount of food. Mr. Huskey provided Ms. Mohrman with copies of receipts of food purchases he has made along with a copy of the receipt of what is owed tothe food supplier. Ms. Mohrman took pictures of the {food available for the residents and observed that very litle food was in the reftigerator and freezer. 28.0n February 28, 2018, Ms. Mohrman asked Ms. Kuhn about incident reports, ‘and Ms. Kuhn stated that she has been completing them and sli 13 them under the door for Me, Hammers. Ms, Kuhn provided Ms. Mohrman with an incident report involving Resident K being found outside in her socks on February 27, 2018. Ms, Kuhn stated thet on February 27, 2018, she returned to the facity at 8:00 p.m. to help pass medications and they could not find Resident K. Ms. Kuhn stated that Resident K was found in the snow outside the west wing emergency door of the facilly and that Resident K was not ‘wearing her outdoor clothing and did not have shoes on 29.0n March 2, 2018, Ms. Mohrman made an unannounced visit othe facility and observed thatthe facilty had not gone grocery shopping or received a delivery of food, 1020,0n March 5, 2018, Ms. Mohrman received a cal from staf member Aleesha Barbeaux at7:30 am, stating that she was the only staff member atthe fait “The right shift staf left and no other staff members arrived to the facil. COUNT! ‘The conduct of Liconsee, as se forth in paragraphs 19, 20 & 24 above, evidences a wilful and substental violation ofthe order issued in sesordance wit 333.20162 License; receipt of completed application; issuance of license within certain period of time; nonrenewable temporary permit; provisional license; procedure for closing facility; order to licensee upon finding of noncompliance; notice, hearing, and status requirements; report; “completed application” defined. (6) Except as provided in part 217, the department, upon finding that a health facility or agency is not operating in accord with the requirements of its license, may: (@) Issue an order dirocting the licensee to: ()) Discontinue admissions. {ii Transfer selected patients out of the facility, {ti Reduce / (iy) Comply with specific requi certification as appropriate. (b) Through the office of the attomey general, initiate misdemeanor proceedings against the licensee as provided in section 20199(1). COUNT Il ‘The conduet of Licensee, as set forth in paragraphs 9, 10, 13, 14, 17, 21 & 30 above, evidences a willful and substantial violation of: 325.1931 Employees; general provisions. (6) The home shall have adequate and sufficient staff on duly. at all times who are awake, fully dressed, and capable of providing for resident needs consistent with the resident service plans, [Note: By this reference paragraphs 3 through 7 are incorporated into this count for the purpose of demonstrating a wilful and substantial violation of the above cited licensing rule) 1"COUNT II ‘The conduct of Licensee, as set forth in paragraphs 8 through 30 above, evidences ‘a wilful and substantial violation of R 325.1931 Employees; general provisions. @) A home shall reat a resident with dignity and his or her personal needs, including protection and safety, shall be Attended to consistent with the resident's service plan. [Note: By this reference paragraphs 3, 6 & 7 are incorporated into this count for the purpose of demonstrating a wilful and substantial violation of the above cited licensing rule] COUNTIV The conduct of Licensee, as set forth in paragraphs 24 and 25 above, evidences ‘wilful and substantial violation of R 325.1992 Rosidont medications (2) The giving, taking, or applying of prescription medications shall be supervised by the home in accordance with the resident's service plan. COUNT V The conduct of Licensee, as set forth in paragraph 11, evidences a wilful and substantial violation of: R 325.1932 Rosidont modications ) A home shall take reasonable precautions to ensure or assure that prescription medication is not used by @ person cher than the resident for whom the medication is prescribed. [Note: By this reference paragraph 3 is incorporated into this count for the purpose of demonstrating a wilful and substantial violation of the above cited licensing rule.) 2COUNT VI “The conduct of Licensee as set forth in paragraphs 8 through 19 above, evidences ‘a wilful and substantial violation of R 325.1921 Governing bodies, administrators, and supervisors. (1) The owner, operator, and governing body of a home shall do all ofthe folowing: (a) Assume full legal responsibilty for the overall conduct and ‘operation of the home. (b) Assure that the home maintains an organized program to provide room and board, protection, supervision, assistance, ‘and supervised personal care for its residents. (©) Assure the availabilty of emergency medical care required by a resident. (@) Appoint a competent administrator who is responsible for ‘operating the home in accordance with the established policies of the home. INote: By this reference paragraphs 3 and 4 are incorporated into this count for the purpose of demonstrating a wilful and substantial violation of the above cited licensing rule] COUNT VII The conduct of Licensee, as set forth in paragraphs 23 & 26 above, evidences a wilful and substantial violation of 325.1924 Reporting of incidents, accidents, elopement. (1) The home shall complete a report of all reportable incidents, accidents, and elopemonts. The incident/accident report shall ‘contain all ofthe following information: (2) The name of the person or persons involved in the incidentiaccident. (b) The date, hour, location, and a narrative description of the facts about the incidentfaccident which indicates its cause, if known, (c) The effect ofthe incident/accident on the person who was involved, the extent of the injures, if known, and if medical treatment was sought from a qualified health care professional. (@) Written documentation of the individuals notfied of the incidentiaccident, along withthe time and date. 8B