**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to consistently honor a resident's choices regarding his daily routine and failed to facilitate the ability to go outside when requested, in one of two residents reviewed for choices (Resident #117). Findings include: Resident #117 (R117) Review of the medical record reflected R117 was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis, depression, bipolar disorder, and anxiety. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/3/25, reflected R117 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/08/25 at 10:45 AM, R117 was observed dressed and seated in a motorized wheelchair. During the observation, R117 shared that he had always been a busy body and, for many years, was up and at work by 7:00 AM. He expressed that having to wait until after lunch for staff assistance to get out of bed kills something in my soul. R117 reported that this delay in receiving morning assistance has been a recurring issue and stated he recently brought it to the attention of staff. R117 stated that he required the sit to stand and staff assistance to transfer out of bed and into his chair. He further expressed feeling incredibly depressed lately. R117 shared that he greatly missed being outdoors. He stated he had been an avid outdoorsman his entire life and strongly desires sunshine and fresh air. Despite being his own responsible party, R117 stated that the facility does not allow him to go outside on his own. He reported making multiple requests for assistance to go outdoors but was consistently told by staff that he is not allowed to do so when he attempts to sign himself out. R117 emphasized that being kept in bed through the morning hours and being restricted from going outside are really messing with my mood. R117 stated that he recently reported to staff that he wanted to drive his chair in front of a bus but explained that he made the comment out of frustration after being left in bed until after 2:00 PM and had no desire to act on any plan. R117 stated it was a statement made out of frustration. R117 stated that he was being told he is now permitted from leaving the building and denied staff offering to supervise him outside. Review of a Progress Note dated 4/8/25 at 7:57 AM stated, writer spoke with resident regarding concerns-resident [R117] voiced that he would like to be an early morning get up, writer will adjust midnight get up list. Review of the Care Plan and Kardax revealed an absence of preference instructions regarding R117's desired morning routine. On 4/09/25 at 11:04 AM, R117 was observed in bed, dressed in a hospital gown. R117 expressed that he is very disappointed and anxious because he was still in bed, despite the facility promising to ensure he would be assisted out of bed in the morning at his desired time. Review of R117's Physician Ordered dated 3/24/25 revealed an active order which stated, may go loa (leave of absence). Review of the Kardax revealed a care instruction which stated monitor location while up in motorized wheelchair. Do not allow to exit facility while in motorized wheelchair. In an interview on 04/10/25 at 12:51 PM, Director of Nursing (DON) B stated that residents should be allowed up at their requested time and that staff should offer to take R117 outside when he desires.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure oral care was provided to one (R81) of two reviewed. Findings include: Review of the medical record reflected R81 admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease and essential tremor. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/20/25, reflected R81 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), had impairment on one upper extremity and one lower extremity and required setup or clean-up assistance for oral hygiene. On 04/08/25 at 11:18 AM, R81 was observed lying in bed. R81 stated their teeth had not been brushed since admitting to the facility, and staff did not provide supplies for them to be able to brush their teeth. R81 reported they would have been able to brush their own teeth, if they had the supplies. On 04/09/25 at 2:06 PM, R81 was observed in bed, watching TV. R81 denied brushing their teeth that day and stated they had not been offered set-up assistance by staff to do so. R81 reported their teeth had not been brushed throughout their admission at the facility. On 04/09/25 at 2:15 PM, Certified Nurse Aide (CNA) N reported their shift started at 7:00 AM and would end at 3:00 PM that day. CNA N reported R81 transferred via hoyer lift and had heavy care needs. CNA N reported R81 mostly required set-up assistance to brush their teeth, unless staff noticed R81 struggling. CNA N reported they had not asked R81 if they wanted to brush their teeth that day, reporting R81 did not feel well that morning. Upon observation of R81's personal care items, with CNA N, it was noted that R81's toothbrush was located in a basin, in their room. The toothbrush was in a sealed, clear, plastic package. R81 did not have toothpaste in their room, upon observation with CNA N. Review of R81's oral hygiene task for the prior 30 days reflected that on 4/9/25 at 12:50 PM, CNA N documented R81 performed oral hygiene with Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. On 04/10/25 at 1:08 PM, R81 was observed lying in bed. R81 reported they had been provided with assistance to brush their teeth the prior afternoon, after the State Agency had been in their room with staff, as well as that morning (4/10/25). R81 reported staff set them up with supplies, and they brushed their own teeth, while in bed. An open toothbrush (no longer in a sealed plastic package) and a tube of toothpaste were observed in a basin in R81's room. R81 reported their mouth had felt dirty due to not having their teeth brushed until the day prior. R81's medical record reflected an order dated, 3/17/25, for the nurse to prepare a toothbrush for oral care after medication pass in the morning and at bedtime. The March 2025 and April 2025 Medication Administration Record (MAR) reflected the order was being documented as completed. In an interview on 04/10/25 at 1:19 PM, Director of Nursing (DON) B reported residents should have been provided oral care at least once a day but could receive oral care as often as they requested. DON B reported the order for the nurse to prepare a toothbrush for oral care in the morning and at bedtime was verification that the resident had supplies for oral care to be done and that the CNA was asked to do oral care.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 134 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, reduced air quality, and inadequate sanitization of dishware and utensils. Findings include: On 04/07/25 at 09:20 A.M., An initial tour of the food service was conducted with Dietary Manager G. The following items were noted: The ceiling mounted return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill plate measured approximately 3-feet-wide by 4-feet-long. 6 of 25 food production kitchen overhead light assembly plastic lens covers were observed soiled with accumulated (dust/dirt/dead insect carcasses). Dietary Manager G indicated he would contact maintenance for necessary repairs as soon as possible. The 2022 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. One-half gallon of Kemps Lactose Free Reduced Fat 2% Milk was observed within the Hoshizaki 2-door reach-in cooler, without an effective open or discard date. The manufacturer's use-by-date was also observed to read 4-24-25. Dietary Manager G indicated the facilities date marking procedure was currently day of opening plus 6 days for a total of 7 calendar days. The 2022 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY 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 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The can opener assembly was observed soiled with accumulated and encrusted food residue. Dietary Manager G stated: I will have staff clean the opener immediately. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The atmospheric vacuum breaker was observed broken and missing the cover plate on the dish machine room hand sink faucet assembly. The 2022 FDA Model Food Code section 5-205.15 states: A plumbing system shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. The mechanical dish machine pounds-per-square-inch (psi) gauge was observed to read 45 (psi), during the final rinse cycle. The 2022 FDA Model Food Code section 4-501.113 states: The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). On 04/07/25 at 10:45 A.M., An initial tour of the facility food service pantries was conducted with Dietary Manager G. The following items were noted: Pantry (100-200 Hall): The Vissani microwave oven face plate surface was observed (etched, scored, corroded, particulate). The damaged face plate surface measured approximately 1-inch-wide by 2-inches-long. Dietary Manager G indicated he would have maintenance replace the damaged microwave oven as soon as possible. Pantry (300-400 Hall): The ice machine dispensing spout was observed mineralized with accumulated and encrusted calcium/lime deposits. Dietary Manager G indicated he would have staff thoroughly clean and sanitize the ice machine dispensing spout assembly as soon as possible. Pantry (500 Hall): The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill plate measured approximately 12-inches-wide by 24-inches-long. Dietary Manager G indicated he would have maintenance thoroughly clean and sanitize the soiled ventilation grill plate as soon as possible. Pantry (600-700 Hall): The Sharp Carousel microwave oven was observed soiled with accumulated and encrusted food residue. Dietary Manager G indicated he would have housekeeping staff thoroughly clean and sanitize the microwave oven interior as soon as possible. The window ledge laminate surface was also observed (etched, scored, missing). The damaged laminate surface measured approximately 1-inch-wide by 10-inches-long. Dietary Manager G indicated he would have maintenance perform necessary repairs as soon as possible. Pantry (600-700 Hall): The Scotsman ice machine dispensing spout was observed mineralized with accumulated and encrusted calcium/lime deposits. Dietary Manager G indicated he would have staff thoroughly clean and sanitize the ice machine dispensing spout assembly as soon as possible. On 04/09/25 at 09:00 A.M., Record review of the Policy/Procedure entitled: General Kitchen Sanitation Policy dated 03/28/2025 revealed under Policy Overview: The facilities Department of Food and Nutrition Services shall maintain kitchen sanitation through compliance with a written cleaning schedule, Food Service Department (FSD) sanitation daily rounds, and monthly sanitation audits. On 04/09/25 at 09:15 A.M., Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 11/01/2020 revealed under Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 11/01/2020 further revealed under Procedure: (1) The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 138 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and reduced air quality. Findings include: On 04/07/25 at 03:50 P.M., An environmental tour of the facility Laundry Service was conducted with Director of Maintenance H and Director of Housekeeping and Laundry Services I. The following items were noted: Two 4-feet-wide by 6-feet-long padded floor mats were observed (etched, scored, particulate), adjacent to the three commercial dryers. The worn padded floor mats were also observed attached to the flooring surface with maroon colored duct tape. Director of Maintenance H indicated he would have staff remove and replace the worn floor mats as soon as possible. The flooring surface was observed (etched, scored, particulate), adjacent to the three commercial washers. The damaged flooring surface measured approximately 7-feet-wide by 10-feet-long. Director of Maintenance H indicated he would have staff replace the worn flooring surface as soon as possible. On 04/07/25 at 04:05 P.M., The corridor carpeted surface was observed stained and soiled, adjacent to resident rooms [ROOM NUMBERS]. The stained and soiled carpet surface measured approximately 2-feet-wide by 4-feet-wide. On 04/08/25 at 10:15 A.M., A common area environmental tour was conducted with Director of Maintenance H and Director of Housekeeping and Laundry Services I. The following items were noted: 200 Hall One clean linen cart cover (pink) was observed (etched, scored, threadbare). Director of Housekeeping and Laundry Services I stated: We need to replace that cover. 300 Hall - 400 Hall Nursing Station: 2 of 6 chairs were observed (etched, scored, threadbare, particulate), exposing the inner Styrofoam padding. Activity Room: 1 of 3 office chairs were observed (etched, scored, particulate), exposing the inner Styrofoam padding. Main Dining Room: The chair railing was observed missing. The missing chair railing measured approximately 12-14 feet-long. Director of Housekeeping and Laundry Services I stated: We have vending machines coming soon to fill the space. Physical Therapy: The hand sink basin faucet assembly was observed loose-to-mount. Director of Housekeeping and Laundry Services I indicated she would contact maintenance for necessary repairs as soon as possible. 500 Hall Meadows Room: 2 of 9 clear plastic overhead light lens covers were observed soiled with dust and dirt deposits. Shower Room: The shower wand assembly was observed missing an atmospheric vacuum breaker. Director of Housekeeping and Laundry Services I indicated she would contact maintenance for necessary repairs as soon as possible. 600 Hall Shower Room Restroom: The hand sink faucet assembly was observed loose-to-mount. Director of Housekeeping and Laundry Services I indicated she would contact maintenance for necessary repairs as soon as possible. Nursing Station: The small black oscillating desk fan was observed soiled with accumulated and encrusted dust/dirt deposits. Director of Housekeeping and Laundry Services I indicated she would have staff thoroughly clean and sanitize the soiled fan as soon as possible. Dining Room Kitchenette: The lower base cabinetry exterior/interior surfaces were observed soiled with accumulated and encrusted food residue. 2 of 4 base cabinet drawers were also observed broken and enlarged from moisture exposure. Director of Housekeeping and Laundry Services I indicated she would have staff thoroughly clean and sanitize the soiled cabinetry as soon as possible. Director of Housekeeping and Laundry Services I also indicated she would contact maintenance for necessary repairs as soon as possible. On 04/08/25 at 02:05 P.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance H and Director of Housekeeping and Laundry Services I. The following items were noted: 103: The Bed-D overbed light assembly upper 48-inch-long fluorescent light bulb was observed non-functional. 202: The restroom commode base caulking was observed (etched, scored, particulate). 209: The Portable Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. The drywall surface was also observed (etched, scored, particulate), adjacent to the Bed-W headboard. The damaged drywall surface measured approximately 5-feet-wide by 5-feet-long. 304: The Portable Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. The restroom vanity countertop laminate edge was also observed missing. The damaged laminate surface measured approximately 2-inches-wide by 26-inches-long. 305: The restroom commode base caulking was observed (etched, scored, particulate). The Portable Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. 307: The restroom vanity countertop was observed (etched, scored, chipped). The damaged laminate surface measured approximately 3-inches-wide by 6-inches-long. The Portable Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. 308: The restroom vanity countertop was observed (etched, scored, chipped), adjacent to the corner edge. The damaged laminate surface measured approximately 2-inches-wide by 12-inches-long. The Portable Terminal Air Conditioning (PTAC) Unit filters were also observed soiled with accumulated and encrusted dust/dirt deposits. 403: The restroom over sink light assembly was observed non-functional. The Portable Terminal Air Conditioning (PTAC) Unit filters (2) were also observed missing from the cabinet housing. 408: The Portable Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. 409: 1 of 2 restroom light assemblies were observed non-functional. Director of Housekeeping and Laundry Services I indicated she would contact maintenance for necessary repairs as soon as possible. 503: The restroom commode base caulking was observed (etched, scored, particulate). The Bed-D (pillow, pillowcase, bed sheets, bedspread) were also observed soiled with accumulated and encrusted bodily fluids and food residue. Director of Housekeeping and Laundry Services I indicated she would have Certified Nursing Assistant (CNA) staff remove the soiled Bed-D bedding as soon as possible. 504: The restroom hand sink basin was observed draining very slow. Director of Housekeeping and Laundry Services I indicated she would contact maintenance for necessary repairs as soon as possible. 507: The restroom commode base caulking was observed (etched, scored, particulate). The Portable Terminal Air Conditioning (PTAC) Unit filters were also observed soiled with accumulated and encrusted dust/dirt deposits. The restroom vanity countertop laminate surface was further observed (etched, scored, particulate). The damaged laminate surface measured approximately 2-inches-wide by 12-inches-long. 508: The restroom commode base caulking was observed (etched, scored, particulate). 516: The restroom vanity countertop edge was observed (etched, scored, particulate). The damaged laminate surface measured approximately 2-inches-wide by 40-inches-long. The Portable Terminal Air Conditioning (PTAC) Unit filters were also observed soiled with accumulated and encrusted dust/dirt deposits. 702: The vanity countertop laminate surface was observed (etched, scored, particulate). The damaged laminate surface measured approximately 2-inches-wide by 30-inches-long. 704: The restroom commode base caulking was observed (etched, scored, particulate). The vanity countertop laminate surface edge was also observed (etched, scored, particulate). The damaged laminate surface measured approximately 2-inches-wide by 12-inches-long. 706: The restroom vanity countertop laminate edge strip was observed loose-to-mount. The damaged laminate surface measured approximately 2-inches-wide by 24-inches-long. 1 of 2 overhead light assemblies were also observed non-functional. The Bed-D overbed upper 48-inch-long fluorescent light bulb was further observed non-functional. 708: The Portable Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. The restroom commode base caulking was also observed (etched, scored, particulate). 711: The restroom vanity countertop was observed (etched, scored, particulate), adjacent to the hand sink basin. The damaged countertop surface measured approximately 2-inches-wide by 4-inches-long. The Portable Terminal Air Conditioning (PTAC) Unit filters were also observed soiled with accumulated and encrusted dust/dirt deposits. The Bed-W drywall surface was further observed (etched, scored, particulate), adjacent to the headboard. The damaged drywall surface measured approximately 3-feet-wide by 5-feet-long. On 04/08/25 at 04:40 P.M., An interview was conducted with Director of Maintenance H regarding the facility maintenance work order system. Director of Maintenance H stated: We have manual work order forms that staff fill out for maintenance and housekeeping requests. On 04/09/25 at 10:00 A.M., Record review of the Manual Work Order form dated 11/2021 revealed the following information: (1) Facility Name, (2) Department/Wing/Room, (3) Date, (4) I.D. No, (5) Work Requested, (6) Justification, (7) Material Cost, (8) Labor Cost, (9) Signature of Department Head, (10) Date Received, (11) Date Work Completed, and (12) Disposition. On 04/09/25 at 10:15 A.M., Record review of the Policy/Procedure entitled: Cycle Cleaning dated 11/01/2020 revealed under Policy: It is the policy of this facility to identify the functional areas in the facility that require cleaning and to use cycle cleaning schedules to outline the frequencies and maintain regularly scheduled environmental service tasks. Record review of the Policy/Procedure entitled: Cycle Cleaning dated 11/01/2020 further revealed under Procedure: (1) Routine cleaning of environmental surfaces and non-critical resident care items shall be performed according to a predetermined schedule and shall be sufficient enough to keep surfaces clean and dust free. On 04/09/25 at 10:30 A.M., Record review of the Policy/Procedure entitled: Maintenance Inspection dated 11/01/2020 revealed under Policy: It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. On 04/09/25 at 10:45 A.M., Record review of the Policy/Procedure entitled: Routine Cleaning and Disinfection dated 08/2022 revealed under Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. On 04/09/25 at 11:00 A.M., Record review of the Manual Work Order forms for the last 30 days revealed no specific entries related to the aforementioned maintenance concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act in one (R102) of four residents reviewed for abuse. Review of the medical record reflected R102 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, vascular dementia, and dementia with behavior disturbances. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/25, reflected R102 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of a Nursing-Progress Note dated 3/8/25 at 4:26 PM revealed Resident [R102] verbally abusing resident. Resident stated he would smack another resident. The note author was identified as Licensed Practical Nurse (LPN) T. In an interview on 3/19/25 at 1:14 PM, LPN T stated that she was familiar with R102. LPN T stated that she did write the Progress Note on 3/8/25, however, could not recall details of the verbal abuse allegation and that R102 gets into arguments with other residents often. LPN T did not report the allegation. In an interview on 3/19/25 at 1:50 PM, Nursing Home Administrator (NHA) A reported that she was unaware of the Progress Note on 3/8/25 and that the expectation would be to maintain safety of both residents and report any abuse allegations immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to, investigate allegations of abuse for one out of four residents (Residents #102). Findings Include: Review of the medical record reflected R102 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, vascular dementia, and dementia with behavior disturbances. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/25, reflected R102 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of a Nursing-Progress Note dated 3/8/25 at 4:26 PM revealed Resident [R102] verbally abusing resident. Resident stated he would smack another resident. The note author was identified as Licensed Practical Nurse (LPN) T. In an interview on 3/19/25 at 1:14 PM, LPN T stated that she was familiar with R102. LPN T stated that she did write the Progress Note on 3/8/25, however, could not recall details of the verbal abuse allegation and that R102 gets into arguments with other residents often. LPN T did not report the allegation. In an interview on 3/19/25 at 1:50 PM, Nursing Home Administrator (NHA) A reported that she was unaware of the Progress Note on 3/8/25 and that the expectation would be to maintain safety of both residents and report any abuse allegations immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for two (Resident #102 and #103) of three reviewed. Review of the medical record reflected R102 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, vascular dementia, and dementia with behavior disturbances. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/25, reflected R102 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R102's Care Plan revealed R102 ambulated independently with the use of a walker. Review of the medical record reflected R103 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included aphasia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/9/25, reflected R103 was rarely understood. On 3/17/25 at 10:47 AM, R102 was observed in his room sleeping. In an interview on 3/19/25 at 10:09 AM, Certified Nursing Assistant (CNA) O stated that one evening, she overheard R103 make a noise and overheard another male resident state, no hey, get out of here! CNA O approached the residents and observed R102 in the room R103. CNA O removed R102 from the room. CNA O stated that R102 is a wanderer, especially in the evening hours and she often hears other residents complaining about R102 going into their rooms. CNA O stated that the staff do their bets to manage R102 and is behaviors, however, lack of staff make it difficult to keep up with R102 going in and out of rooms. On 3/19/25 at 10:48 AM, Resident #106 (R106) was observed seated outside of his room. R106 resided across the hall from R102. R106 states that he sits out in the hallway often and reported that he observed the incident when R102 entered a female residents room. R106 stated [R102] goes in and out of rooms all the time, it drives me dam* nuts! In an interview on 3/20/25 at 8:51 AM, LPN Y reported that R102 is confused and can be aggressive at times. LPN Y stated that R102 tends to wander more during the evening hours and has observed R102 wandering into other residents rooms. Review of a Behavior Note dated 10/18/24 at 1:29 AM revealed R102 redirected two times out of other patient's (resident's) rooms . confusion appears to increase with the lateness of the hour . Review of a Nursing-Progress Note dated 11/7/24 at 6:34 PM revealed R102 wanders in and out of other residents rooms and bathrooms . Review of a Behavior Note dated 11/7/24 at 2:51 AM revealed R102 up many times during the night wandering in hallway. Redirected out of patient's rooms . Review of a Behavior Note dated 2/17/25 at 5:06 PM revealed R102 observed self-ambulating throughout unit with walker .wandering in other patients' rooms often . Review of a Behavior Note dated 2/18/25 at 3:57 PM revealed R102 observed attempting to enter other patient rooms . Review of R102's Care Plan revealed an absence of a Care Plan to address an effort to minimize or restrict 102 from wandering into other resident's room. Review of R103's Care Plan revealed an absence of interventions to ensure R102 does not wander back into her room again. In an interview on 3/20/25 at 12:38 PM, Director of Nursing (DON) B confirmed an absence of a Care Plan for the wandering into other rooms behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide showers per care plan for two (Resident #104, #105) of three reviewed for activities of daily living. Findings include: Resident #104 (R104) Review of the medical record reflected R104 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness and dislocation of internal left hip prothesis. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/28/25, reflected R104 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 3/17/25, at 11:26 a.m., R104 was observed in bed watching television. R104 was wearing a hospital gown and appeared ungroomed. R104 stated that she was unimpressed with the care she was receiving at the facility. She expressed concerns about not receiving showers consistently and call lights not being answered in a timely manner, sometimes waiting over an hour for assistance. R104 reported that she often resorts to using her telephone to contact the front desk to alert staff that her call light is on and she required assistance. According to R104, certified nursing assistants frequently tell her that they are understaffed and have many other residents to care for. She also stated that, particularly in the afternoon and at night, staff will intentionally leave her call light activated, preventing her from reactivating it when she needs assistance. To work around this, she contacts the front desk to request help. R104 expressed frustration regarding her scheduled shower day on Saturday. When she requested a shower, staff informed her that they did not have time, and she was instead given the option of a bed bath. She was dissatisfied with this alternative, as she wanted an actual shower and to have her hair washed. R104 stated that she requested a shower again on Sunday, which was designated as a shower make-up day, but was once more told that staff did not have time to assist her. As a result, she had not received a shower. R104 stated that if she declines a bed bath over a shower, the staff will report that R104 refused a shower. R104 stated that she does not refuse a shower, but does not accept being provided a bed bath instead of a shower for time saving purposes. R104 emphasized that this was not the first time she had experienced these issues. Review of R104's medical record revealed that the scheduled shower days were Wednesdays and Saturdays. Review of R104's Care Plan revealed R104 was a transfer assist of two staff members. Review of the Activities for Daily Living Care Plan reflected, assist to bathe/shower as needed, implemented on 8/15/24. Review of the shower task list for R104 revealed the following: 2/19/25: Marked as not applicable. 2/22/25: Marked as refused. 2/26/25: Marked as not applicable. 3/1/25: Marked as bed bath. 3/5/25: Marked as not applicable. 3/8/25: Marked for receiving a shower 3/12/25: Marked for receiving a shower 3/15/25: Marked as refused. During the week of 3/17/25, A confidential staff member (SM D) confirmed that they are a direct care staff member and stated that staffing at the facility is inadequate. SM D reported that most residents in the [NAME] and Meadows units are fully dependent on staff for care and that the facility does not take acuity into consideration when assigning staff to the units. SM D also stated that she is unable to complete her tasks as outlined in the [NAME] and Care Plan. During the week of 3/17/25, a confidential staff member (SM E) reported that they are a direct care staff member and expressed concerns about staffing levels. SM E stated that one of the Certified Nursing Assistants (CNAs) has to wrap to the adjacent unit, and due to the double doors, it is impossible to be notified of call lights from the other unit. SM E further reported that teamwork is an issue, often resulting in call lights remaining activated for extended periods without notification to the assigned CNA or nurse, especially the residents in the wrapped rooms. Additionally, SM E noted that the [NAME] and Meadows units have residents with higher acuity and behavioral needs. According to SM E, essential care tasks such as oral care, checking for brief changes, and providing showers are not being completed due to insufficient staffing. As a result, SM E has offered bed baths in place of showers. In an interview on 3/19/25 at 8:45 AM, CNA G, who primarily works second shift, stated that there is room for improvement regarding staffing levels. CNA G reported that she regularly works in the [NAME] and Meadows units and, due to the lack of staffing, there is no guarantee for the safety and care of the residents. CNA G expressed the same concern about wrapping to the adjacent unit, noting that there is no way to be notified if a call light is activated in the other unit. When asked whether she is able to complete her assigned duties, CNA G stated that it is unrealistic to complete all required care as outlined in the [NAME] and Care Plan. She further explained that the [NAME] and Meadows units house residents with higher acuity and behavioral concerns, such as wandering. Additionally, she reported that a large percentage of residents require a mechanical Hoyer lift, and finding a second staff member to assist is often very difficult. In an interview on 3/18/25 at 1:41 PM, CNA H reported that she commonly works day and afternoon shifts in the [NAME] and Meadows units. She described staffing levels as terrible and stated that she frequently observes residents who are saturated or soiled in their beds, requiring complete bed linen changes. CNA H also raised concerns about wrapping to the adjacent unit, noting that there is no way to know if a call light is activated there. She stated that call lights often remain activated for a long time. Additionally, CNA H reported that she is unable to complete all required care as outlined in the [NAME] and, to save time, she offers bed baths instead of showers. She also stated that due to staffing shortages, she is unable to take her entitled breaks. In an interview on 3/19/25 at 8:57 AM, CNA I reported that staffing is terrible. CNA I explained that most of the time, there are 80 residents that reside on the Meadows and [NAME] units and confirmed that the residents on those units are higher acuity and have behaviors. CNA I stated that the staffing is unrealistic and she has had to handle complaints from family about long call light response times. CNA I stated that she is unable to complete the tasks per the Kardax, including showers and turning and repositioning. CNA I stated it takes all the effort to ensure that the residents brief and dry which does not leave time for much else. CNA I stated that often she will discover residents wet and soiled at the beginning of her shift. In an interview on 3/20/25 at 9:43 AM, Registered Nurse (RN) C stated that the process for showers is to offer the scheduled shower and if the resident refuses, offer a bed bath. RN C stated that it was not acceptable to provide a bed bath instead of a shower if the resident is requesting a shower. In an interview on 3/20/25 at 12:38 PM, Director of Nursing (DON) B stated that the expectation would be to provide a shower to a resident that wanted a shower. Resident #105 (R105) Review of the medical record reflected R105 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness, need for assistance with personal care, and reduced mobility. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/21/24, reflected R105 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R105's care plan reflected that R105 required one person assist for transfers and staff assistance with personal hygiene. On 3/19/25 at 11:43 AM, R105 was observed in bed, wearing a hospital gown and unkempt. R105 expressed frustration because on her scheduled shower days, Tuesdays and Saturdays, she is being told staff is too busy to give her a shower, therefore R105 has no other choice but to accept a bed bath. R105 stated she wants a shower. R105 denied being offered a shower on an as needed basis or on the shower makeup day. R105 stated that she refuses to sign the shower sheet indicating that she refused a shower because she isn't refusing the shower, she's refusing the bed bath that's offered. R105 stated that this is a reoccurring problem and most recently, that on 3/18/25, she was told she had to have a bed bath instead of a shower. Review of R105's medical record shows instruction for shower days Tuesday and Saturday evening shift. Review of R105's Shower Task documentation revealed the following: 2/25/25: Marked as bed bath 3/1/25: Marked as bed bath 3/4/25: Shower given 3/8/25: Marked as bed bath 3/11/25: Resident refused 3/15/25: No documentation for scheduled shower day 3/18/25: Bed bath During the week of 3/17/25, A confidential staff member (SM D) confirmed that they are a direct care staff member and stated that staffing at the facility is inadequate. SM D reported that most residents in the [NAME] and Meadows units are fully dependent on staff for care and that the facility does not take acuity into consideration when assigning staff to the units. SM D also stated that she is unable to complete her tasks as outlined in the [NAME]. During the week of 3/17/25, a confidential staff member (SM E) reported that they are a direct care staff member and expressed concerns about staffing levels. SM E stated that one of the Certified Nursing Assistants (CNAs) has to wrap to the adjacent unit, and due to the double doors, it is impossible to be notified of call lights from the other unit. SM E further reported that teamwork is an issue, often resulting in call lights remaining activated for extended periods without notification to the assigned CNA or nurse, especially the residents in the wrapped rooms. Additionally, SM E noted that the [NAME] and Meadows units have residents with higher acuity and behavioral needs. According to SM E, essential care tasks such as oral care, checking for brief changes, and providing showers are not being completed due to insufficient staffing. As a result, SM E has offered bed baths in place of showers. In an interview on 3/19/25 at 8:45 AM, CNA G, who primarily works second shift, stated that there is room for improvement regarding staffing levels. CNA G reported that she regularly works in the [NAME] and Meadows units and, due to the lack of staffing, there is no guarantee for the safety and care of the residents. CNA G expressed the same concern about wrapping to the adjacent unit, noting that there is no way to be notified if a call light is activated in the other unit. When asked whether she is able to complete her assigned duties, CNA G stated that it is unrealistic to complete all required care as outlined in the [NAME]. She further explained that the [NAME] and Meadows units house residents with higher acuity and behavioral concerns, such as wandering. Additionally, she reported that a large percentage of residents require a mechanical Hoyer lift, and finding a second staff member to assist is often very difficult. In an interview on 3/18/25 at 1:41 PM, CNA H reported that she commonly works day and afternoon shifts in the [NAME] and Meadows units. She described staffing levels as terrible and stated that she frequently observes residents who are saturated or soiled in their beds, requiring complete bed linen changes. CNA H also raised concerns about wrapping to the adjacent unit, noting that there is no way to know if a call light is activated there. She stated that call lights often remain activated for a long time. Additionally, CNA H reported that she is unable to complete all required care as outlined in the [NAME] and, to save time, she offers bed baths instead of showers. She also stated that due to staffing shortages, she is unable to take her entitled breaks. In an interview on 3/19/25 at 8:57 AM, CNA I reported that staffing is terrible. CNA I explained that most of the time, there are 80 residents that reside on the Meadows and [NAME] units and confirmed that the residents on those units are higher acuity and have behaviors. CNA I stated that the staffing is unrealistic and she has had to handle complaints from family about long call light response times. CNA I stated that she is unable to complete the tasks per the Kardax, including showers and turning and repositioning. CNA I stated it takes all the effort to ensure that the residents brief and dry which does not leave time for much else. CNA I stated that often she will discover residents wet and soiled at the beginning of her shift. In an interview on 3/20/25 at 9:43 AM, Registered Nurse (RN) C stated that the process for showers is to offer the scheduled shower and if the resident refuses, offer a bed bath. RN C stated that it was not acceptable to provide a bed bath instead of a shower if the resident is requesting a shower. In an interview on 3/20/25 at 12:38 PM, Director of Nursing (DON) B stated that the expectation would be to provide a shower to a resident that wanted a shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake numbers MI00150030 and MI00150146. Based on observation, interview, and record review the facility failed to maintain sufficient staff to meet residents' needs timely and provide scheduled showers for three (Resident #101, #104, #105) of seven reviewed for staffing. Resident #101 (R101) Review of the medical record reflected R101 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness and contractures of the left and right hand. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/9/25, reflected R101 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R101's Care Plan reflected she required assistance of two staff members via mechanical lift for transferring. On 3/17/25 at 11:09 AM, R101 was observed in bed watching television. R101 reported that staffing sucks and often experience call light responses that are up to an hour. R101 also reported that staff will come in, ask R101 what she needs, turn off the call light without providing the requested service, and not return. R101 stated that CNAs come in and complain to R101 about being short staffed or report to R101 how many residents that they are assigned to and tell R101 she will have to just wait. R101 stated that she has sat in her own urine and feces for extended periods of time due to her call light not being answered in an acceptable time frame. Resident #104 (R104) Review of the medical record reflected R104 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness and dislocation of internal left hip prothesis. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/28/25, reflected R104 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 3/17/25, at 11:26 a.m., R104 was observed in bed watching television. R104 was wearing a hospital gown and appeared ungroomed. R104 stated that she was unimpressed with the care she was receiving at the facility. She expressed concerns about not receiving showers consistently and call lights not being answered in a timely manner, sometimes waiting over an hour for assistance. R104 reported that she often resorts to using her telephone to contact the front desk to alert staff that her call light is on and she required assistance. According to R104, certified nursing assistants frequently tell her that they are understaffed and have many other residents to care for. She also stated that, particularly in the afternoon and at night, staff will intentionally leave her call light activated, preventing her from reactivating it when she needs assistance. To work around this, she contacts the front desk to request help. R104 expressed frustration regarding her scheduled shower day on Saturday. When she requested a shower, staff informed her that they did not have time, and she was instead given the option of a bed bath. She was dissatisfied with this alternative, as she wanted an actual shower and to have her hair washed. R104 stated that she requested a shower again on Sunday, which was designated as a shower make-up day, but was once more told that staff did not have time to assist her. As a result, she had not received a shower. R104 stated that if she declines a bed bath over a shower, the staff will report that R104 refused a shower. R104 stated that she does not refuse a shower but does not accept being provided a bed bath instead of a shower for time saving purposes. R104 emphasized that this was not the first time she had experienced these issues. Resident #105 (R105) Review of the medical record reflected R105 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness, need for assistance with personal care, and reduced mobility. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/21/24, reflected R105 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R105's care plan reflected that R105 required one person assist for transfers and staff assistance with personal hygiene. On 3/19/25 at 11:43 AM, R105 was observed in bed, wearing a hospital gown and unkempt. R105 expressed frustration because on her scheduled shower days, Tuesdays and Saturdays, she is being told staff is too busy to give her a shower, therefore R105 has no other choice but to accept a bed bath. R105 stated she wants a shower. R105 denied being offered a shower on an as needed basis or on the shower makeup day. R105 stated that she refuses to sign the shower sheet indicating that she refused a shower because she isn't refusing the shower, she's refusing the bed bath that's offered. R105 stated that this is a reoccurring problem and most recently, that on 3/18/25, she was told she had to have a bed bath instead of a shower. During the week of 3/17/25, A confidential staff member (SM D) confirmed that they are a direct care staff member and stated that staffing at the facility is inadequate. SM D reported that most residents in the [NAME] and Meadows units are fully dependent on staff for care and that the facility does not take acuity into consideration when assigning staff to the units. SM D also stated that she is unable to complete her tasks as outlined in the [NAME]. During the week of 3/17/25, a confidential staff member (SM E) reported that they are a direct care staff member and expressed concerns about staffing levels. SM E stated that one of the Certified Nursing Assistants (CNAs) has to wrap to the adjacent unit, and due to the double doors, it is impossible to be notified of call lights from the other unit. SM E further reported that teamwork is an issue, often resulting in call lights remaining activated for extended periods without notification to the assigned CNA or nurse, especially the residents in the wrapped rooms. Additionally, SM E noted that the [NAME] and Meadows units have residents with higher acuity and behavioral needs. According to SM E, essential care tasks such as oral care, checking for brief changes, and providing showers are not being completed due to insufficient staffing. As a result, SM E has offered bed baths in place of showers. In an interview on 3/19/25 at 8:45 AM, CNA G, who primarily works second shift, stated that there is room for improvement regarding staffing levels. CNA G reported that she regularly works in the [NAME] and Meadows units and, due to the lack of staffing, there is no guarantee for the safety and care of the residents. CNA G expressed the same concern about wrapping to the adjacent unit, noting that there is no way to be notified if a call light is activated in the other unit. When asked whether she is able to complete her assigned duties, CNA G stated that it is unrealistic to complete all required care as outlined in the [NAME]. She further explained that the [NAME] and Meadows units house residents with higher acuity and behavioral concerns, such as wandering. Additionally, she reported that a large percentage of residents require a mechanical Hoyer lift, and finding a second staff member to assist is often very difficult. In an interview on 3/18/25 at 1:41 PM, CNA H reported that she commonly works day and afternoon shifts in the [NAME] and Meadows units. She described staffing levels as terrible and stated that she frequently observes residents who are saturated or soiled in their beds, requiring complete bed linen changes. CNA H also raised concerns about wrapping to the adjacent unit, noting that there is no way to know if a call light is activated there. She stated that call lights often remain activated for a long time. Additionally, CNA H reported that she is unable to complete all required care as outlined in the [NAME] and, to save time, she offers bed baths instead of showers. She also stated that due to staffing shortages, she is unable to take her entitled breaks. In an interview on 3/19/25 at 8:57 AM, CNA I reported that staffing is terrible. CNA I explained that most of the time, there are 80 residents that reside on the Meadows and [NAME] units and confirmed that the residents on those units are higher acuity and have behaviors. CNA I stated that the staffing is unrealistic and she has had to handle complaints from family about long call light response times. CNA I stated that she is unable to complete the tasks per the Kardax, including showers and turning and repositioning. CNA I stated it takes all the effort to ensure that the residents brief and dry which does not leave time for much else. CNA I stated that often she will discover residents wet and soiled at the beginning of her shift. In an interview on 3/19/25 at 10:25 AM, Licensed Practical Nurse (LPN) EE reported that staffing is troubling at times, especially for the CNAS. LPN EE stated that the nurses have to wrap to the adjacent unit that's that it is difficult to care for people on another unit behind double doors, which can result in delay of being notified and/or providing care. Review of the medical record reflected R105 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness, need for assistance with personal care, and reduced mobility. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/21/24, reflected R105 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R105's care plan reflected that R105 required one person assist for transfers and staff assistance with personal hygiene. On 3/19/25 at 11:43 AM, R105 was observed in bed, wearing a hospital gown and unkempt. R105 expressed frustration because on her scheduled shower days, Tuesdays and Saturdays, she is being told staff is too busy to give her a shower, therefore R105 has no other choice but to accept a bed bath. R105 stated she wants a shower. R105 denied being offered a shower on an as needed basis or on the shower makeup day. R105 stated that she refuses to sign the shower sheet indicating that she refused a shower because she isn't refusing the shower, she's refusing the bed bath that's offered. R105 stated that this is a reoccurring problem and most recently, that on 3/18/25, she was told she had to have a bed bath instead of a shower. In an interview on 3/20/25 at 1:45 PM, Staffing Coordinator (SC) DD reported that staffing is determined by census of the facility. When asked if acuity was discussed when determining sufficient staffing for the unit, SC DD denied talking about acuity in relation to staffing.

This citation pertains to Intake MI00147863 Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 (R203) of 4 residents reviewed which would include intervention for communication and coordination with endocrinology for management of diabetes resulting in the potential for a lack of needed care. Findings include: Review of the Electronic Medical Record (EMR) revealed that R3 had an admission date of 10/10/22. R3 had the following pertinent diagnoses: Type II Diabetes (a condition due to a problem with the way the body regulates and uses glucose), Malignant Neoplasm of the left kidney (a cancerous tumor), Malignant Neoplasm of the lung, Malignant Neoplasm of the Pancreas, and Malignant Neoplasm of the bone. According to the EMR R3 was receiving cancer treatment and also was under the care of an endocrinologist (a specialist who diagnoses and treats conditions related to hormones and endocrine glands). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/4/24 revealed R201 scored 15 out of 15 indicating intact cognition on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 8/2/24 R3 discharged from the facility. According to a Physician's Team C note entered the previous day (8/1/24) was seen on that day with a plan for transfer to another facility. Further review of the EMR revealed an order dated 3/22/24 with instructions regarding blood glucose levels to contact the endocrinology clinic in the event of the following: If pt (patient).having frequent high or low blood sugar levels (aim for glucose of 100-200mg/dl). The order included the telephone number of the endocrinology clinic. Review of the care plan for R3 dated 1/20/24 included an entry addressing diabetes care but did not include the intervention for communicating and coordinating with the endocrinologist. On 11/21/24 at 4:25 PM during interview with the Director of Nursing (DON) the care plan review was discussed and the lack of entry regarding the communication and coordination of care. The DON said that is not something that would usually be added, but it is something to look at. Review of an article published by the Joint Commission in 2020 states in part, Comprehensive care plans are dynamic documents maintained by an interdisciplinary team that contain specific, actionable information for clinicians and staff across multiple care settings. And according to an article published by NurseJournal.org in 2024 states in part, Nursing care plans are individualized and ensure consistency for nursing care of the patient, document patient needs and potential risks, and help patients and nurses work collaboratively toward optimal outcomes.

This citation pertains to Intake MI00147863 Based on interview and record review the facility failed to follow physician's order for communication and coordination with endocrinology for management of diabetes care for 1 (R3) of 4 residents reviewed resulting in high glucose levels. Findings include: Review of the Electronic Medical Record (EMR) revealed that R3 had an admission date of 10/10/22. R3 had the following pertinent diagnoses: Type II Diabetes (a condition due to a problem with the way the body regulates and uses glucose), Malignant Neoplasm of the left kidney (a cancerous tumor), Malignant Neoplasm of the lung, Malignant Neoplasm of the Pancreas, and Malignant Neoplasm of the bone. EMR R3 was receiving cancer treatment and also was under the care of an endocrinologist (a specialist who diagnoses and treats conditions related to hormones and endocrine glands). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/4/24 revealed R201 scored 15 out of 15 indicating intact cognition on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Nurse On 8/2/24 R3 discharged from the facility. According to a Physician's Team C note entered the previous day (8/1/24) was seen on that day with a plan for transfer to another facility. Further review of the EMR revealed an order dated 3/22/24 with instructions regarding blood glucose levels to contact the endocrinology clinic in the event of the following: If pt (patient).having frequent high or low blood sugar levels (aim for glucose of 100-200mg/dl). The order included the telephone number of the endocrinology clinic. Further review of the EMR revealed the following documented blood glucose levels: On 7/4/24 blood glucose levels were 329 at 9:05 AM, 419 at 12:22 PM and 312 at 5:29 PM. There were no progress notes on this date to indicate that the endocrinology clinic was notified of high glucose levels. On 7/5/24 blood glucose levels were 332 at 1:34 PM and 337 at 8:33 PM. There were no progress notes on this date to indicate that the endocrinology clinic was notified of high glucose levels. On 7/6/24 blood glucose levels were 282 at 9:52 AM, 264 at 8:33 PM and 225 at 4:53 PM. There were no progress notes on this date to indicate that the endocrinology clinic was notified of high glucose levels. On 7/7/24 blood glucose levels were 247 at 8:26 AM, 354 at 11:26 AM, 251 at 5:27 PM, and 306 at 8:02 PM. There were no progress notes entered on this date to indicate the elevated blood glucose levels were addressed with endocrinology. On 7/8/24 blood glucose levels were 257 at 8:13 AM, 238 at 12:13 PM, 260 at 5:00 PM, and 198 at 9:21 PM. There were no progress notes to indicate communication with endocrinology. On 7/9/24 blood glucose levels were 226 at 8:04 AM, 293 at 11:53 AM, and 277 at 5:04 PM. There were no progress notes to indicate communication with endocrinology. EMR review of the physician's orders also revealed no new physician's orders written during this 6-day period. Further review of the EMR revealed a note entered 7/19/24 by Medical Doctor (MD) O which stated the following: I spoke with the patient and her daughter for over 30 minutes to address her concerns about her blood sugar. Her endocrinologist was contacted for updated insulin regimen and her BS (blood sugar) has been appropriately trending downwards into normal limits. On 11/21/24 at 10:53 PM during interview with Nurse Practitioner (NP) K the blood glucose monitoring and care were asked about. NP K explained their current physicians group took over at the end of June or beginning of July and NP K recalled that R3 was a cancer patient also receiving steroids at the time. NP K said for those reasons endocrinology was monitoring R3 closely. We were communicating back and forth and said there had been a change in insulin dosage due to a change in steroid dosage. The adjustment was a combination of us and endocrinology, NP K said. NP K said, I don't know how often endocrinology was being contacted. On 1/21/24 at 3:43 PM during interview with the Director of Nursing (DON) B the records for the dates 7/4/24 - 7/9/24 were reviewed. During the discussion concerning communication and coordination of care services with endocrinology which appeared (based on documentation) to be lacking, DON B said It does and that It is a concern, but I want to make it clear the physician's group is here Monday through Friday. According to an article published by Oncology Nursing in 2017 titled Importance of Glycemic Control in Cancer Patients with Diabetes: Treatment through End of Life stated in part, Cancer patients with diabetes are at increased risk for developing infections, being hospitalized , and requiring chemotherapy reductions or stoppages.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pertaining to Intake MI00145739: Based on interview and record review the facility failed to administer medications as ordered for one (R2) of three reviewed, resulting in R2's strong dissatisfaction with care, final refusal of continued stay, and resident leaving the facility to obtain medical care. Findings include: On 8/2/24 record review of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with pertinent diagnoses of Infection following a Procedure, Presence of Aortocoronary Bypass Graft, and Presence of Prosthetic Heart Valve. According to an MDS dated [DATE] R2 had a Brief Interview for Mental Status (BIMS) of 15/15 indicating intact cognition. On 8/2/24 at 11:20 AM a telephone interview with R2 was held. R2 explained I had C Difficile. (Clostridioides Difficile is a bacterium which causes diarrhea and colon damage). R2 explained the medicine for C Difficile was supposed to be given every 6 hours and that throughout the stay at least 3 doses were missed. R2 expressed dissatisfaction with care because throughout his stay at the facility medications were frequently delayed and R2 considered care substandard. R2 reported he left the facility and went back to the hospital for treatment. Review of the Medication Administration Record (MAR) revealed R2 was ordered to receive Vancomycin (antibiotic) 125 milligrams by mouth every 6 hours for C-Diff for 14 days beginning on 6/25/24. The MAR revealed R2 missed doses on 7/4/24 at 12:00 AM, 6:00 AM, and 12:00 PM. Review of the progress note entered by Licensed Practical Nurse (LPN) C on 7/3/24 at 11:23 PM revealed Vancomycin was not administered because it was out of stock and an order was put in with pharmacy. Record review of the EMR further revealed a note entered by Licensed Practical Nurse (LPN) C 7/4/24 at 2:14 AM stating the following: patient expressed he was angry because he had to miss a dose of vancomycin due to it being out and not reordered. I did call the pharmacy to get the prescription refilled and explained the situation to the patient. Review of the progress note entered by Licensed Practical Nurse (LPN) C on 7/4/24 at 5:23 AM revealed Vancomycin was not administered because it was on order from the pharmacy. Record review of the EMR further revealed a note entered by Licensed Practical Nurse (LPN) D 7/4/24 at 1:42 PM which documented the following: resident's assigned nurse requested writer to speak to resident. resident is upset and would like to leave AMA. Record review of the EMR further revealed a note entered by LPN E at 1:43 PM which documented the following: Vancomycin HCl Oral Capsule 125 MG Give 1 capsule by mouth every 6 hours for c-diff for 14 Days. Patient refused medication. Record review of the EMR further revealed a note entered by LPN E at 1:47 PM which documented that resident had expressed upset. over missed medication the previous night and then early morning. LPN E attempted to talk with R2 about the situation and R2 responded by becoming . increasingly upset. R2 called a family member to pick him up. According to the note R2 refused to sign AMA paperwork. On 8/7/24 at 9:23 AM a telephone interview was held with LPN C who recalled the events documented 7/3/24 and 7/4/24. LPN C recalled that R2 got . really upset. because LPN C had found in the medication cart an empty box when the Vancomycin was due. When LPN C was asked about back up medication she explained it was later known to her back up medication (Vancomycin) had been available in the building. On 8/7/24 at approximately 11:45 AM during interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) the dissatisfaction of R2 was discussed and the particular concern that caused him to leave the facility on 7/4/24. The DON talked about the holiday weekend this occurred and explained the PYXIS (an automated medication dispensing system) had been the backup system for medication and DON stated, There was no available backup in the building, they had used it all referring to the Vancomycin. On 8/7/24 the pharmacy was contacted, and the representative said a copy of the medication record of type and amount of (Vancomycin) which was in the PYXIS on 7/4/24 was in the process of being emailed to administration. Review of the Transactions by Item/Procedure report from the pharmacy revealed the facility had eight capsules of Vancomycin 125 milligrams in stock at the time R2 was due to receive the medication on 7/4/24. On 8/7/24 at 1:46 PM a subsequent interview with the DON revealed there had been backup medication (Vancomycin) available in the PYXIS on 7/3/24 and 7/4/24 which could have been used and that fact had not been known until the pharmacy data sheet had been requested during survey and emailed during survey. The DON talked about having had a conversation with LPN C who confirmed the fact that there had been a lack of understanding concerning the PYXIS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a confidential Resident Council meeting on 3/21/2024 at 12:45 PM, five of seven residents reported that staff talk on their phones with ear buds on when they are working and in resident rooms. They stated that they also have watches on and talk through it when they should be helping residents. One resident reported that a CNA (certified nursing assistant) had ear buds on and was talking on the phone the entire time while caring for him. Five residents also stated that staff don't wear name tags or it's flipped the other way so they don't know who was taking care of them and we can't make a complaint about them being on the phone because we don't know their name and if you ask them their name, they get an attitude with you. One resident said agency staff was worse because they don't wear name tags. During an interview on 3/21/2024 at 2:57 PM, the Nursing Home Administrator (NHA) A said that she wasn't aware of ongoing concerns regarding staff being on phones and she said, in March at the Resident Council meeting they said things were getting better. NHA A said that she was working on getting new name tags for staff. NHA A also said that they just started using agency staff and it's challenging with them. On 3/22/2024 at 12:55 PM, NHA A stated in an email that they do not have a policy regarding cell phone use in resident care areas. Based on observation, interview, and record review, the facility failed to demonstrate respect and dignity for 2 (Resident #55 and #78) of 2 residents reviewed for dignity, and 5 of 7 in the confidential group meeting, resulting in feelings of frustration and/or unmet resident care needs. Findings include: Resident #78 Review of the medical record revealed that Resident #78 (R78) was admitted to facility on 1/26/24 with diagnoses including gastrointestinal tumor, malignant neoplasm of prostate, unspecified dementia, psychotic disorder with hallucinations, and adult failure to thrive. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/31/24 revealed a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). Section F reflected that it was very important to R78 to choose what clothes to wear. Section GG of the same MDS revealed that R78 required setup assist with eating; moderate assistance with toileting and upper body dressing; and maximal assist with bathing, lower body dressing, and personal hygiene. In an observation and interview on 3/19/24 at 1:41 PM, R78 was observed lying in bed, on their back, dressed in a long-sleeved navy-blue sweater with dried white, crusty material noted at the neckline and to extend down the right side of shirt to bottom edge as well as onto the right shirt sleeve from the elbow region to the cuff. R78 was observed to have a white, incontinency brief in place but was otherwise bare from the waist down. R78 opened their eyes when name their name was called, and verbalized Hi and reported that he did not want to go to school without pants on. On 3/19/24 at 2:56 PM, a Resident Representative interview was completed with R78's Responsible Party (RP) J. RP J stated that he was able to visit his father daily, that he had been getting good care but was concerned that since last Friday (3/15/24), R78 had been dressed in the same dirty sweater. RP J stated that on Friday, 3/15/24, the staff had assisted R78 in dressing in the blue sweater and that he had observed him to have the same blue sweater on during his daily visits on Saturday (3/16/24), Sunday (3/17/24), Monday (3/18/24), and again today (Tuesday, 3/19/24). RP J stated the sweater had become increasingly dirty with each passing day, had dry, crusted food across the front, and that he had requested both yesterday and today (3/19/24) for the sweater to be changed and had been told by staff that they would get to it. Per RP J, R78 was a very proud man and that having dirty clothes on would for sure be a dignity issue for his dad as was his normal routine to shave and put on clean clothes daily and that he would be frustrated and embarrassed had he not been confused. On 3/19/24 at 3:31 PM, R78 was observed lying in bed, on their right side, with their legs swung out to the right side of the bed with their bare feet resting on floor. R78 was observed with the same blue sweater in place with dried, white crusty material across the front right side and sleeve, but was otherwise observed without clothes from the waist down. A white incontinency brief was observed on the floor at R78's feet. R78 reported that he needed to get cleaned up for the day and would then be on his way. On 3/20/24 at 7:41 AM, R78 was observed lying in bed, on their back, with the head of bed at an approximate 30-degree angle. R78 was dressed in the same long-sleeved navy-blue sweater with dried, white crusty material continuing to be observed on entire front right side of shirt and at right sleeve. R78 was observed to have a white incontinency brief in place but was otherwise without clothing from the waist down. R78 was awake and alert but confused stating that he was just resting a bit before he got cleaned up and dressed for work. On 3/20/24 at 9:29 AM, R78 was observed lying in bed, on their back, with their head of bed positioned at an approximate 75-degree angle. A clothing protector was observed to be fastened around R78's neck covering the front of the same long-sleeved navy-blue sweater. Dried white, crusty material continued to be observed at R78's right shirt sleeve. Resident #55 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], R55 was admitted to the facility on [DATE] with diagnosis that included seizure disorder. R55 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) assessment. On 03/19/24 at 12:45 pm during an interview with R55, he reported he had a concern with the staffs chronic use of cell phones while providing care was upsetting to him. R55 elaborated that he believes the fact most staff do not wear name tags, exacerbates the issue. On 03/21/24 09:12 AM, during an interview with Registered Nurse (RN) V reported she was aware of complaints that staff talk on their phones/watches, and utilize the use of ear buds to try to conceal it. RN V stated for the most part this was agency staff.

Based on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting, resulting in unresolved concerns and unmet needs of residents. Findings include: During a confidential Resident Council meeting on 3/21/2024 at 12:45 PM, four of seven residents reported that call light concerns have been brought up for months in Resident Council meetings and the facility doesn't follow up on the resolutions and the problem isn't fixed. Six of seven residents stated that call lights have been an issue for at least 6 months. They stated that afternoons, midnights, and weekends are bad where they have to wait for 1 1/2 to 2 hours to get help. One resident said, Staff don't seem to care and they say that they will be right back and they don't come back or they go to get another aide and turn off the light and forget. Five of seven residents reported that staff talk on their phones with ear buds on when they are working and in resident rooms. They stated that they also have watches on and talk through it when they should be helping residents. One resident reported that a CNA (certified nursing assistant) had ear buds on and was talking on the phone the entire time while caring for him. Review of the Resident Council monthly meeting notes from October 2023 to March 2024 revealed that call lights were brought up as a concern at the monthly meetings on 10/4/2023, 12/6/2023, 1/3/2024, 2/6/2024 and 3/5/2024. Review of the Resident Council monthly meeting notes from October 2023 to March 2024 revealed that staff talking on their phone was brought up as a concern at the monthly meetings on 1/3/2024 and 2/6/2024. Review of resident concern forms (separate from Resident Council concerns) from October 2023 to March 2024 revealed additional call light concerns dated 10/24/2023, 11/12/2023, 12/18/2023, 12/28/2023, 2/12/2024, 2/13/2024, 2/20/2024, 3/1/2024, 3/5/2024 and 3/13/2024. During an interview on 3/21/2024 at 2:57 PM, Activities Manager (AM) AL stated that she was aware of concerns with call lights and phones and she said that sometimes these concerns come and go from month to month. During an interview on 3/21/2024 at 2:57 PM, the Nursing Home Administrator (NH) A said that she was the Grievance Official and that she attended the Resident Council meeting on 2/6/2024. NH A stated that she wasn't aware of ongoing concerns regarding call lights and staff being on phones and said, In March at the Resident Council meeting they said things were getting better. Review of the concern form from Resident Council dated 3/5/2024, AM AL documented under concern, council voiced that call lights have gotten better in the past month but they still have to wait long wait times especially in the evenings and nights. Review of the Investigations of Grievances Policy with an approved date of 10/1/2022 Under compliance guidelines #4, revealed It is the responsibility of the Administrator as the designated grievance official for the facility to review each written grievance for proper investigation, follow-up and resolution. Resolution of the grievance will be relayed to the complainant upon completion. On 3/22/2024 at 12:55 PM, NH A stated in an email that they do not have a policy regarding cell phone use in resident care areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the accuracy of one discharge Minimum Data Set (MDS) assessment for one resident (resident #122) of 2 reviewed for discharge. Findings include: According to the clinical record, including the Minimum Data Set (MDS) dated ARD 2/16/24- completed 3/1/24 reflected R122 was admitted to the facility on [DATE]. The discharge MDS reflected section A0310 question F and G reflected R122 had a planned discharge and return to the facility was not anticipated. Question A.2105 of the MDS reflected R122 was transferred to the hospital. Review of the Nurses progress notes dated 2/16/24 reflected R122 was discharged home with his wife. On 03/26/24 at 10:01 AM, during an Interview with Registered Nurse (RN) U she confirmed R122 was discharged home and MDS that was completed 03/01/24 was coded incorrectly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to confirm that the Pre-admission Screening (PAS)/Annual Resident Review (ARR) (PASARR) Level I determination request was sent to the Community Mental Health Service Program (CMHSP) for a level II Omnibus Budget Reconciliation Act (OBRA) evaluation for one (Resident #26 ) of two reviewed for PASARR, resulting in the potential for delayed mental health services and unmet psychosocial needs. Findings include: Resident #26 (R26) Review of the medical record revealed Resident #26 (R26) was initially admitted to the facility on [DATE] with diagnoses that included unspecified Dementia with psychotic disturbance and Schizophrenia. According to Resident #26 (R26)'s Minimum Data Set (MDS) dated [DATE], revealed R26 scored 06 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R26 required assistance with toileting, showering/bathing, getting dressed and personal hygiene. R26 can be resistant to participating with ADL (activities of daily living) care. Record review revealed a Preadmission screening(PAS), Annual Resident Review (ARR) dated 9/29/23 reflected ARR with indication that R26 had current diagnoses (dx) of mental illness, had received treatment for mental illness, had routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days, and there was presenting evidence of mental illness or dementia with explanation noted to state, Resident has a dx of dementia, schizophrenia, bipolar disorder, and insomnia. Resident is currently taking Risperdal 0.5mg (milligrams) every day, fluoxetine hcl 20mg every day and trazodone hcl 150mg every night at bedtime. No 3878 noted for 9/29/23 3877. During an interview on 03/22/24 at 08:11, Social Worker (SW) W stated the Pasarr for 05/23 may have been missed and was still looking for the 09/23 Pasarr 3878. SW W stated they merged systems, and they are still trying to locate it. SW W stated she would have an update to this writer that afternoon. SW W had been looking for this document for 2 days. Record review on 03/22/24 revealed the 05/23 3878 Pasarr was completed and uploaded to the medical record. The 09/23 3878 was not completed within the time frame necessary. The 09/23 3878 was completed on 03/21/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement comprehensive care plans for 2 (Resident #78 and Resident #110) of 26 residents reviewed, resulting in the potential for unmet care needs, weight loss and increased injury risk with recurrent falls. Findings include: Resident #78 Review of the medical record revealed that Resident #78 (R78) was admitted to facility on 1/26/24 with diagnoses including gastrointestinal tumor, malignant neoplasm of prostate, unspecified dementia, psychotic disorder with hallucinations, and adult failure to thrive. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/31/24 revealed a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). Section F reflected that it was very important to have R78 to choose what clothes to wear. Section GG of the same MDS revealed that R78 required setup assist with eating; moderate assistance with toileting and upper body dressing; and maximal assist with bathing, lower body dressing, and personal hygiene. On 3/20/24 at 7:41 AM, R78 was observed lying in bed, on their back, with the head of bed at an approximate 30-degree angle. The bed was noted to be positioned at knee height level. R78 was awake and alert but confused stating that he was just resting a bit before he got cleaned up and dressed for work. On 3/20/24 at 9:29 AM, R78 was observed lying in bed, on their back, with the head of bed positioned at an approximate 75-degree angle and height of bed at knee level. R78 was observed to have their eyes open pulling at a white bed sheet covering their legs and waist. On 3/20/24 at 12:30 PM, R78 was observed to be lying in bed, on their back, with the head of bed positioned at an approximate 30-degree angle and height of bed at knee level. R78 was awake and alert but confused stating, I'm here in this area but unable to elaborate further. Review of R78's Incident Report dated 3/19/24 at 11:45 PM indicated that R78 had an un-witnessed fall with the Nursing Description within the report and a Nursing Progress Note in R78's medical record dated 3/20/24 at 1:04 AM both stating, .called to room by assigned CENA [Competency Evaluated Nurse's Aide]. The resident was observed on floor next to his bed laying on his rt. [right] side. Resident immediately assessed for injury. No injury found .Pt [patient] assisted back to bed by 2 CENAs .New intervention s/p [status post] fall: Low Bed. Review of R78's Fall Care Plan Focus indicated, At risk for falls due to impaired balance/poor coordination, poor safety awareness, potential medication side effects . with an associated Intervention dated 3/19/24 which reflected, Low bed. Review of R78's [NAME] (tool used by the Certified Nurse Aide/CNA/CENA to guide them as to the care needs of a specific resident) within the section titled Safety indicated, Low bed. In an observation and interview on 3/20/24 at 2:20 PM, Certified Nurse Aide (CNA) H was observed to exit R78's room. CNA H confirmed familiarity with R78 and that she was his assigned aide that date since the start of her shift at 9:30 AM. Per CNA H, R78 required extensive assist of 1 to 2 staff members with all care including bed mobility, transfers, oral care, and dressing and was incontinent of both bowel and bladder requiring assist with incontinency care and brief changes. CNA H denied knowledge of whether R78 had experienced any recent falls, denied that she had received shift report from off-going CNA or from the assigned nurse upon arrival to the unit and that she had not yet had a chance to review R78's [NAME] since she had arrived at work. CNA H again reiterated that, to her knowledge, R78 had experienced no recent falls but because of his confusion had positioned his bed at the lowest level upon completion of incontinency care just now although stated that she was unaware if R78's [NAME] indicated to place the bed in that position or not. Upon review, CNA H stated that R78's [NAME] indicated low bed, was unaware of the position R78's bed had been in throughout the morning but confirmed that she had just placed it in the low position. . In an interview on 3/20/24 at 2:57 PM, Registered Nurse/Assistant Director of Nursing (RN/ADON) C stated that any resident incident including falls would be passed on in nurse-to-nurse shift report and that the assigned CNA would be alerted to a resident fall or any other change in condition by the assigned nurse. RN/ADON C further stated that any new interventions would be included in the care plan linked to the [NAME] with the expectation that the CNAs review the [NAME] at that start of each shift and implement the indicated interventions. RN/ADON C stated that it would be her expectation that R78's bed always be maintained in the lowest position apart from care provision, as outlined on R78's care plan and [NAME] post fall on the night of 3/19/24. Review of the facility policy titled, Care Plan - Comprehensive and Revision with an 8/25/23 date of revision stated, Policy Overview: A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Review of the facility policy titled, Fall Management Guidelines with a 12/13/23 issue date stated, Policy Overview: The purpose of this policy is to provide guidelines to assist with fall risk identification and fall management of residents in the facility .Care Planning: The facility staff, with input of the attending physician, will implement a resident-centered comprehensive care plan that addresses the fall management program, the goal for fall management, individualized interventions .and the plan for reduction of risk and or risk for injury related to falls . Resident #110 Review of the facility's policy titled Weights with a revision date of 2/1/24 reflected the guidelines for obtaining weights. The policy stated weights are obtained upon admission and then weekly for a total of four weeks . Review of an admission Record revealed Resident #110 (R110) admitted to the facility on [DATE] with diagnoses which included repeated falls, muscle weakness, depression, pressure ulcers, severe protein-calorie malnutrition, and other drug induced secondary Parkinsonism. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/18/24, reflected R110 scored 11 of out 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Care Plan reflected R110 was a one person assist for most activities of daily living. In an observation and interview on 03/26/24 at 8:32 AM, R110 was observed in bed with his head of bed elevated and attempting to feed himself breakfast. A scoop of scrambled eggs and a scoop of ground sausage was observed in a clamshell container on R110's bedside table. 1% milk was observed on the table with a straw and a Styrofoam cup with a lid and no straw. R110 had 4 apple juice containers on the table and a condiment cup with a lid that appeared to contain chocolate pudding was out of reach from R110. R110 was observed slowly bringing scrambled eggs to his mouth, dropping some from his fork and onto his chest on two occasions. R110 was very slow when attempting to bring food to his mouth to consume his meal. R110 stated that the food was alright. Review of R110's weight since admission revealed the following: 1/12/2024 22:21 165.2 Lbs (pounds) 1/25/2024 10:30 134.2 Lbs 1/30/2024 09:35 132.0 Lbs 2/9/2024 09:27 130.4 Lbs 2/11/2024 06:48 128.6 Lbs 2/12/2024 13:34 128.6 Lbs 2/14/2024 13:30 128.8 Lbs 2/20/2024 09:27 130.6 Lbs 2/27/2024 20:39 127.8 Lbs 3/5/2024 21:40 130.0 Lbs Review of an Admit/Readmit note dated 1/12/2024 at 10:44 PM revealed Patient arrived with transportation from .Hospital. Patient use [sic] assistive devices such as a wheelchair and walker. He is a fall risk and has had falls. He is occasionally incontinent and needs assistance with daily living and set up meals . Review of a Nutrition PN note dated 1/16/2024 at 12:52 PM revealed R110's initial admission weigh of 165.2 pounds seemed inaccurate and review of the hospital paperwork revealed R110 weight was 138.6 pounds which visually appeared more appropriate. A reweigh was requested. Review of the weights revealed that the reweigh for R110 was not obtained. A Nutrition/Dietary Note dated 2/14/2024 at 11:40 PM revealed R110' s current weight was 128 pounds. Will strike admission weight of 165.2 from record as an error. Hospital weight 1/9 (1/9/24) was 138.6. [Weight] is still down 7.2% from this hospital weight a month ago which is a significant change .He typically can feed himself with set up but needs additional help at times. R110 was provided a cup of enhanced pudding with meals as one of his ordered supplements. Review of R110 Care Plan revealed a nutritional risk care plan related to dysphasia (difficulty swallowing) with mechanically altered diet, psych dxs (diagnosis), COPD (chronic obstructive pulmonary disease), GERD (gastroesophageal reflux disease), serve PCM (protein calorie malnutrition) with sig (significant) weight loss, impaired skin integrity. Further review of the Care Plan revealed that there was no intervention for set up assistance for meals for R110. Review of the [NAME] (portion of the medical record that Certified Nursing Assistants use to gather care need information on residents) revealed no instruction to provide set up assistance for meals for R110. In an interview on 03/26/24 at 11:03 AM, Registered Dietician (RD) T, RD T verified during conversation that R110 required set up assistance for meals. When queried about the meaning of setup assistance for meals, RD T stated that it required opening drinks, removing lids, inserting straws into cups, and cutting up food if needed. When asked if the lid for the enhanced pudding should be in reach of R110 with the lid removed, RD T stated that it should.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 1 (Resident #78) of 3 residents reviewed, resulting in unmet care needs and the potential for a decline in emotional and physical health. Findings include: Review of the medical record revealed that Resident #78 (R78) was admitted to the facility on [DATE] with diagnoses including gastrointestinal tumor, malignant neoplasm of prostate, unspecified dementia, psychotic disorder with hallucinations, and adult failure to thrive. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/31/24 revealed a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). Section F reflected that it was very important to R78 to choose what clothes to wear. Section GG of the same MDS revealed that R78 required setup assist with eating; moderate assistance with toileting and upper body dressing; and maximal assist with bathing, lower body dressing, and personal hygiene. In an observation and interview on 3/19/24 at 1:41 PM, R78 was observed lying in bed, on their back, dressed in a long-sleeved navy-blue sweater with dried white, crusty material noted at neckline and to extend down right side of shirt to bottom edge as well as onto the right shirt sleeve from the elbow region to the cuff. R78 was observed to have a white, incontinency brief in place but was otherwise bare from the waist down. R78 opened their eyes when their name was called and verbalized Hi and reported that he did not want to go to school without pants on. On 3/19/24 at 2:56 PM, a Resident Representative interview was completed with R78's Responsible Party (RP) J. RP J stated that he was able to visit his father daily, that he had been getting good care but was concerned that since last Friday (3/15/24), R78 had been dressed in the same dirty sweater. RP J stated that on Friday, 3/15/24, the staff had assisted R78 in dressing in the blue sweater and that he had observed him to have the same blue sweater on during his daily visits on Saturday (3/16/24), Sunday (3/17/24), Monday (3/18/24), and again today (Tuesday, 3/19/24). RP J stated the sweater had become increasingly dirty with each passing day, had dry, crusted food across the front, and that he had requested both yesterday and today (3/19/24) for the sweater to be changed and had been told by staff that they would get to it. Per RP J, R78 was a very proud man and that having dirty clothes on would for sure be a dignity issue for his dad as was his normal routine to shave and put on clean clothes daily and that he would be frustrated and embarrassed had he not been confused. On 3/19/24 at 3:31 PM, R78 was observed lying in bed, on his right side, with their legs swung out to the right side of bed with bare feet resting on floor. R78 was observed with same blue sweater in place with dried, white crusty material across the front right side and sleeve but was otherwise observed without clothes from the waist down. A white incontinency brief was observed on the floor at R78's feet. R78 reported that he needed to get cleaned up for the day and would then be on his way. On 3/20/24 at 7:41 AM, R78 was observed lying in bed, on their back, with the head of bed at an approximate 30-degree angle. R78 was dressed in the same long-sleeved navy-blue sweater with dried, white crusty material continuing to be observed on the entire front right side of the shirt and at the right sleeve. R78 was observed to have a white incontinency brief in place but was otherwise without clothing from the waist down. R78 was awake and alert but confused stating that he was just resting a bit before he got cleaned up and dressed for work. On 3/20/24 at 9:29 AM, R78 was observed lying in bed, on their back, with the head of bed positioned at an approximate 75-degree angle. A clothing protector was observed to be fastened around R78's neck covering the front of the same long-sleeved navy-blue sweater. Dried white, crusty material continued to be observed at R78's right shirt sleeve. Review of R78's ADL (activities of daily living) Care Plan Focus indicated, ADL Self care deficit as evidenced by Muscular dystrophy, pneumonia, debility with a Goal that stated, Will be clean, dressed, and well groomed daily to promote dignity and psychosocial wellbeing and associated Interventions that reflected, ADL assist of 2 person, bed mobility 2 person, toileting 2 person, eating 1:1 assist, self care x1 assist . and Assist with daily hygiene, grooming, dressing, oral care and eating as needed all with a 2/7/2024 date of initiation. Further review of R78's comprehensive care plan was not noted to include a care plan focus, goal, or intervention to reflect that R78 refused any care. Review of documentation included within R78's Upper Body Dressing task from 3/15/24 to 3/20/24 indicated that R78 required moderate to dependent assist with task with no episodes of resident refusal indicated. Review of R78's progress notes from 3/15/24 to 3/20/24 was not noted to include any episodes of care refusal. In an interview on 3/20/24 at 2:20 PM, Certified Nurse Aide (CNA) H confirmed familiarity with R78 and that she was his assigned aide that date. Per CNA H, R78 required extensive assist of 1 to 2 staff members with all care including bed mobility, transfers, oral care, and dressing and was incontinent of both bowel and bladder requiring assist with incontinency care and brief changes. CNA H stated that she had also been R78's assigned CNA from 1:00 PM to 3:00 PM on 3/19/24, had noticed the navy-blue sweater that he had on was dirty, hadn't had time to change it, and had passed that information on to the next shift. CNA H further stated that when she had arrived to work that morning (3/20/24), had noted R78 to have the same dark navy-blue long-sleeved sweater on but that his hospice aide had since completed his bed bath, removed the blue sweater, and placed a facility gown. CNA H stated that, to her knowledge, R78 never refused care. In an interview on 3/20/24 at 2:57 PM, Registered Nurse/Assistant Director of Nursing (RN/ADON) C stated that the expectation for ADL care included ensuring each resident was groomed and dressed in clean clothes or a gown daily per their preference. Per RN/ADON C, the assigned CNA would then document completion of each task, including grooming and dressing, within [Name redacted-electronic documentation used by staff to record care provided at or near the point of care) and that any care refusal would be indicated within the same POC task but that the assigned nurse may also make a nurse note entry to reflect the refusal. Upon review of R78's Upper Body Dressing task and progress notes over the last week, RN/ADON C stated that she did not see any documentation to reflect that R78 had refused care, nor did she see a care plan focus or intervention that reflected that R78 refused personal care. Review of the facility policy titled, Activities of Daily Living (ADL) with a revised date of 12/7/23 stated, Policy Overview: Resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene .Guidelines .Appropriate care and services will be provided for residents who are unable to carry out ADL independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care .).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain catheter orders for catheter care for one (Resident #3) of one reviewed for catheters, resulting in the potential for increased risk of infection. Findings Include: According to the facility's policy titled Catheter Care with an issued date of 8/24/23 It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. General Guidelines: Catheter care will be performed every shift and as needed by nursing personnel . Review of the face sheet revealed R3 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included post-polio syndrome (deterioration of nerve cells called motor neurons over many years that leads to loss of muscle strength and dysfunction), major depressive disorder, anxiety disorder, bipolar disorder, adjustment disorder with anxiety, schizoaffective disorder, calculus of kidney (kidney stone, a hard deposit that forms in the kidneys), hydronephrosis (excess fluid in a kidney due to a backup of urine) with renal and ureteral calculus obstruction, obstructive and reflux uropathy, and malignant neoplasm of prostate. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/5/24 revealed R3 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The same MDS reflected that R3 required assistance from two people for most activities of daily living. R3 discharged from the facility. In an observation and interview on 03/19/24 at 12:49 PM, R3 was in his room wearing headphones and listening to a device. R3 was understood and easily conversant. R3 expressed that he had grown increasingly anxious over the past few months over some recent health concerns including a new diagnosis of prostate cancer and a recent surgery. An indwelling foley catheter bag was observed hanging off R3's bedside. R3 stated that the foley catheter had recently been placed after issues with kidney stones and urinary retention. Review of the Physician Orders for R3 revealed Foley catheter care every shift every night shift every Wednesday for Foley and Suprapubic Care Monitor urinary meatus and rotate anchor site when needed with a discontinued date of 2/25/24. Review of a Nursing admission Note dated 2/27/2024 at 6:05 PM revealed R3 readmitted into [room number] via stretcher .at 5:50pm. assisted into bed, call light in reach. foley cath (catheter) in place and draining clear amber urine . doctor notified of readmit and orders verified. Review of the Physician Order revealed that there was no order for Foley Catheter Care implemented after R3 readmitted to the facility with an indwelling foley catheter. In a telephone interview on 03/22/24 at 10:17 AM, Licensed Practical Nurse (LPN) F reported that she was familiar with R3's care and was aware that he had readmitted to the facility with an indwelling Foley Catheter. LPN F stated that there should be orders for monitoring and documenting urine output, maintaining patency for the Foley Catheter, and daily catheter care. When asked if she was aware of the daily catheter care being performed on R3, LPN F stated that she had not observed it but thinks it was getting completed by the Certified Nursing Assistants (CNA). Review of the Treatment Administration Record for the dates of 2/27/24 until 3/20/24 revealed no indication that Foley Catheter care was completed. Review of the [NAME] (part of the electronic medical record that certified nursing assistants use to gather care information) revealed no instruction for daily Foley Catheter care. In an interview on 03/26/24 at 2:54 PM, Assistant Director of Nursing (ADON) C acknowledged that there was no catheter care order for R3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nutritional and hydration needs were met and failed to obtain weights per policy for resident (Resident #110) of 5 residents reviewed for nutrition, resulting in the potential for altered nutrition status and unmet needs. Findings Include: Review of the facility's policy titled Weights with a revision date of 2/1/24 reflected the guidelines for obtaining weights. The policy stated .weights are obtained upon admission and then weekly for a total of four weeks . Review of an medical record revealed Resident #110 (R110) admitted to the facility on [DATE] with diagnoses which included repeated falls, muscle weakness, depression, pressure ulcers, severe protein-calorie malnutrition, and other drug induced secondary Parkinsonism. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/18/24, reflected R110 scored 11 of out 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Care Plan reflected R110 was a one person assist for most activities of daily living (ADL). In an observation and interview on 03/26/24 at 8:32 AM, R110 was observed in bed with his head of bed elevated and attempting to feed himself breakfast. A scoop of scrambled eggs and a scoop of ground sausage was observed in a clamshell container on R110's bedside table. 1% milk was observed on the table with a straw and a Styrofoam cup with a lid and no straw. R110 had 4 apple juice containers on the table and a condiment cup with a lid that appeared to contain chocolate pudding was out of reach from R110. R110 was observed slowly bringing scrambled eggs to his mouth, dropping some from his fork and onto his chest on two occasions. R110 was very slow when attempting to bring food to his mouth to consume his meal. R110 stated that the food was alright. Review of R110 Care Plan revealed a nutritional risk care plan related to dysphasia (difficulty swallowing) with mechanically altered diet, psych dxs (diagnosis), COPD (chronic obstructive pulmonary disease), GERD (gastroesophageal reflux disease), serve PCM (protein calorie malnutrition) with sig (significant) weight loss, impaired skin integrity. One of the interventions included obtaining weigh per policy. Review of R110's weight since admission revealed the following: 1/12/2024 22:21 165.2 Lbs (pounds) 1/25/2024 10:30 134.2 Lbs 1/30/2024 09:35 132.0 Lbs 2/9/2024 09:27 130.4 Lbs 2/11/2024 06:48 128.6 Lbs 2/12/2024 13:34 128.6 Lbs 2/14/2024 13:30 128.8 Lbs 2/20/2024 09:27 130.6 Lbs 2/27/2024 20:39 127.8 Lbs 3/5/2024 21:40 130.0 Lbs Review of an Admit/Readmit note dated 1/12/2024 at 10:44 PM revealed Patient arrived with transportation from .Hospital. Patient use [sic] assistive devices such as a wheelchair and walker. He is a fall risk and has had falls. He is occasionally incontinent and needs assistance with daily living and set up meals . Review of a Nutrition PN note dated 1/16/2024 at 12:52 PM revealed R110's initial admission weigh of 165.2 pounds seemed inaccurate and review of the hospital paperwork revealed R110's weight was 138.6 pounds which visually appeared more appropriate. A reweigh was requested. Review of the weights revealed that the reweigh for R110 was not obtained. A Nutrition/Dietary Note dated 2/14/2024 at 11:40 PM revealed R110' s current weight was 128 pounds. Will strike admission weight of 165.2 from record as an error. Hospital weight 1/9 (1/9/24) was 138.6. [Weight] is still down 7.2% from this hospital weight a month ago which is a significant change .He typically can feed himself with set up but needs additional help at times. R110 was provided a cup of enhanced pudding with meals as one of his ordered supplements. In an interview on 03/26/24 at 11:03 AM, Registered Dietician (RD) T reported that newly admitted residents are weighed upon admission and then weekly for 4 weeks. If a reweigh is requested, it is expected to be completed right away. When asked if R110's reweigh and four weekly weights were obtained per policy, RD T reviewed the weights and stated that they were not. RD T verified during conversation that R110 required set up assistance for meals. When queried about the meaning of setup assistance for meals, RD T stated that it required opening drinks, removing lids, inserting straws into cups, and cutting up food if needed. When asked if the lid for the enhanced pudding should be in reach of R110 with the lid removed, RD T stated that it should. On 3/20/2024 at 10:01 AM, Resident #110 (110) was observed in his room, lying flat in his be with a clothing protector on. R110's breakfast of eggs and grits were not eaten. Water was observed in a large Styrofoam cup that was dated 11:00 PM-3/19/2024 to 7:00 AM-3/20/2024. The cup was full and had no ice. Resident # 110 asked for a drink of water, but the water cup was on a bedside table, which was over R110's bed, R110 stated he was not able to reach the cup of water. R110 stated he could not raise the head of his bed up, and he needed staff to give him a drink.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient staff to meet resident needs as reported in a confidential Resident Council meeting and Resident #'s (2,8,49, 55, 59 and 80) resulting in anger, frustration, increased risk of falls and the potential for unmet care needs. Findings include: During a confidential Resident Council meeting on 3/21/2024 at 12:45 PM, six of seven residents stated that call lights have been an issue for at least six months. They stated that afternoons, midnights, and weekends are bad where they have to wait for 1 1/2 to 2 hours to get help. One resident said, Staff don't seem to care and they say that they will be right back and they don't come back or they go to get another aide and turn off the light and forget. Three of seven residents also stated that the facility was supposed to have two staff present when using the hoyer lift (allows a person to be lifted and transferred with minimal physical effort) and sometimes there was only one staff available. Review of the Resident Council monthly meeting notes from October 2023 to March 2024 revealed that call lights were brought up as a concern at the monthly meetings on 10/4/2023, 12/6/2023, 1/3/2024, 2/6/2024 and 3/5/2024. Review of resident concern forms (separate from Resident Council concerns) from October 2023 to March 2024 revealed additional call light concerns dated 10/24/2023, 11/12/2023, 12/18/2023, 12/28/2023, 2/12/2024, 2/13/2024, 2/20/2024, 3/1/2024, 3/5/2024 and 3/13/2024. During an interview on 3/21/2024 at 2:57 PM, Activities Manager (AM) L stated that she was aware of concerns with call lights and that these concerns come and go from month to month. During an interview on 3/21/2024 at 2:57 PM Nursing Home Administrator (NHA) A said that she that she wasn't aware of ongoing concerns regarding call lights and she said, in March at the Resident Council meeting they said things were getting better. NHA A stated that she was surprised there were call light concerns and residents were saying they have to wait a long time for help since they meet the state requirements for staffing and have managers on each shift. Review of the concern form from Resident Council dated 3/5/2024, AM L documented under concern, council voiced that call lights have gotten better in the past month but they still have to wait long wait times especially in the evenings and nights. During an observation on 3/19/2024 at 12:43 PM, two call lights were observed to be on. The call lights made a sound in the hallway and at the nurses station. The call lights also lit up in the hall outside of the resident's room, at the end of the hall, and at the nurses' station. Two staff members were observed within view of the call lights, including within hearing distance of the beeping sound. Neither staff member responded to the call lights. Three staff members were observed on the hall 200 hall talking to each other next to one of the resident's room with the call light on, but did not respond to the call light. Two other staff members were observed passing lunch trays but did not stop to answer the call lights. During the same observation on the 100 hall, one call light was observed to be on, a nurse was observed to pass the room, but not stop to answer the call light. Two other call lights then were turned on, but staff observed at the nurses' station did not respond. One nurse was observed to be standing at a medication cart in view of the hallway call light and within in hearing distance, but did not respond to the call light. In an observation on 3/20/2024 at 9:21 AM, a call light on the 100 hall was observed to be on. A nurse was observed at 9:32 AM to leave the hall and did not answer the call light. A housekeeper was observed to pass the room, and go across the hall without answering the call light. The nurse returned to the hall at approximately 9:33 AM, but did not respond to the call light, and went into another resident's room across the hall. The call light was answered at 9:34 AM. Review of Resident 49 (R49) medical record reflected the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview Mental Status (BIMS) score of 15 out of 15 (cognitively intact). During an interview with R49 on 3/19/2024 at 12:25 pm, it was reported the call light response time was unacceptable and the wait time on afternoon and midnight shift was usually one hour. Record review for R80 reflected a BIMS score of 13 (cognitively intact) during an interview with R80 on 3/19/2024 at 12:31pm it was reported that the facility was understaffed and the wait time was an hour or longer. Resident 55's MDS dated [DATE] reflected a BIMS score of 15 out of 15 (cognitively intact) and was interviewed on 03/19/24 at 12:47 PM , R55 reported the wait time for assistance could be up to 3 hours and on a weekend you can just forget it! Resident #2 (R2)'s MDS dated [DATE] reflected a BIMS score of 15. R2 reported night and weekends were very bad and and the chances of getting help was zero to none, that they (staff) will get to you on their terms. R2 stated he dreaded the weekends and found it nerve racking knowing you were not going to be cared for. Resident 59 (R59) MDS dated [DATE] reflected a BIMS score of 15. On 3/19/24 at 2:00 pm, R59 reported staffing and call light response time was a concern and there was extremely long wait times for help, R59 elaborated that it was very typical for staff not to respond at all for 90 minutes and often would enter the room and turn off the call light stating they will be back in a second and an hour or two will go by before you see them again. Resident 8 (R8) MDS dated [DATE] reflected a BIMS score of 15. On 03/19/24 at 03:22 PM, R8 stated it took to long to get help, R8 stated it was a minimum of an hour, and thought 15 minutes would be acceptable. R8 stated he had previously complained to the Nursing staff but nothing changes. R8 further stated that 2nd, 3rd shifts and any and all weekends were extraordinarily bad. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure opened medications were appropriately labeled and stored (R17, R60, R33) and that expired medications were disposed of in 4 of 8 medication carts reviewed for labeling and storage, resulting in the potential for decreased medication efficacy and adverse side effects. Findings include: On 3/21/24 at 7:58 AM, [NAME] Unit Medication Cart 2 was reviewed in the presence of Licensed Practical Nurse/Unit Manager (LPN/UM) D. During the review, an uncapped Albuterol Inhaler with dried, crusty brown material at the inhaler mouthpiece was observed lying in the top right medication cart drawer. A peeling pharmacy label on the inhaler reflected R60's name with no open date indicated. LPN/UM D confirm that the Albuterol Inhaler was an active medication, that the brown debris had to be some sort of food particle from not being cleaned after use, and that she would be disposing of and obtaining a new one. LPN/UM D stated that the inhaler should have been dated when opened, cleaned after use, the cap placed back on the mouthpiece, and stored in either the box it was delivered in or a labeled plastic bag. LPN/UM D further stated that she audited the medication cart at least weekly to ensure all medications were labeled with open dates, stored where they were supposed to be in the cart and within their expiration date stating that she was unsure of where the inhaler had come from or when it had been opened. Review of R60's medical record revealed an active order dated 3/15/24 for Albuterol Sulfate Inhaler with as needed administration for shortness of breath. Review of the corresponding Medication Administration Record (MAR) dated 2/1/24 - 2/29/24 and 3/1/24 - 3/31/24 reflected that the inhaler had been signed out as administered twice in 2/2024 (2/12 and 2/29) with no indication noted on the 3/2024 MAR that the medication had been administered. On 3/21/24 at 8:38 AM, Maple Unit Medication Cart 1 was reviewed in the presence of LPN G. During the review, an uncapped Albuterol Inhaler was observed lying directly on the bottom of the second drawer of the medication cart. The inhaler was noted with a handwritten label indicating R17's last name with no open date indicated. LPN G confirmed that the inhaler was an active medication for R17, was unsure as to where the cap was as could not be located within the cart and would be throwing out and ordering a new one as was undated and had no idea when it was opened. On 3/21/24 at 9:42 AM, the Meadows Unit Medication Cart 4 was reviewed in the presence of LPN F. During the review an opened Symbicort Inhaler box with a pharmacy label indicating R33's name and a pharmacy delivery date of 12/20/23 was noted. No open date was indicated on either the box or inhaler. LPN F confirmed that the inhaler was an active medication for R33 as received twice daily, denied knowledge of when the inhaler was opened as confirmed that both the box and inhaler lacked an open date and that as the inhaler was only good for 90 days after opening would be disposing of and ordering a new one as would be expired if opened on the indicated pharmacy delivery date of 12/20/23. Review of R33's medical record revealed an active order dated 1/18/24 for Symbicort Inhaler with every 12-hour administration. Review of the corresponding MAR dated 3/1/24 - 3/31/24 reflected twice daily administration from 3/1/24 thru the 9:00 AM dose on 3/21/24. On 3/21/24 at 10:49 AM, the Cyprus Unit Medication Cart was reviewed in the presence of LPN I and LPN/UM E. During the review an opened, unlabeled, and undated Insulin Glargine pen was observed in the top left medication cart drawer. LPN/UM E stated that she was unsure why it was in the medication cart, who it belonged to, or when it was opened. LPN/UM E further stated that as the pen was opened, would expect the pen to be labeled with a resident specific name as well as an open date and would be discarding as had no idea who the pen was for or when it had been opened. During the same medication cart review, an uncapped, unlabeled, undated Albuterol Inhaler was noted in the second drawer of the cart. LPN/UM E stated that she would be discarding the inhaler and had no way of knowing whose inhaler it was or when it was opened and could provide no further explanation as to why the inhaler was stored uncapped and unlabeled in the cart. In an interview on 3/21/24 at 11:03 AM, Registered Nurse/Assistant Director of Nursing (RN/ADON) C stated that since insulins, inhalers, and eye drops had varying expiration dates based on their open date, that the facility referenced the Medications with Shortened Expiration Dates form to determine how long each specific medication was good for. RN/ADON C stated that the expectation was for any opened inhaler to be labeled with a resident name and open date, discarded by the expiration date, and stored with the cap in place to the mouthpiece and ideally in the container that they were delivered in. RN/ADON C further stated that the expectation was for any opened insulin pen to be labeled with both a resident name and open date, discarded by the expiration date, and would not expect to ever see an opened insulin pen in a medication cart without a name or opened date on it. Per RN/ADON C, the opened, unlabeled, undated insulin pen in the Cyprus Unit Medication Cart was likely pulled from the backup pharmacy kit and should have been labeled with a resident name and date upon opening. Review of the facility policy titled Medication and Treatment Storage with an 8/7/23 issued date stated, Policy Overview: It is the policy of this facility to ensure accurate labeling and dating of medications and treatments for safe administration and safe and secure storage .General Guidelines .Medications designed for multiple administrations (e.g., inhalers, eye drops), the label will identify the specific resident for whom it was prescribed . Review of the facility provided reference form titled Medications with Shortened Expiration Dates with a 9/23 revised date indicated for Symbicort to Discard when the counter reads 00 or 90 days after removal from the protective foil package.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 130 residents who receive meal services (1 nothing by mouth residents, or NPO) out of the facility's total census of 131 residents. Findings include: 1. On 3/19/24 at 10:24 AM, an accumulation of dust and debris was observed on the interior utensil drawer adjacent to the clean dry storage rack. On 3/19/24 at 10:35 AM, an accumulation of dust, hair, as well as pink and green colored debris was observed on the interior utensil drawer on the on the kitchen's main prep line. At this time upon interview with the Dietary Manager, staff K, the surveyor inquired if the facility had any policies in place regarding cleaning related job duties for staff to follow to which they stated, Yes. I will have someone clean out this whole drawer. On 3/19/24 at 10:24 AM, the surveyor requested a copy of the facility's cleaning policy to review. On 3/19/24 at 10:48 AM, liquid milk was observed on the interior and exterior of seven milk crates, and on a 3' by 4' section of the tile flooring in the walk in cooler. At this time the surveyor inquired with staff K on if they thought the flooring was being cleaned timely and sufficiently to which they replied, we clean it throughout the day. I talked to my supplier, and this is an issue on the production line at the assembly plant. They stated this is going to take another couple weeks most likely to figure out how to properly correct it. On 3/19/24 at 10:50 AM, the surveyor asked staff K what the facility plans on doing moving forward knowing the length of time stated by their supplier to potentially correct this issue to which they replied, this is not normal for us. I'm not sure what else to do other that keep trying to mop it up throughout the day, but it will be like that again the next morning. On 3/20/24 at 9:10 AM, record review of a document titled, daily kitchen checklist revealed that the facility has systems in place to ensure proper cleaning and sanitizing of surfaces and equipment occurs. Review of 2017 U.S. Public Health Service Food Code, Chapter 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, directs that: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 2. On 3/19/24 at 9:24 AM, an air gap of at least 1 and twice the diameter of the receiving drain was not observed present on any of the three-compartment sink's drain lines. At this time upon interview with the Dietary Manager, staff K, the surveyor inquired if there had been any recent changes to the plumbing system since the last survey to which they replied, not that I'm aware of, but I'll talk to maintenance about it. Review of 2017 U.S. Public Health Service Food Code, Chapter 5-203.14 Backflow Prevention Device, When Required directs that: A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under § 5-202.13 P 3. On 3/19/24 at 9:52 AM, five, warm to the touch, six inch wide and twelve inch tall plastic wrapped containers dated 3/19/24, were observed in the reach in cooler adjacent to the coffee and juice station, with visible condensation on the interior of the containers. Labeling on these containers identified pork (two containers), mac and cheese, pureed eggs, and noodles. Additionally, two, six inch wide and twelve inch tall plastic wrapped containers dated 3/17/24, were observed with visible condensation on the interior of the containers labeled as soup, and beef. On 3/19/24 at 9:55 AM, upon interview with Dietary Manager, staff K, the surveyor requested the facility's cooling log to review to which they replied, we don't use one. We only cool small amounts of food. At this time the surveyor asked staff K how they verify the food items being cooled are following a cooling process as recommended in the current FDA food code to ensure the safety of the food items being served to the residents to which they stated, we normally don't do this in advance, I'm not sure why the cook did this. I will set the soup and beef aside so they won't be used. At this time the surveyor requested temperatures to be taken of the cooling food items started earlier in the day to which they stated, of course, they would have been done around nine o'clock, right after breakfast. On 3/19/24 between 9:58 AM, and 10:04 AM, temperatures taken by staff K via a thermometer revealed temperatures ranging from 47 degrees F to 62 degrees F. On 3/19/24 at 10:05 AM staff K stated to the surveyor, I'll transfer these to the freezer now to make sure they get cold enough quickly and talk to the cook about this. Review of 2017 U.S. Public Health Service Food Code, Chapter 3-501.15 Cooling Methods directs that: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; Pf (2) Separating the FOOD into smaller or thinner portions; Pf (3) Using rapid cooling EQUIPMENT; Pf (4) Stirring the FOOD in a container placed in an ice water bath; (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00142268 Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse, and report the findings to the State Agency for one resident (Resident #3) of three residents reviewed for abuse and neglect. Findings include: Review of the clinical record reflected Resident #3 (R3) was an [AGE] year old female admitted to the facility on [DATE] and transferred back to the hospital on [DATE] with diagnosis that included end stage renal disease. Review of the facility grievance log dated 01/24/24 reflected a concern for R3, the concern was identified as nursing/customer service. Review of R3's concern form reflected the concern was received on 01/16/24. The concern form reflected R3 was evaluated at the hospital/out patient clinic on 01/12/24 for a concern related to her fistula. Review of the Nurse Practitioner progress notes at the out patient clinic reflected (R3) was .Very upset about going back to the rehab facility. She notes it is very bad and she is scared to go back. She asked to stay at the hospital. She states the people at the rehab facility kicked or hit her to wake her up and the food is horrible. The section of the concern form completed by former Nursing Home Administrator (NHA) D Under the heading Documentation of Facility Follow up dated 01/16/24 reflected Spoke [sic] w/ daughter. The section of the form Resolution of Concern signed by NHA D and dated 01/29/24 reflected R3 was used to getting more attention at the hospital and R3 had a Brief Interview Mental Status of 8 (mildly impaired cognition.) This section of the form was checked Yes concern was resolved. Former NHA D was onsite during the investigation and provided a document titled Abuse Allegation Investigation/Interviews dated 01/16/24, the interview reflected R3 was interviewed by NHA D and had no concerns related to abuse. On 02/08/24 at 12:20 pm during an interview with former NHA D she reported she completed the investigation in conjunction with NHA A and together they did not substantiate abuse. Former NHA D reported that when she spoke with R3's daughter, the daughter stated R3 was fighting an infection and thought that her mother liked the extra attention that the hospital can provide. When queried if other residents were interviewed about an allegation of abuse, Former NHA D said no. When queried if any staff were interviewed Former NHA D said no. When requested to see the facility incident reported incident, former NHA D stated she did not substantiate abuse therefore she did not report it to the State Agency. On 02/08/24 at 12:45 pm, during an interview with current NHA A the documentation listed above was reviewed, NHA A agreed the kicking and hitting a resident was an allegation of abuse and should have been thoroughly investigated and reported to the State Survey Agency. Review of the facility's abuse policy updated 5/24/2023 reflected on page 3. The facility will ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property and crimes are reported immediately to the Administrator and: Reported to the State Survey Agency immediately but no later than 2 hours after the allegation is made if the allegation involves abuse or results in serious bodily injury and to other officials (including adult protective services and or law enforcement, when applicable. Page 4. of the abuse policy reflected Identifying and interviewing all involve persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations (such as other residents, family members, staff who worked closely with the alleged perpetrator/and or alleged victim.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake number MI00141165. Based on observation, interview, and record review the facility failed to ensure care plan interventions were followed for one out of eight residents (Resident #3), resulting in a right and left tibia (shinbone) and right femur (upper leg bone) fracture from a fall out of bed. Findings Included: Per Resident #3's (R3) Minimum Data Set (MDS), R3 was discharged to the hospital on [DATE] with an anticipated return to the facility. Review of an MDS dated [DATE], revealed R3 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 (moderately impaired cognition). The assessment revealed that both of R3's legs were impaired, and also R3 was totally dependent on staff for rolling right to left while in bed. Review of R3's list of diagnoses revealed R3 had multiple sclerosis (MS-a disease that affects the central nervous system). Record review of a care plan that was in place for activities of daily living (ADLs) dated 11/30/2018 and revised on 10/17/2023, revealed R3 had an, ADL Self care deficit related to weakness, impaired mobility .MS, CVA (stroke) .limited ROM (range of motion-movement) to bilateral (both) lower extremities and left upper extremity related to MS. An intervention was in place that required two staff members to assist R3 with bed mobility, and ADLs. The intervention was last revised on 5/22/2023. Review of a Kardex (a resident care guide for Certified Nurse Aids), no date, revealed R3 required two staff members to assist with bed mobility and ADL's. Review of a facility reported incident (FRI) revealed that on 11/17/23 around 2:30 PM, Certified Nurse Aid (CNA) C provided a bed bath to R3. The report revealed CNA C had R3's bed raised up to her waist level (approximately 3-4 feet), R3 was lying on her back when CNA C turned R3 away from her to R3's right side. The report revealed CNA C was on the left side of R3's the bed, she rolled R3 onto her right side and tucked her left leg under her right leg. The report further revealed that R3, .yelled out, my leg is moving and I am starting to roll ., CNA C then, leaped over the resident (R3), holding onto her upper body and was able to lower the resident to the floor . Further review of the same report revealed R3 was not able to be assisted back into her bed due to, .the severe pain in her legs . The report revealed R3 was transferred to the hospital, and around 9:30 PM during a follow-up phone call the hospital reported R3 had, .sustained a left and right tibia fracture, right femur fracture and a right patella (knee) fracture . Review of a written statement by CNA C dated 11/17/2023, revealed CNA C knew R3 was a two person assist for rolling/turning in bed. The statement revealed R3's bed was raised up to waist level, CNA C was on the left side of R3's bed, CNA C tucked R3's left leg under her right leg, and then rolled R3 away from herself which placed R3 onto her right side. Per CNA C's statement R3 said, .oh no my legs are moving, and I am starting to roll ., then both of R3's legs fell over the side of the bed, CNA C then leaped over the bed, held onto R3's upper body, and slowly lowered R3 to the floor. Review of a written interview dated 11/20/2024, that Administrator A held with CNA C, revealed CNA C stated she knew R3 was a two person assist, and tired to get a co-worker to help her give R3 a bed bath, but her co-worker was to busy. The interview revealed that while R3 was turned to her right side, CNA C went to R3's left side to clean her back and back side, when R3 said that she was slipping. CNA C then leaped over (the bed), grabbed R3 under both of her arms, lowered her to the floor, and then R3 immediately complained about pain in her right leg. In an interview on 11/30/2023 at 12:47 PM, CNA C stated that on 11/17/2023 she gave R3 a bed bath. CNA C said she asked another staff member for help with R3's bed bath her, but said all the other staff were to busy. CNA C said she wanted to clean R3 up before she ended her shift, because R3 was soiled. CNA C said she pulled R3 towards herself and placed R3 on her right side, then went around the bed to the the left side of R3 to put a brief underneath her. CNA C said R3 told her that her leg was slipping, and she saw her falling off the bed, so she went over and across the bed, grabbed R3 from her under her arms from R3's backside, but could not hold onto R3 any longer so she had to lower R3 to the floor. During the same interview CNA C further stated that she knew R3 was care planned as a two person assist for turning her while in bed, but said she was not able to find another staff member to assist her. CNA C said she could not leave R3 with a dirty brief and no bath, so she told R3 that she would clean her up, but it would just be her providing the care, which CNA C said R3 was okay with. In an interview on 11/30/2023 at 2:00 PM, R3 was observed in her room in her bed, which was observed to be a large wide bed. R3's bed was observed to be raised up approximately 3 feet high. R3 stated that on 11/17/2023 CNA C had given her a bed bath by herself. R3 said her bed bath had been completed, and CNA C was doing something in her room (did not know what) when she told CNA C that she was slipping off the bed. R3 said she had no control of either of her legs because of her MS diagnosis, and she was not able to pull her legs back up onto the bed to stop herself from rolling off her bed, so she fell from 4 feet up onto her full body weight landing on the floor. R3 said after she fell onto the floor her legs started to hurt. Review of an, EMPLOYEE COUNSELING & CORRECTIVE ACTION RECORD dated 11/21/2023, revealed CNA C was given a written warning due to Carlessness (sig) or Negligence in the performance of the job assignment. The record also revealed, On 11/17/2023 you (CNA C) did not follow, name redacted, (R3's) plan of care. CNA C signed the record on 11/21/2023. Review of a hospital discharge summary date 11/24/2023 revealed under, Hospital Course, .admitted after fall from bed at her facility with multiple closed fractures of both lower extremities . Review of the hospital X-ray notes dated 11/17/2023 revealed, R3 had right femur, right tibia, and left tibia fractures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide accurate reasoning and advanced written notice prior to a room change for one resident (Resident #36) of one resident reviewed for room changes, resulting in frustration with the potential for increased anxiety, misinformation of the reason for the room change and lack of opportunity to for resident questions. Findings include: Resident #36: According to the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/23, Resident # 36 (R36) was a [AGE] year old resident with diagnoses that included major depression and anxiety. Review of the Brief Interview for Mental Status (BIMS) reflected R36 scored 15 out of 15 (cognitively intact). On 04/04/23 at 08:43 AM, R36 was interviewed at bedside and reported last December she was moved to her current room which was located on a locked unit designated for dementia. R36 stated she did not have dementia, was not an elopement risk, was not given an option to be moved and received little to no notice or warning that a room change was going to occur. They just came and told me I had to move. Further review of R36's clinical record reflected a facility form titled Notification of Room/Roommate Change the form was dated 12/01/2022 15:00 and reflected R36 was moved to the current room located on the secured unit on 12/01/22. The same form further indicated that R36 was moved for reason of Dually certified bed not available. During an interview with admission Director P on 04/10/23 03:38 PM she reported having a role in room changes but could not recall specifics that pertained to R36's room change on 12/01/22. Of note, admission Director P stated every bed in the facility was dually certified on 12/01/22 . On 04/10/23 04:21 PM, during an interview with Director of Nursing (DON) B whom was the person who completed the Notification of Room/Roommate Change reported the facility was dually certified and had been for years. When queried why R36 was moved on 12/01/22 which reflected R36 had to be moved to a dually certified bed if the entire facility was dually certified at that time . DON B stated that did not make sense and she would look into the situation further. On 04/12/23 02:58 PM during an interview with Nursing Home Administrator NHA A , she stated all beds were dually certified on 12/01/22 but at that time they thought the bed certifications may change and the facility was trying to be proactive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide the resident's representative information regarding the facility's bed hold policy for one resident (Resident #34) of two residents reviewed, resulting in the residents representative not being informed of the ability to hold the bed within the facility. Findings included: Resident #34 (R34): Review of the medical record revealed R34 was originally admitted to the facility 08/10/2022 and most recently re-admitted [DATE] (following a recent hospital stay on 02/19/2023) with diagnoses that included chronic ischemic heart disease, congestive heart failure (CHF), atherosclerotic heart disease of coronary artery, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation, gastro-esophageal reflux, hypercholesteremia, chronic viral hepatitis C, hypertension, anxiety, depression, and benign prostatic hyperplasia (prostate enlargement). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2023, revealed R34 had a Brief Interview for Mental Status (BIMS) of 10 (moderately impaired cognition) out of 15. During observation and interview on 04/05/2023 at 09:43 a.m. R34 was observed laying on his bed. R34 explained that he recently had a short stay at the hospital sometime in February of this year and explained that he was happy to be back at the facility. During review of R34's medical record revealed that he had several discharges to the hospital during his residency at the facility. The most recent discharges occurred 01/20/2023 and 02/19/2023. R34's medical record demonstrated that he was not his own responsible person and that his daughter was appointed his Durable Power of Attorney for Health Care (DPOA). The medical record revealed a progress note dated 01/20/2023 that stated, daughter called and notified of fathers condition & transfer out, Acute Care Transfer/Transport During Covid-19 Pandemic/Facility Initiated Transfer For Nursing Homes/Bed Hold Policy/Covid-19 status of building & resident all completed and sent with resident and HVA staff to hospital. The medical record did not demonstrate that R34's DPOA had received a copy of the Facility Initiated Transfer for Nursing Homes/Bed Hold Policy. R34's medical record did not demonstrate that the daughter was notified or received the Facility Initiated Transfer for Nursing Homes/Bed Hold Policy for the hospital transfer that occurred on 02/19/2023. Review of the facility policy entitled Bed Hold Policy (no date present) did not explain when or to who a facility Bed Hold Policy must be provided upon discharge from the facility. The Bed Hold Policy state To arrange for a behold, or discuss the Centers bed hold policy, please contact the Centers Business Office Manager. In an interview on 04/12/2023 at 09:15 a.m. Nursing Home Administrator (NHA) A explained that a discharge packet was provided to the residents at the time of discharge to the hospital. She explained that the discharge packet included the facilities Bed Hold Policy. NHA A explained that once the Bed Hold Policy had been provided that the nursing staff wrote a progress note in the medical record of that resident. NHA A could not explain if R34's DPOA had been provided a copy of the Bed Hold Policy for the discharges of R34 that occurred on 01/20/2023 or 02/19/2023. NHA A explained that she would attempt to locate the documentation that would demonstrate that R34's DPOA had been provided a copy of the Bed Hold Policy. She explained that it would have been the responsibility of the Business Office Manager to contact the residents DPOA. In an interview on 04/12/2023 at 12:58 p.m. Nursing Home Administrator (NHA) A explained that documentation that R23's Durable Power of Attorney (DPOA) had received the facility Bed Hold Policy could not be located. NHA A explained that the Business Office Manager was not aware that it was her responsibility to notify Guardians or DPOA's of any residents that had been discharged to the hospitals. NHA A agreed that notification of the facility Bed Hold Policy was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a Preadmission/Annual Resident Review (PAS/ARR) was accurately completed upon admission and failed to ensure an accurate PAS/ARR level one OBRA (Omnibus Budget Reconciliation Act of 1993) was sent to Community Mental Health Services Program (CMHSP) for a level two OBRA evaluation for 1 resident (Resident #31) of 2 residents reviewed for PAS/ARR from a total sample of 24, resulting in the potential for unmet mental health needs. Findings include: Resident #31: According to the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/23, Resident # 31 (R31) was admitted to the facility on [DATE] with diagnoses that included anxiety, bi-polar disorder and depression. Further review of the MDS reflected R31 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Record review of both electronic medical record and paper medical record reflected R31's Pre admission Screening form reflected it was all nos, indicating that resident #31 did not have a current diagnoses of Mental Illness or Dementia and had not routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. When in actuality, according to the clinical record, R31 did have a current diagnosis of mental illness and was prescribed psychotropic medications. On 04/06/23 at 01:38 PM during an interview with Social Worker (SW) J she reviewed the electronic medical record along with the PAS/ARR form located in the medical record. SW J agreed the PAS/ARR was inaccurate since R31's admission and had not been corrected/updated or made accurate to reflect R31's status. SW J further acknowledged that due to the inaccuracy and failure to correct the PAS/ARR level one OBRA (Omnibus Budget Reconciliation Act of 1993) was not sent to Community Mental Health Services Program (CMHSP) for a level two OBRA evaluation. SW J reported she had recently completed an audit to ensure all PAS/ARR were current however the accuracy of R31's PAS/ARR got missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15 (R15): Review of the medical record revealed R15 was admitted to the facility 03/26/2016 with diagnoses that included seizures, stage 3 kidney disease, right knee pain, mood disorder, adjustment disorder, depression, traumatic brain injury, hydrocephalus (buildup of fluid in the brain), adult failure to thrive, osteoporosis (brittle/fragile bones), macular degeneration (degenerative condition affecting the retina), glaucoma (buildup of fluid in eye), gastro-esophageal reflux, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/16/2023, revealed R15 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. During observation and interview on 04/04/2023 at 11:38 a.m. R15 was observed lying in bed. R15 explained that wanted to be discharged from the facility but no one had assisted him with that plan. R15 explained that he had talked with Social Worker (SW) DD and SW J about his desire to be discharged . Review of the medical record demonstrated care plan problem statement Patient does not show potential for discharge to the community due to need for 23/7 medical care and supervision for medical issues, memory deficits and physician debility. That problem statement was revised 04/10/23 by SW J. In an interview on 04/10/2023 at 09:48 a.m. Social Worker DD explained that he had knowledge that R15 had a desire to be discharge in the past. He explained that he had not spoken with R15 regarding his discharge plan. In an interview on 04/12/2023 at 10:57 a.m. Social Worker J explained that R15 desired to be discharged from the facility. She explained that she had not assisted R15 with this plan because he was not able to be discharged . When asked why he could not be discharged , she explained that R15 had a guardian who had been appointed to him in 2019 after he was determined to be incompetent. SW J could not explain why R15'smost recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/16/2023, revealed R15 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15 and still was incompetent. SW J could not explain why R15's last competency evaluation was completed in 2019. SW J offered to place a referral for competency during this interview. SW J explained that she had spoken to the guardian regarding discharge but could not provide any documentation. SW J explained that she had a conversation with R15 last night regarding discharge but failed to document that meeting. SW J could not explain why R15's discharge plan did not explain that he wanted to go home or any interventions to assist him in meeting his goal of discharge. SW J agreed that the plan of care did not provide any interventions on how to assist R15 with his desire for discharge. SW J did not provide any documentation demonstrating that social services assisted R15 with his desired discharge planning. Resident #22 (R22): Review of the medical record revealed R22 was admitted to the facility 02/16/2023 with diagnoses that included depression, anemia (low amount of blood), hyperlipemia (high fat content in blood), neuropathy (nerve damage), insomnia, anxiety, seizures, urinary retention, malignant neoplasm of breast (breast cancer), hypertension, dysphagia (difficulty swallowing), tremors, and dizziness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/22/2023, revealed R22 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 04/03/2023 at 02:08 R22 was observed lying down in bed. R22 explained that she was going to be discharged soon but did not know what the plan was to be. She explained that she had requested to talk with a social worker but she no one has talked with her as of this date. Review of the medical record demonstrated plan of care that stated, Patient shows potential for discharge and patient, relative, or representative expresses with for discharge. The plan of care for discharge had been updated since 2/20/2023. In an interview on 04/06/2023 at 01:43 p.m. Social Worker (SW) J was asked to review the discharge plan of care for R22. SW J reviewed the plan of care and explained that it was her understanding that R22 would be discharged home with her daughter. SW J was asked why the plan of care did not reflect that information. SW J explained that she had been told by the previous facility cooperation that owned the facility that the care plan was not to be specific and individualized. In an interview on 04/10/2023 at 09:37 a.m. Social Worker (SW) DD explained that R22 had different discharge plans during her stay at the facility. He explained that each family member of R22 had different plans for their mother's discharge, while R22 wanted something totally different. SW DD explained that the daughter wanted for R22 to go home with her. The son wanted R22 to go home with him, but there was a housing issue. SW DD explained that the current plan was that R22 wanted a referral made to an assisted living facility and was to be discharged [DATE]. When asked where that documentation was present, SW DD explained that he had e-mails with that information but had not recorded anything in the medical record. SW DD agreed that the discharge plan of care was not accurate and should have been updated. SW DD could not explain why the plan of care was not updated. Resident #48 (R48): Review of the medical record revealed R48 was admitted to the facility 01/15/2020 with diagnoses that included chronic obstructive pulmonary disease (COPD), depression, type 2 diabetes, benign hyperplasia (enlarge prostate), obstructive and reflux uropathy (obstruction of urine flow), panic disorder, hypertension, cerebral infarction (ischemic stroke), obstructive sleep apnea, stage 4 kidney disease, coronary artery disease, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2023, revealed R48 had a Brief Interview for Mental Status (BIMS) of 11 (moderately impaired cognition) out of 15. During observation and interview on 04/05/2023 at 09:57 a.m. R48 was observed lying in bed. R48 explained that he was to be discharged to another facility, but the facility was doing nothing to assist him with his discharge plan. Review of the medical record revealed R48 had a plan of care that stated, Patient shows potential for discharge and patient, relative, or representative expresses wish for discharge. That discharge plan was last revised on 02/20/2023. The medical record also revealed that R48 had a plan of care that stated, Patient does not show potential for discharge to the community due to long term stay. Requires 24-hour care/supervision. That discharge plan was last revised 01/20/2023. R48's medical record also demonstrated a progress note that was entered 01/20/2023 that stated, Resident still is hoping to transition to a long-term care facility in [NAME]. Writer is working on transfer. In an interview on 04/13/2023 at 11:00 a.m. Social Worker (SW) J explained that R48 had expressed a desire to transfer to another facility in [NAME], Michigan. She explained that a previous Social Worker had been assisting him with that transfer. She explained that Social Worker left the facility the middle of March 2023. SW J explained that she was the Director of Social Services, but she had not followed up since March 2023. SW J explained that she her time had been mainly spent on assisting with new admissions and discharges of short stay residents. SW J reviewed R48's discharge plan and agreed that the discharge plan of care was not accurate. SW J could not explain why the discharge plan of care had not been updated to reflect R48's current discharge plan. Based on observation, interview and record review, the facility failed to develop and implement an effective patient-centered discharge planning process for four residents (Resident #15, Resident #22, Resident #40, and Resident #48) of six residents reviewed for discharge planning, resulting in frustration, psychosocial distress, unresolved concerns related to discharge status and overall dissatisfaction with care. Findings include: Review of the facility, Social Services Guidelines, dated 8/2021, reflected, Information about the discharge planning is initially documented in the Social Services Assessment and History. Discharge planning progress notes are used to document the development of any updates or revisions to the discharge plan and the patient's readiness for discharge .Discharge Plan: Begin to format the patient's discharge plan at the initial contact with a newly admitted patient .As frequently as the situation dictates, review the patient's readiness for discharge and the plan's appropriateness. Document updates to the plan as they occur throughout the stay . Resident #40: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R40 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), heart disease, heart failure, kidney disease, diabetes, chronic obstructive pulmonary disease, hemiplegia post intercranial bleed affecting dominate right side, bipolar disorder (manic depression), atrial fibrillation, and anemia. The MDS reflected R40 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required one-person physical assist with bed mobility, transfers, locomotion on unit, toileting, dressing, hygiene, and bathing. The MDS reflected R40 had no evidence of behaviors. During an observation and interview on 4/4/23 at 11:10 a.m., R40 was in a contact isolation room in bed and appeared alert and able to answer questions without difficulty. R40 reported was admitted to the facility after an acute hospital admission stay and had a court appointed guardian that he was very unhappy with. R40 reported does not think he needs a guardian and reported VA hospital had indicated he was competent to make his own decisions. R40 reported had been working with facility Social Worker, who no longer worked at facility, related to discharge plans and revoke guardianship for several months but still has guardian and unaware of plans to transfer. R40 reported did not care for Social Worker (SW) J and stated, if it was up to her, he would never get out of this place. R40 reported had spoken with local ombudsman related to concerns and was unsure if concern form had been completed at facility for reported concerns. R40 stated, feels no senior should be treated this way because he has rights. R40 reported seen by psychiatric services at the facility and reported did not feel safe because personal items disappear all the time. During an interview on 4/13/23 at 9:44 a.m., SW J reported working at the facility as the Social Worker Director for two years. SW J reported SW W was R40's SW prior to leaving the facility in November 2022 because R40 did not care for SW J. SW J reported facility recently hired SW DD in March of 2023 who was currently worked with R40 with SW J behind the scenes. SW J reported R40 will not work with SW J because he believes SW J is why R40 is still at facility. SW J reported R40 had a court appointed guardian service and reported R40 does not feel he needs a guardian. SW J verified R40's BIM score was 15/15. SW J reported R40 wanted guardian services terminated and R40's court appointed guardian instructed facility not to assist R40 with the guardian termination because R40 had to do it for himself if R40 wanted to be his own person. SW J reported direction from prior Administrator (NHA) R and R40's guardian group. SW J reported had to request cognitive re-evaluation for R40 and had done last week. After SW J was requested to provide evidence SW J reported after reviewing R40's Medical Record reported request was not send and would do that day. SW J reported facility physician does not feel R40 can make own medical decisions, but VA does and reported physiologist comes to the facility every two weeks. SW J was unable to answer why competency re-evaluation was not requested prior to that day. SW J reported it had been over a year that R40 wanted to discharge, and guardian did not disagree but reported was unable to move out of the state prior to finding guardian in state he preferred to move, to be closer to family. SW J reported R40 was invited to quarterly Care Conferences along with Court Appointed Guardian services and were times both R40 and guardian did not participate. SW J reported R40 comprehensive Care Plans should be updated with changes in plans for discharge and reported was not aware until three weeks prior that it was her responsibility to update Care Plans including Discharge Care Plans and verified R40 Care Plans were not up to date. During an interview on 4/13/23 at 11:10 a.m., SW J reported prior SW W started employment 9/2022 through 2/2023, after prior NHA R was coving R40's Social Work needs. SW J reported prior to NHA R providing SW services R40 was followed by another SW who terminated employment March 2022. SW J reported prior NHA R provided R40 SW services because R40 did not care for SW J, but was overall manager, responsible for Social Work Department. SW J reported SW DD was hired about one month ago and was R40's current social worker. SW J verified R40 had wanted to transfer to another facility out of state to be closer to family for several months and that is why they requested re-evaluation for competency. This surveyor requested evidence of request. Review of the Resident incapacity to Give Informed Consent and to Exercise Resident Rights document, reflected one physician signature dated 7/11/22(document did not include required second physician signature.) Review of the VA(Veteran Affairs) Hospital Discharge records, faxed to the facility 11/9/22 at 1:25 p.m., reflected notes that included, [Named R40] is quite concerned about his guardianship status. He is not sure how he ended up with a guardian and does not think needs one. Per ICU, they were also concerned about the ethics of his guardianship, as he is consentable and expressed that he wants to be full code, but the guardian (a private company) had him as DNAR .He would like assistance .getting out of his guardianship situation. -Consult social work . Review of R40's Annual Michigan Department of Health and Human Services Comprehensive Level II Evaluation, dated 1/31/23, reflected subjective evaluation notes that included, In terms of placement, [named R40] indicated that his ECF[extended care facility] social worker, [named SW W] is working on getting him discharged to an ECF in Wintersville, Ohio called [named facility]. He noted that he has family and several friends in the [NAME] Virginia/Ohio area and he is looking forward to being closer to them .contributing factors to his depression and anxiety being being here (at the ECF) .Objective Evaluation: Assessor spoke with [named guardian staff] at Guardian Care on 1/12/23 .In terms of movement towards discharge to an ECF closer to [NAME] Virginia, [named guardian staff] reported Well he can't leave the state of Michigan since he has a guardianship here. I haven't seen or heard of anything [regarding discharge]. There aren't any upcoming court dates in the system .Assessor spoke with ECF social worker, [named SW W], on 1/12/23 .reported no major changes in [named R40] mood or behaviors, however, did note, [named R40] was actually evaluated by psychologist recently who deemed him competent. Him and I are trying to get him to [NAME] Virginia but with the guardian it's kind of tricky.' [named SW W] is working with the ECF administrator to complete the needed paperwork in order to terminate guardianship however no court date is set yet. [named SW W] stated once guardianship is terminated, [named R40] would move to a VA contracted ECF in Ohio new [NAME] Virginia .Assessor spoke with OBRA treatment services staff [named] on 1/13/23 who reported [named R40] mood, behaviors, and cognition have remained relatively stable throughout the last year. He consistently reports that he is depressed or sad related to his finances, frustration with his guardian, and his desire to transfer to a nursing facility in Ohio.Clinical Symptoms: Behaviors, Easily agitated towards ECF staff, anxiety and depression related to wanting to move, passive death wish .Affective Development .He endorsed mild depression and anxiety related to wanting to discharge to be closer to his friends/family .Recommendations .ECF Social Work .Please continue to work with [named R40] and his legal guardian to continue exploring [named R40's] desire to return to his home state of [NAME] Virginia .Cognitive Abilities Addendum: [Named] Psychology Consult on 11/14/22 Reason for referral: Facility SW requested psychologist to evaluate and determine decision making capacity. Per clt, he wants to terminate his guardian and be his own responsible party .Attending physician indicated in chart: [named R40 physician GG]. Psych order in chart dated 11/12/22 for psych consult re: reassess need for guardianship and if he is competent .Standardized testing completed: SMMSE: 11/14/22, clt scored 29/30 which indicated no cognitive/memory issues. 07/11/22, clt scored 29/30 which indicated no cognitive/memory issues .PHQ-9: 11/14/22, clt scored a 10 which indicated moderate depression. 07/11/22, clt scored an 8 which indicated mild depression .Based on the clinical structured interview, standardized testing, observations made on clt, and info in chart, psychologist determined that he is able to make informed medical and legal decisions. Review of the Clinical Psychologist Note, signed 11/14/22, reflected R40 was evaluated to assess capacity to make informed medical and legal decisions. Continued review of the document reflected, In psychologist's professional opinion, psychologist determined that [named R40] is able to make informed medical and legal decisions. Review of R40 Social Service Progress Note, dated 6/14/2021 at 7:38 a.m., reflected, Writer spoke to [named R40] and issued the new court date paperwork explaining that he has a Zoom hearing on 7/12 and stated that writer would be in to assist with the Zoom hearing. [Named R40] was agreeable for writer to assist .[named R40] had no change in mood or behaviors, he was cooperative with staffs interview and then continued to discuss the upcoming court date and how angry he is that the guardian closed his bank account and does not feel that his guardian has his best interest. Writer explained that we can discuss that at his court date with the judge and they will handle it . The Progress Note was written by SW J. Review of the Social Service Progress Note, dated 7/21/2021 at 12:05 p.m., reflected R40's court appointed guardian was changed to [named guardian services]. Review of R40 Care Plan Progress Note, dated 8/18/2021 at 8:37 a.m., reflected, Writer spoke to [named R40} and informed him that his care conference will be rescheduled r/t not hearing back from his guardian. [named R40] stated that they have not returned his calls either. Writer explained that since he wants to go to Florida, writer wants his guardian to be in attendance or at least via phone. [named R40] gave writer a card for admissions for a Brookdale facility in Florida stating that he wants to go to. Writer stated that she has to have permission from his guardian in order to send him out of state. Writer explained that she would try and call his guardian after morning meetings and see if we can get it rescheduled. Will continue to monitor, provide support and address any issues/concerns as they arise. Review of R40 Social Service Progress Note, dated 8/26/2021 at 9:12 a.m., reflected, Writer received a phone call from [named R40] this morning stating that he wanted to return to [NAME] Virginia. Writer stated that she received a voicemail from the guardian stating that she's unable to transfer him out of state because he's under the guardian care, however she would be able to transfer him to an assisted living facility. [named R40] stated that the guardian never said that to him. Writer stated that she would contact the guardian this morning and see what can be done. Will continue to monitor, provide support and address any issues/concerns as they arise. Review of R40 Social Service Progress Note, dated 8/26/2021 at 2:00 p.m., reflected, [named R40] stopped writer in the hall, writer explained that she left his guardian a voicemail requesting a call back r/t his transfer. Writer explained to [named R40] again that she's unable to transfer him out of state, because of his guardianship. [named R40] became angry and started yelling at writer in the hall, and called her names. Writer explained that she will not be called names and will wait to hear from the guardian about transfer. Will continue to monitor. Note was written by SW J. Review of R40 Social Services Progress Note, dated 8/31/2021 at 3:29 p.m., reflected, Writer received a voicemail on Friday around 5pm and another voicemail on Monday around 2:30pm from [named R40] requesting a call back to speak to him. Writer went to speak with him and he stated that he wants to go to [NAME] Virginia. Writer explained that she can't transfer him out of state without the guardian's permission, however if he wanted to transfer in the [NAME] Arbor area that can be accomplished. [named R40] stated that he does not want to do that, he wants to go to [NAME] Virginia. [NAME] became agitated that writer was ignoring him. Writer explained that she's not ignoring him, she was off on Monday, [named R40] stated that writer never calls him back. Writer explained that she does not call him, but she comes down to see him when she can. [named R40] denied writers statement and then became agitated again and said he wants to go to [NAME] Virginia. Writer explained that she can't do that unless she has permission from the guardian. [named R40] became agitated and defensive stating that writer does not do anything for him, writer explained that she does what she can, but its inappropriate for him to be yelling, swearing and calling writer names .Writer stated she would contact the guardian about the transfer, [named R40] then stated that he wanted a court date because he does not feel he needs a guardian. Writer explained that she can't make that determination but would reach out to the guardian. Will continue to monitor, provide support and address any issues/concerns as they arise. Note written by SW J. Review of R40 Social Work Note, dated 11/15/2021 at 10:07 a.m., reflected, admitted on [DATE][date after note], for Long Term Care services .[named R40], who prefers to be called [named R40]; was readmitted to [Named facility]. [named R40] is a DNR, alert and oriented x3, although he does have a guardian in place prior to admission to the facility. [named R40] goal is to go to [NAME] Virginia, however at this time [named R40] will remain LTC at this facility, until guardianship can be switched to a company in [NAME] Virginia. [named R40] stated that his lawyer in [NAME] Virginia is working on switching the guardianship. Will continue to monitor and address any issues/concerns as they arise. Note written by SW J. Review of R40 Social Service Progress Note, dated 4/28/2022 at 12:41 p.m., reflected, .admitted on [DATE], for Long Term Care services .Annual assessment completed with [named R40]. BIMS score of 15 indicates cognitively intact, PHQ-9 score of 8 indicates potential for mild depression. Guardianship has been granted and Guardian's Care Inc is the responsible party. [named R40] is a DNR, alert and oriented x3, able to make needs known, can be pleasant and cooperative with staff at times and can also be irritable at times. [named R40] ultimate discharge goal is to return to the community in [NAME] Virginia, facility and Ombudsman are assisting with possible transfer. [named R40] has a dx of bipolar disorder and receives Zoloft 75mg Qday and Valproic Acid 250mg Qday for dx of Bipolar d/o. Mood appears stable overall, no behaviors noted this quarter. Will continue to monitor, provide support and address any issues/concerns as they arise. Review of the Care Conference Note, dated 5/20/2022 1:10 p.m., reflected, Care conference held. Those in attendance include Activities Dietary Nursing Social Services The patient attended. The discharge planning process in not active at this time. DNR at this time .There is no current acute illness present. There are no current changes to pain management. No significant changes in activities of daily living at this time .Physical Therapy is not being received. Occupational Therapy is not being received. Speech Therapy is not being received .The patient is not their own decision maker. Guardian's Care Inc.[named]. Patient is not exhibiting behavioral symptoms. No ancillary services provided Audiology Dental Podiatry Vision Patient/Family education and/or follow up is not indicated at this time .The patient/responsible party did not request a copy of the current care plan. The patient/responsible party did not request a copy of the current physician orders. [Guardian not present] Comments: Quarterly care conference held with [named R40], he stated that he's doing fine, but wants to be seen by his doctor. He declined any other issues/concerns. Guardian did not attend via phone as she did not answer the phone when staff called her. Will continue to monitor, provide support and address any issues/concerns as they arise. Review of R40 Social Services Note, dated 7/27/2022 at 4:32 p.m., reflected, Quarterly MDS completed with a BIMS score of 15 indicating no cognitive impairments and a PHQ-9 score of 2 indicating minimal depressive symptoms. Resident voiced he feels depressed because he does not feel he needs a guardian and would like to discharge to [NAME] Virginia. Writer to continue to work with resident on discharge planning. Writer to also continue to provide support as needed. Note written SW W. (One year after resident requested to transfer and concerns about need for guardian). Review of R40 Social Services Progress Note, dated 9/19/2022 at 9:14 a.m., reflected, Writer called a facility of choice for resident to discuss transfer. The facility told writer there is an application process and a wait list. Will discuss with resident to complete application. Spoke with resident's guardian regarding discharge planning to [NAME] Virginia. Resident's guardian stated she has no concerns with him transferring, but will have to confirm there is a guardian in place in the location of the transfer prior to the transfer occurring .When writer got off the phone, resident's community social worker was in the office to discuss resident. Writer explained current discharge planning progress. Social worker stated no other questions or concerns. Writer to continue to follow and provide support. Note written by SW W. Review of R40 Social Services Progress Note, dated 9/21/2022 1:17 p.m., reflected, Writer emailed back and forth with VA SW regarding resident's request to transfer. Discussed transferring to a VA contracted facility and then to the community. Writer also asked if the VA would be able to assist with guardianship for resident to transfer. VA SW stated the VA does not assist with guardianship, but to call the county probate court where resident will be residing. Writer to continue to follow and provide support. Review of R40 Social Services Progress Note, dated 9/27/2022 3:19 p.m., reflected, Writer spoke with resident regarding update with transfer. Writer told resident that the VA SW stated a transfer to a different SNF with a VA contract would be easiest and then transfer to the community once in [NAME] Virginia. Resident was agreeable to this plan. Writer to continue to follow and provide support. Note completed by SW W. Review of R40 Social Service Note, dated 10/6/2022 8:11 a.m., reflected, Writer called and spoke with the VA in PA regarding resident's transfer. VA SW pulled resident up in system and stated she would start the process to transfer resident's service down there. PA SW will be sending an email to AA SW and writer to discuss the steps that needs to happen moving forward on resident's transfer. Will continue to follow and provide support as needed. Note completed by prior SW W. Review of R40 Care Conference Note, dated 11/3/2022 3:56 p.m., reflected, Resident is currently out at hospital for quarterly care conference. IDT called and left message with resident's guardian and reviewed plan of care among IDT. Reviewed resident's code status, advance directives and ancillary services. Writer reported transfer to a different SNF and actively working on the discharge . Review of R40 next Care Conference Note, dated 1/26/2023 1:50 p.m., reflected, Care conference held. Those in attendance include Activities Dietary Social Services The patient attended. [No mention of Guardian services]. The discharge planning process is active at this time. Plans to discharge to a Nursing Home. Currently working on transferring to a SNF in Ohio. Full code status at this time .Physical Therapy is not being received. Is not receiving Occupational Therapy. Is not receiving Speech Therapy .The patient is not their own decision maker. Guardian Care Inc. Patient is not exhibiting behavioral symptoms . Review of the Electronic Medical Record (EMR), dated 1/26/23 through 4/11/23, reflected no evidence of progress or efforts towards resident request for transfer to another facility closer to family that had been in the progress for almost two years. Review of R40 Social Services Progress Note, dated 4/11/2023 at 8:35 a.m., reflected, SW met with Resident per his request (per concern form) re: f/u on Resident's desire to terminate legal Guardianship, move out of state, and live his best life. Resident states he would like to first move to Ohio for a while, and then move to [NAME] Virginia. In Ohio, he states former SW informed him that he would not have VA coverage until he officially became a Resident of the state of Ohio which would take 45 days. Then he would be able to apply for the coverage/have it transferred to OH, to that particular service area . Note completed by SW DD. (After R40 interview with surveyor on 4/4/23 related to mentioned concerns). Review of Concern Form, dated 4/10/23, reflected R40 contacted NHA A via telephone and requested to speak with facility Social Worker related to concerns. The document reflected SW DD met with R40 to discuss process for ongoing concern related to terminating Legal Guardian and moving away. The form included section labeled, Results of action taken: with handw[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide assistance to ensure ancillary services were arranged for 1 of 2 residents (Resident #49) reviewed for optical care, resulting in delayed care and treatment and anger and frustration. Findings include: Resident #49: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident # 49 (R49) was an [AGE] years old and admitted to the facility with diagnoses of heart failure, diabetes and chronic obstructive pulmonary disease. R49 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) . On 04/03/23 at 02:04 PM R49 was observed sitting in a wheel chair, he was articulate and engaged in conversation easily. R49 reported having had cataracts and previously had cataract surgery. R49 stated he needed the cataracts removed and was told by staff he had and appointment in 4 months. R49 reported a 4 month wait time was not acceptable, and had reached out to Social Worker (SW) J several times for help with the matter but gets dismissed by SW J. R49 stated he was so upset by the delay in the appointment he contacted his former eye care professional and was told they could see him within a week or two. R49 then stated he could not keep that appointment because the facility was no longer covered the expense of transportation and due to R49 receiving Medicaid benefits he could not cover the cost of transportation to his former provider which was approximately 20 miles. R49 stated again he had asked SW J for help but had not heard back. R49 reported the cataract was very bothersome to him and the delay in receiving treatment was frustrating and angered him. On 04/12/23 T 10:28 AM, during an interview SW J she reported the new owner of the facility cut off their ability to pay for transportation. SW J elaborated and stated R49 liked to make his own appointments and that was why she had not provided him with any assistance. SW J added R49 was required to have cataract surgery in the hospital due to his medical condition. When queried what medical condition R49 had that required cataract removal to be done in the hospital, SW J stated she wasn't sure but that was what someone told her. When queried why none of this was documented SW J did not respond. On 04/13/23 at 10:58 AM during a follow up interview with SW J she reported it was the Unit Manager's job to assist with arranging outside appointments. SW J later in the conversation reported it was the scheduler's job to assist with outside services. When queried if she had notified R49 of this when he requested your help, SW Jdid not answer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI000131821. Based on interview and record review the facility failed to ensure that a thorough investigation, including root cause analysis, was conducted for one out of three residents (Resident 539) who had a fall with injury, resulting in the potential for further falls to occur. Findings Included: Resident #539: Resident 539 (R539) no longer resided at the facility at the time of the onsite investigation. Per the facility face sheet R539 was admitted to the facility on [DATE] and had diagnoses of left side hemiplegia (paralysis of one side of the body). Record review of a Minimum Data Set (MDS) dated [DATE] revealed R539 scored a 99 on her Brief interview for Mental Status (BIMS) which revealed R539 was not able to perform the test due to poor cognitive ability. The MDS revealed R539 had no history of falls. Record review of an incident report filled out by Registered Nurse (RN) H dated 7/11/2022, revealed R539 was found on the floor next to her bed by Certified Nurse Aid (CNA) I, and revealed R539 stated she was walking and fell down. The report also revealed R539 had a 9.5 cm (centimeter) bump on her forehead, was sent to the hospital, the cause of the incident was didn't expect patient transfers herself., and the corrective action was to lower her bed to the floor. Review of a documented FALL-NURSE STATEMENT from RN H dated 7/11/2022, revealed CNA I was walking in the hallway when she found R539 on the floor next to her bed. Record review of a Patient-Statement dated 7/11/2022, revealed RN H documented R539 stated she was walking before the fall, was in no pain, and did not turn her call light on. The statement was signed by RN H however R539 did not sign or date the statement. Review of a documented statement by CNA I dated 7/11/2022, revealed CNA I stated she had assisted a family member to turn R539 in bed around dinner time before the incident occurred. CNA I's statement revealed R539's call light was not on, and her bed was in a low position. The statement was not signed, but revealed via phone. At the top of CNA I's statement revealed a place to document the name and titled of the person performing the interview, and the name of the resident, which were both blank. In an interview on 4/10/2023 at 10:47 AM, Administrator A stated Director of Nursing (DON) B would have done and completed an investigation into R539's fall on 7/11/2023, and said R539 said she was walking, therefore stated she knew what had caused the fall. In and interview on 4/10/2023 at 10:51 AM, DON B stated she did not think an investigation of the incident (R539's fall) had been done, and stated that she believed there was only the incident report that was completed regarding R536's fall. In an interview on 4/10/2023 at 11:56 AM, RN, H stated that R539 had not ever attempted to get up out of bed on her own. RN H said R539's bed was almost to the lowest position at the time of her fall. RN H said CNA I told her that R539 was on the floor, and while doing an assessment R539 told her she had been walking, but said that was not true because R539 was confused, and was not able to turn herself in bed, nor could R539 stand up on her own. In an interview on 4/12/2023 at 11:22 AM, CNA I stated that a family member had assisted her with turning R539 to her right side, then she lowered the bed, made sure R539 was safe and not to close to the edge of the bed, then left the room. CNA I stated that approximately an hour later she was walking by R539's room and noticed she was not in her bed, and then found R539 on the floor in her room. CNA I further stated that another staff member was with her, but could not recall who. CNA I said R539 was on the floor between the wall and her bed, lying on her right side. CNA I further stated that R539 could not communicate, and when she and RN Hasked her what happened she said nothing. CNA I said R539 was not able to sit up, stand up, nor take any steps, and was 100% dependent on staff for all activities of daily living (ADL's). No statement or identification of the other staff member was found when reviewing staff statements. In another interview on 4/12/2023 at 9:34 AM, DON B stated that R539 was not able to walk, but obviously tried to get up and walk. DON B said she did not have more than the two staff (CNA I and RN H) statements because they were the only two staff members involved, and said she could not interview R539 because she was sent to the hospital. DON B said she knew the injury occurred because R539 had fallen and hit her head, and said R539 would have had to gotten up and walked because there were no other possibilities. In an interview on 4/12/2033 at 8:45 AM, Occupational Therapist (OT) Q reviewed R539's therapy notes, and stated R539 was a moderate assist for rolling in bed, and said she was not able to roll on her own, and would not unless another person was guiding her. OT Q said R539's left hand was flaccid (not able to move it). OT Q said R539 required maximum assistance to go from a lying to sitting position, and from bed to chair R539 required total assistance. OT Q stated R539 was not able to go from lying to sitting, to standing, then walking on her own. OT Q further stated that R539 never walked while in therapy which included OT and Physical Therapy (PT). OT Q said R539 was not able to bear weight on her left side. Review of the facility's policy and procedure dated 2001, and titled, Fall Practice Guide revealed on page #12 an algorithm or diagram of steps to be taken in the event a resident has a fall which included, conducting an investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12 (R12): Review of the medical record revealed R12 was admitted to the facility 12/5/2020 with diagnoses that included congestive heart failure (CHF), hypertension, chronic respiratory failure, type 2 diabetes, atherosclerotic heart disease, occlusion (blockage) and stenosis (narrowing) of carotid artery, atrial fibrillation, vascular dementia, anxiety, psychotic disturbances, mood disturbance, insomnia, gout (buildup of uric acid in bone joints) , dysphagia (difficulty swallowing), and anemia (low blood count). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/2023, revealed R12 had a Brief Interview for Mental Status (BIMS) of 99 (unable to participate in assessment). During observation on 04/05/2023 at 08:00 a.m. R12 was observed setting on the side of her bed eating breakfast. She repeatedly was making grunting sounds and saying help. R12 did not respond to verbal stimulation. In an interview on 04/10/2023 at 10:34 a.m. Certified Nursing Aide (CNA) CC explained that R12 did have behaviors of grunting and saying help repeatedly. CNA CC explained that the behaviors had been getting worse. She also explained that she was not aware of any interventions that would help R12 during these behaviors. She explained that she only knew to place an alert in the point of care documentation that would notify the nurse, but she also explained that she does not chart the behavior everyday it occurs because she knew the nurses were aware of it. She explained that these R12's behaviors occurred every day. Review of the medical record revealed R12 had the problem statement cognitive loss as evidence by dx (diagnosis) of vascular dementia with behaviors. No identification of R12 recent behaviors or interventions to assist the resident. In an interview on 04/12/23 at 10:31 a.m. Social Worker (SW) J explained that she was aware of behaviors that had been observed for R12. SW J explained that she was made aware by alerts when residents have behaviors. She also explained that she was made aware by a progress note (04/04/2023) that R12 had been yelling. When asked if behavior of R12 were tracked she explained that behaviors are not tracked in the computer charting (point of care) by the staff. She explained that alerts are reviewed at a morning meeting each day. She further explained that she does not have charting in the progress notes demonstrating that alerts are reviewed and what if any action was taken. She explained that she tracks the behaviors of resident on a word document. SW J was asked to review the plan of care for R12. She confirmed that the new behaviors were not located in the plan of care and no new interventions were present for the new behaviors that had been exhibited. SW J explained that she should have placed those behaviors in the plan of care and included interventions to assist the staff in providing care to R12. SW J could not explain why the plan of care was not updated. SW J was asked if the facility had a Behavior Management Program Policy. SW J explained that three was a policy but she did not have access to it, she explained that the Nursing Home Administrator had it. SW J explained that she had not read the policy in over 6 years. She admitted that she had not read the policy since transferring to this building from another building in the company. When questioned SW J if she suggested any interventions to put in place for R12 she responded, I guess we can provide her with a psychiatric consult. Resident #15 (R15): Review of the medical record revealed R15 was admitted to the facility 03/26/2016 with diagnoses that included seizures, stage 3 kidney disease, right knee pain, mood disorder, adjustment disorder, depression, traumatic brain injury, hydrocephalus (buildup of fluid in the brain), adult failure to thrive, osteoporosis (brittle/fragile bones), macular degeneration (degenerative condition affecting the retina), glaucoma (buildup of fluid in eye), gastro-esophageal reflux, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/16/2023, revealed R15 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. During observation and interview on 04/04/2023 at 11:38 a.m. R15 was observed lying in bed. R15 explained that wanted to be discharged from the facility but no one had assisted him with that plan. R15 explained that he had talked with Social Worker (SW) DD and SW J about his desire to be discharged . Review of the medical record demonstrated care plan problem statement Patient does not show potential for discharge to the community due to need for 23/7 medical care and supervision for medical issues, memory deficits and physician debility. That problem statement was revised 04/10/23 by SW J. In an interview on 04/10/2023 at 09:48 a.m. Social Worker DD explained that he had knowledge that R15 had a desire to be discharge in the past. He explained that he had not spoken with R15 regarding his discharge plan. In an interview on 04/12/2023 at 10:57 a.m. Social Worker J explained that R15 desired to be discharged from the facility. She explained that she had not assisted R15 with this plan because he was not able to be discharged . When asked why he could not be discharged , she explained that R15 had a guardian who had been appointed to him in 2019 after he was determined to be incompetent. SW J could not explain why R15'smost recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/16/2023, revealed R15 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15 and still was incompetent. SW J could not explain why R15's last competency evaluation was completed in 2019. SW J offered to place a referral for competency during this interview. SW J explained that she had spoken to the guardian regarding discharge but could not provide any documentation. SW J explained that she had a conversation with R15 last night regarding discharge but failed to document that meeting. SW J could not explain why R15's discharge plan did not explain that he wanted to go home or any interventions to assist him in meeting his goal of discharge. SW J agreed that the plan of care did not provide any interventions on how to assist R15 with his desire for discharge. SW J did not provide any documentation demonstrating that social services assisted R15 with his desired discharge planning. Resident #34 (R34): Review of the medical record revealed R34 was originally admitted to the facility 08/10/2022 and most recently re-admitted [DATE] (following a recent hospital stay on 02/19/2023) with diagnoses that included chronic ischemic heart disease, congestive heart failure (CHF), atherosclerotic heart disease of coronary artery, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation, gastro-esophageal reflux, hypercholesteremia, chronic viral hepatitis C, hypertension, anxiety, depression, and benign prostatic hyperplasia (prostate enlargement). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2023, revealed R34 had a Brief Interview for Mental Status (BIMS) of 10 (moderately impaired cognition) out of 15. During observation and interview on 04/05/2023 at 09:43 a.m. R34 was observed laying on his bed. R34 explained that he recently had a short stay at the hospital sometime in February of this year and explained that he was happy to be back at the facility. During review of R34's medical record it was revealed that R34 had a care plan that stated, At risk for behavior symptoms r/t (related to) Alzheimer's disease/dementia. No specific types or behaviors that had been exhibited were list on R34's plan of care. In an interview on 04/12/2023 at 10:47 a.m. Social Worker J explained that R34 does exhibit certain behaviors such as walking around with his front wheel walker when he is anxious and can be verbally aggressive when the facility staff. Social Worker J could not explain why R34's behaviors had not been included on his plan of care or what why interventions had not been listed. SW J was asked to provide behavior tracking for R34's behaviors. She explained that there are not specific behaviors that are tracked for R34. SW J could not provide any documentation for behaviors that R34 had exhibited. SW J explained that she had spoken to R34 last week but did not write a progress note regarding that discussion. Resident #48 (R48): Review of the medical record revealed R48 was admitted to the facility 01/15/2020 with diagnoses that included chronic obstructive pulmonary disease (COPD), depression, type 2 diabetes, benign hyperplasia (enlarge prostate), obstructive and reflux uropathy (obstruction of urine flow), panic disorder, hypertension, cerebral infarction (ischemic stroke), obstructive sleep apnea, stage 4 kidney disease, coronary artery disease, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2023, revealed R48 had a Brief Interview for Mental Status (BIMS) of 11 (moderately impaired cognition) out of 15. During observation and interview on 04/05/2023 at 09:57 a.m. R48 was observed lying in bed. R48 explained that he was to be discharged to another facility, but the facility was doing nothing to assist him with his discharge plan. Review of the medical record revealed R48 had a plan of care that stated, Patient shows potential for discharge and patient, relative, or representative expresses wish for discharge. That discharge plan was last revised on 02/20/2023. The medical record also revealed that R48 had a plan of care that stated, Patient does not show potential for discharge to the community due to long term stay. Requires 24-hour care/supervision. That discharge plan was last revised 01/20/2023. R48's medical record also demonstrated a progress note that was entered 01/20/2023 that stated, Resident still is hoping to transition to a long-term care facility in [NAME]. Writer is working on transfer. In an interview on 04/13/2023 at 11:00 a.m. Social Worker (SW) J explained that R48 had expressed a desire to transfer to another facility in [NAME], Michigan. She explained that a previous Social Worker had been assisting him with that transfer. She explained that Social Worker left the facility the middle of March 2023. SW J explained that she was the Director of Social Services, but she had not followed up since March 2023. SW J explained that she her time had been mainly spent on assisting with new admissions and discharges of short stay residents. SW J reviewed R48's discharge plan and agreed that the discharge plan of care was not accurate. SW J could not explain why the discharge plan of care had not been updated to reflect R48's current discharge plan. Resident #92 (R92): Review of the medical record revealed R92 was admitted to the facility 06/17/2019 with diagnoses that included pulmonary embolism, abnormal heart beat, cardiac murmurs (abnormal sound of blood in heart), fatigue, restless leg syndrome, pulmonary nodule (mass), dysphagia (difficulty swallowing), muscle wasting and atrophy, subdural hemorrhage (brain bleed), anxiety, psychotic disorder with delusions, psychotic disorder with hallucinations, polyosteioarthritis (joint pain and stiffness), diverticulosis (abnormal pouch in intestinal wall of the intestines), stage 2 kidney failure, neuropathy (nerve damage), Parkinson's disease, type 2 diabetes, insomnia, gastro-esophageal reflux, hyperlipidemia, and Lewy body dementia. ). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/05/2023, revealed R92 had a Brief Interview for Mental Status (BIMS) of 11 (moderately impaired cognition) out of 15. During observation and interview on 04/10/2023 at 08:29 a.m. R92 was observed sitting up in a chair was the side of her bed eating breakfast. R92 was unable to answer questions and just kept saying doing good. Review of the medical record revealed R92 had a plan of care that stated, Paranoia/Suspiciousness and hallucinations as evidenced by: she stated that she believes people are trying to force her to go to the hospital, someone is forcing her to have a brain procedure, related to: unknown cause, my be related to her reading books. A lot of her feeling things are reality to her. She sites from recent books she has read or when she is listening to her roommates TV shows. She will make comments about the person is coming after her from the show. This care plan problem statement was last updated 04/12/2023. The only intervention listed of for that problem was to administer medication per physician orders, which was last updated 04/12/2023. In an interview on 04/12/2023 at 10:54 a.m. Social Worker J explained that R92 had delusions that her dad was supposed to pick her up. SW J could not demonstrate that those delusions were in R92's plan of care. SW J explained interventions for those delusions were that R92 was easily redirectable, and that staff should take her back to the room and set and talked with her. SW J could not demonstrate that that any intervention was listed on R92's plan of care other than administer medication per physician orders. SW J could not provide any behavior tracking for R92. Review of the facility entitled document Behavioral Management Guidelines, with a date of 03/2022, demonstrated on page 4 of 8 stated: Behaviors are documented in the clinical record. Alerts can be entered POC. Mood/behavior progress notes document the evaluation of reported behaviors. The same document demonstrated on page 4 of 8 stated, The individuals comprehensive care plan addresses the behavior management program, the goal for the behavior management, individualized interventions to address the patients specific risk factors and the plan for reduction of risk related to behaviors. Review of the facility job description for Director of Services demonstrated a Position Summary which stated, Under the supervision of the Administrator, the Director of Social Services assumes responsibility and accountability for the provision of medially relates social services that assist the residents to attain or maintain the highest practicable physical, mental and psychosocial well being. Services provided meet professional standards of social work practice, consistent with state and federal laws and regulations. Manages employees of the Social Service Department. Guides facility staff in matters of resident advocacy, protection and promotion of residents' rights. In collaboration with the Administrator, allocates resources in an efficient and economic manner to provided medically related social services. The same job description demonstrated Performance Standards that stated: - Demonstrates working knowledge and ability to interpret and implement facility policies and procedures to staff. - Assists with the admission, discharge, and transfer of residents. - Demonstrates assessment skills sufficient to evaluate residents' behavior, to collect data and to evaluate psychosocial needs, risk factors for psychosocial deterioration and residents' responses to interventions. - Provides or arranges for social work or other mental health counseling services as need to attain or maintain highest practicable mental and psycho-social well-being. - Record progress notes in the clinical record including subjective findings, objective symptoms, observations of behavior, interventions provided to resident and resident's responses to interventions. - Completes assessments, which identify residents with current needs for social service interventions to improve or maintain functional abilities and those residents at risk of psychosocial deterioration. - Suggests approaches and methods of interacting with residents that maintain and enhance the person's dignity and individuality. - Identifies ways to accommodate residents' choices, preferences, and customary routines. Includes these approaches in plan of care and gives this information to direct care staff. - Provides information about community resources for legal, financial, mortuary and other services. Intervenes on behalf of residents, as needed. Assists with application for benefits and procurement of services, clothing, personal care items from community sources outside the facility. Examples include but are not limited to; dental/denture care, podiatric care, eye care, hearing services, assistive devices, and equipment, talking books, absentee ballots, and transportation services. - Maintains contact with interested family members, legal representatives with consent of resident to inform them of changes in condition, discharge planning efforts, and to encourage family participation in developing the plan of care. - Evaluates facility residents for discharge potential. Provides discharge planning services when discharge is anticipated that reflect the resident's and family's preferences for care, coordination of post discharge care and services, including transportation, and how resident will access and pay for services. Prepares discharge summary for resident's record that is available, with consent of resident, for release to authorized persons or agencies. Review of the facility, Social Services Guidelines, dated 8/2021, reflected, Information about the discharge planning is initially documented in the Social Services Assessment and History. Discharge planning progress notes are used to document the development of any updates or revisions to the discharge plan and the patient's readiness for discharge .Discharge Plan: Begin to format the patient's discharge plan at the initial contact with a newly admitted patient .As frequently as the situation dictates, review the patient's readiness for discharge and the plan's appropriateness. Document updates to the plan as they occur throughout the stay . Review of the facility document, OPTALIS HEALTH CARE JOB DESCRIPTION, DIRECTOR OF SOCIAL SERVICES, undated, reflected POSITION SUMMARY Under the supervision of the Administrator, the Director of Social Services assumes responsibility and accountability for the provision of medially relates social services that assist the residents to attain or maintain the highest practicable physical, mental and psychosocial wellbeing. Services provided meet professional standards of social work practice, consistent with state and federal laws and regulations. Manages employees of the Social Service Department. Guides facility staff in matters of resident advocacy, protection and promotion of residents' rights .Interviews residents, interested family members, legal representatives and significant others to obtain and update information needed to develop individualized plans of care, to accommodate individual needs and preferences and to protect and promote residents' rights .Identifies ways to accommodate residents' choices, preferences, and customary routines. Includes these approaches in plan of care and gives this information to direct care staff .Provides information about community resources for legal, financial, mortuary and other services. Intervenes on behalf of residents, as needed. Assists with application for benefits and procurement of services, clothing, personal care items from community sources outside the facility. Examples include but are not limited to; dental/denture care, podiatric care, eye care, hearing services, assistive devices, and equipment, talking books, absentee ballots, and transportation services .Maintains contact with interested family members, legal representatives with consent of resident to inform them of changes in condition, discharge planning efforts, and to encourage family participation in developing the plan of care .Evaluates facility residents for discharge potential. Provides discharge planning services when discharge is anticipated that reflect the resident's and family's preferences for care, coordination of post discharge care and services, including transportation, and how resident will access and pay for services. Prepares discharge summary for resident's record that is available, with consent of resident, for release to authorized persons or agencies .Demonstrates working knowledge of laws and regulations that influence provision of care and services in nursing facilities . Resident #40: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R40 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), heart disease, heart failure, kidney disease, diabetes, chronic obstructive pulmonary disease, hemiplegia post intercranial bleed affecting dominate right side, bipolar disorder (manic depression), atrial fibrillation, and anemia. The MDS reflected R40 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required one-person physical assist with bed mobility, transfers, locomotion on unit, toileting, dressing, hygiene, and bathing. The MDS reflected R40 had no evidence of behaviors. During an observation and interview on 4/4/23 at 11:10 a.m., R40 was in a contact isolation room in bed and appeared alert and able to answer questions without difficulty. R40 reported was admitted to the facility after an acute hospital admission stay and had a court appointed guardian that he was very unhappy with. R40 reported does not think he needs a guardian and reported VA hospital had indicated he was competent to make his own decisions. R40 reported had been working with facility Social Worker, who no longer worked at facility, related to discharge plans and revoke guardianship for several months but still has guardian and unaware of plans to transfer. R40 reported did not care for Social Worker (SW) J and stated, if it was up to her, he would never get out of this place. R40 reported had spoken with local ombudsman related to concerns and was unsure if concern form had been completed at facility for reported concerns. R40 stated, feels no senior should be treated this way because he has rights. R40 reported seen by psychiatric services at the facility and reported did not feel safe because personal items disappear all the time. During an interview on 4/13/23 at 9:44 a.m., SW J reported working at the facility as the Social Worker Director for two years. SW J reported SW W was R40's SW prior to leaving the facility in November 2022 because R40 did not care for SW J. SW J reported facility recently hired SW DD in March of 2023 who was currently worked with R40 with SW J behind the scenes. SW J reported R40 will not work with SW J because he believes SW J is why R40 is still at facility. SW J reported R40 had a court appointed guardian service and reported R40 does not feel he needs a guardian. SW J verified R40's BIM score was 15/15. SW J reported R40 wanted guardian services terminated and R40's court appointed guardian instructed facility not to assist R40 with the guardian termination because R40 had to do it for himself if R40 wanted to be his own person. SW J reported direction from prior Administrator (NHA) R and R40's guardian group. SW J reported had to request cognitive re-evaluation for R40 and had done last week. After SW J was requested to provide evidence SW J reported after reviewing R40's Medical Record reported request was not send and would do that day. SW J reported facility physician and consuting physiologist does not feel R40 can make own medical decisions, but VA does and reported physiologist comes to the facility every two weeks. SW J was unable to answer why competency re-evaluation was not requested prior to that day. SW J reported it had been over a year that R40 wanted to discharge, and guardian did not disagree but reported was unable to move out of the state prior to finding guardian in state he preferred to move, to be closer to family. SW J reported R40 was invited to quarterly Care Conferences along with Court Appointed Guardian services and were times both R40 and guardian did not participate. SW J reported R40 comprehensive Care Plans should be updated with changes in plans for discharge and reported was not aware until three weeks prior that it was her responsibility to update Care Plans including Discharge Care Plans and verified R40 Care Plans were not up to date. SW J verified it was SW job to advocate for residents best interest. During an interview on 4/13/23 at 11:10 a.m., SW J reported prior SW W started employment 9/2022 through 2/2023, after prior NHA R was coving R40's Social Work needs. SW J reported prior to NHA R providing SW services R40 was followed by another SW who terminated employment March 2022. SW J reported prior NHA R provided R40 SW services because R40 did not care for SW J, but was overall manager, responsible for Social Work Department. SW J reported SW DD was hired about one month ago and was R40's current social worker. SW J verified R40 had wanted to transfer to another facility out of state to be closer to family for several months and that is why they requested re-evaluation for competency. This surveyor requested evidence of request. Review of the Resident incapacity to Give Informed Consent and to Exercise Resident Rights document, reflected one physician signature dated 7/11/22(document did not include required second physician signature.) Review of the VA(Veteran Affairs) Hospital Discharge records, faxed to the facility 11/9/22 at 1:25 p.m., reflected notes that included, [Named R40] is quite concerned about his guardianship status. He is not sure how he ended up with a guardian and does not think needs one. Per ICU, they were also concerned about the ethics of his guardianship, as he is consentable and expressed that he wants to be full code, but the guardian (a private company) had him as DNAR .He would like assistance .getting out of his guardianship situation. -Consult social work . Review of R40's Annual Michigan Department of Health and Human Services Comprehensive Level II Evaluation, dated 1/31/23, reflected subjective evaluation notes that included, In terms of placement, [named R40] indicated that his ECF[extended care facility] social worker, [named SW W] is working on getting him discharged to an ECF in Wintersville, Ohio called [named facility]. He noted that he has family and several friends in the [NAME] Virginia/Ohio area and he is looking forward to being closer to them .contributing factors to his depression and anxiety being being here (at the ECF) .Objective Evaluation: Assessor spoke with [named guardian staff] at Guardian Care on 1/12/23 .In terms of movement towards discharge to an ECF closer to [NAME] Virginia, [named guardian staff] reported Well he can't leave the state of Michigan since he has a guardianship here. I haven't seen or heard of anything [regarding discharge]. There aren't any upcoming court dates in the system .Assessor spoke with ECF social worker, [named SW W], on 1/12/23 .reported no major changes in [named R40] mood or behaviors, however, did note, [named R40] was actually evaluated by psychologist recently who deemed him competent. Him and I are trying to get him to [NAME] Virginia but with the guardian it's kind of tricky.' [named SW W] is working with the ECF administrator to complete the needed paperwork in order to terminate guardianship however no court date is set yet. [named SW W] stated once guardianship is terminated, [named R40] would move to a VA contracted ECF in Ohio new [NAME] Virginia .Assessor spoke with OBRA treatment services staff [named] on 1/13/23 who reported [named R40] mood, behaviors, and cognition have remained relatively stable throughout the last year. He consistently reports that he is depressed or sad related to his finances, frustration with his guardian, and his desire to transfer to a nursing facility in Ohio.Clinical Symptoms: Behaviors, Easily agitated towards ECF staff, anxiety and depression related to wanting to move, passive death wish .Affective Development .He endorsed mild depression and anxiety related to wanting to discharge to be closer to his friends/family .Recommendations .ECF Social Work .Please continue to work with [named R40] and his legal guardian to continue exploring [named R40's] desire to return to his home state of [NAME] Virginia .Cognitive Abilities Addendum: [Named] Psychology Consult on 11/14/22 Reason for referral: Facility SW requested psychologist to evaluate and determine decision making capacity. Per clt, he wants to terminate his guardian and be his own responsible party .Attending physician indicated in chart: [named R40 physician GG]. Psych order in chart dated 11/12/22 for psych consult re: reassess need for guardianship and if he is competent .Standardized testing completed: SMMSE: 11/14/22, clt scored 29/30 which indicated no cognitive/memory issues. 07/11/22, clt scored 29/30 which indicated no cognitive/memory issues .PHQ-9: 11/14/22, clt scored a 10 which indicated moderate depression. 07/11/22, clt scored an 8 which indicated mild depression .Based on the clinical structured interview, standardized testing, observations made on clt, and info in chart, psychologist determined that he is able to make informed medical and legal decisions. Review of the Clinical Psychologist Note, signed 11/14/22, reflected R40 was evaluated to assess capacity to make informed medical and legal decisions. Continued review of the document reflected, In psychologist's professional opinion, psychologist determined that [named R40] is able to make informed medical and legal decisions. Review of R40 Social Service Progress Note, dated 6/14/2021 at 7:38 a.m., reflected, Writer spoke to [named R40] and issued the new court date paperwork explaining that he has a Zoom hearing on 7/12 and stated that writer would be in to assist with the Zoom hearing. [Named R40] was agreeable for writer to assist .[named R40] had no change in mood or behaviors, he was cooperative with staffs interview and then continued to discuss the upcoming court date and how angry he is that the guardian closed his bank account and does not feel that his guardian has his best interest. Writer explained that we can discuss that at his [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the physician reviewed and acted upon identified medication regimen irregularities for one resident (Resident #76) of five residents reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Resident #76: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], Resident 76 (R76) was originally admitted to the on 3/3/21 and readmit on 3/01/23 diagnosis of diabetes . Review of the medication administration record (MAR) for the month of April 2023 reflected 8 units of insulin was administered every night as ordered by the physician. Review of the Pharmacy recommendations dated 1/05/23 reflected R76 had been ordered Glargine 8 units in the evening , R76 was not on a sliding scale coverage and the most recent blood sugar from 11/18/22 20:15 was 135. milligrams. The Pharmacy recommended the current dose and need for accucheck or sliding scale coverage and write prescription. The form had 3 places to make a check mark for a singular response. 1. accept the recommendation above and implement as written and 2. Accept the recommendation above with the following modifications _________. or 3. which was to decline the recommendation with a spot for rational for the decline. The bottom of the form was where the Physician was to sign. R76's January 5th 2023 pharmacy recommendation was left without any of the boxes checked/addressed and did not have a physician signature. On 04/13/23 08:53 AM Director of Nursing ( DON) B reported she was responsible for following through of pharmacy recommendations and ensuring they reach the Physician and are acted upon with physician signature. DON B reported she was not the DON at the facility in January of 2023 and could not account for why the former DON had not followed through. According to the facility policy titled Providing Pharmacy Products Services dated 01/01/08 and with a revision date of 01/01/23, page 2. #11. reflected The attending Physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate behavior monitoring during the use of psychotropic medication for two residents (Resident #34 and Resident #92) of five residents reviewed for psychotropic mediation usage resulting in the potential of residents receiving unnecessary psychotropic medication. Findings Included: Resident #34 (R34): Review of the medical record revealed R34 was originally admitted to the facility 08/10/2022 and most recently re-admitted [DATE] (following a recent hospital stay on 02/19/2023) with diagnoses that included chronic ischemic heart disease, congestive heart failure (CHF), atherosclerotic heart disease of coronary artery, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation, gastro-esophageal reflux, hypercholesteremia, chronic viral hepatitis C, hypertension, anxiety, depression, and benign prostatic hyperplasia (prostate enlargement). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2023, revealed R34 had a Brief Interview for Mental Status (BIMS) of 10 (moderately impaired cognition) out of 15. During observation and interview on 04/05/2023 at 09:43 a.m. R34 was observed laying on his bed. R34 explained that he recently had a short stay at the hospital sometime in February of this year and explained that he was happy to be back at the facility. During review of R34's medical record it was revealed that R34 had a care plan that stated, At risk for behavior symptoms r/t (related to) Alzheimer's disease/dementia. No specific types or behaviors that had been exhibited were list on R34's plan of care. The interventions only included, Administer medications per physician order. Attempt psychotropic drug reduction per physician orders, and Psych referral as needed. Non-pharmacological interventions were not included in the plan of care. Review of R34's medication physician orders demonstrated that R34 was receiving Depakote (Divalproex Sodium) oral tablet delayed release 125 mg (milligrams) two times per day for anxiety, order was written 03/27/2023. R34 was also receiving Buspirone HCl (hydrocholoride) oral Tablet 10 mg at bedtime for anxiety, order was written 02/21/2023. R34 was receiving Prozac oral capsule 20 mg one time per day for depression, order was written 2/21/2023. No evidence of gradual dose reduction (GDR) was located in the medical record. In an interview on 04/12/2023 at 10:57 a.m. Social Worker J explained that R34 does exhibit certain behaviors such as walking around with his front wheel walker when he is anxious and can be verbally aggressive with the facility staff. Social Worker J could not explain why R34's behaviors had not been included on his plan of care or what why interventions had not been listed. SW J explained that behaviors are not tracked in the computer charting (point of care) by the staff. She explained that alerts are reviewed at a morning meeting each day. She further explained that she does not have charting in the progress notes demonstrating that alerts are reviewed and what if any action was taken. She explained that she tracks the behaviors of resident on a word document. None was provided by time of exit. She explained that she does not track any specific behaviors for R34 but does visit with the staff occasionally regarding his behavior. When asked how the facility could verify that the psychotropic medication was effective, if the facility was not monitoring behaviors, if the facility was not tracking behaviors SW J responded If not having behaviors the medication must be effective. SW J did not provide any other explanation. Resident #92 (R92): Review of the medical record revealed R92 was admitted to the facility 06/17/2019 with diagnoses that included pulmonary embolism, abnormal heart beat, cardiac murmurs (abnormal sound of blood in heart), fatigue, restless leg syndrome, pulmonary nodule (mass), dysphagia (difficulty swallowing), muscle wasting and atrophy, subdural hemorrhage (brain bleed), anxiety, psychotic disorder with delusions, psychotic disorder with hallucinations, polyosteioarthritis (joint pain and stiffness), diverticulosis (abnormal pouch in intestinal wall of the intestines), stage 2 kidney failure, neuropathy (nerve damage), Parkinson's disease, type 2 diabetes, insomnia, gastro-esophageal reflux, hyperlipidemia, and Lewy body dementia. ). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/05/2023, revealed R92 had a Brief Interview for Mental Status (BIMS) of 11 (moderately impaired cognition) out of 15. During observation and interview on 04/10/2023 at 08:29 a.m. R92 was observed sitting up in a chair was the side of her bed eating breakfast. R92 was unable to answer questions and just kept saying doing good. Review of the medical record revealed R92 had a plan of care that stated, Paranoia/Suspiciousness and hallucinations as evidenced by: she stated that she believes people are trying to force her to go to the hospital, someone is forcing her to have a brain procedure, related to: unknown cause, my be related to her reading books. A lot of her feeling things are reality to her. She sites from recent books she has read or when she is listening to her roommates TV shows. She will make comments about the person is coming after her from the show. This care plan problem statement was last updated 04/12/2023. The only intervention listed of for that problem was to administer medication per physician orders, which was last updated 04/12/2023. Review of R92's medical orders demonstrated that R92 was receiving clonazepam 0.5 mg (milligrams) twice per day for anxiety, which was written 06/22/2022. R92's medical orders demonstrated R92 was receiving Quetiapine Fumarate 25 mg two time per day for psychosis secondary to Parkinson, which was written 06/21/2022. R92's medical record demonstrated R92 was receiving Seroquel 50 mg at bed time for psychosis secondary for Parkinson, which was written 06/21/2022. Review of last attempted GDR was 5/19/22. Progress notes stated, Target symptoms have not been sufficiently relived by non-pharmacological interventions. In my professional opinion, the continued use of the present medication regimen is in accordance with relevant current standards of practice. Any type of dose reduction at this time would likely impair resident function and cause psychiatric instability by exacerbation of underlying symptoms, so the resident is NOT a candidate for Gradual Dose Reduction at the present time. Review of R92's medical record did not demonstrate any behavior tracking. In an interview on 04/12/2023 at 10:54 a.m. Social Worker J explained that R92 had delusions that her dad was supposed to pick her up. SW J could not demonstrate that those delusions were in R92's plan of care. SW J explained interventions for those delusions were that R92 was easily redirectable, and that staff should take her back to the room and set and talked with her. SW J could not demonstrate that that any intervention was listed on R92's plan of care other than administer medication per physician orders. SW J could not provide any behavior tracking for R92. Review of the facility entitled document Behavioral Management Guidelines, with a date of 03/2022, demonstrated on page 2 of 8 stated: The use of psychoactive medications should only utilized as long as necessary as demonstrated by the patients behavior. As behaviors decrease, re-evaluation of the use of the medication should occur. On page 4 of 8 stated: Behaviors are documented in the clinical record. Alerts can be entered POC. Mood/behavior progress notes document the evaluation of reported behaviors. The same document demonstrated on page 4 of 8 stated, The individuals comprehensive care plan addresses the behavior management program, the goal for the behavior management, individualized interventions to address the patients specific risk factors and the plan for reduction of risk related to behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to that ensure dental services were provided in a timely manner for 2 of 2 residents (Resident #49 and Resident #62) reviewed for dental care and services, resulting in anger, embarrassment and discomfort. Findings include: Resident #49: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident # 49 (R49) was an [AGE] years old and admitted to the facility with diagnoses of heart failure, diabetes and chronic obstructive pulmonary disease. R49 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) . On 04/03/23 at 02:04 PM R49 was observed sitting in a wheel chair, he was articulate and engaged in conversation easily. R49 reported having had an attempt his dentures replaced/repaired at the facility in December 2022 and has not received them. R49 further stated that due to the delay he made a request to Social Worker J to see his long standing Dentist in the community, R49 stated that SW J told him that was not possible and he was required to follow up with the facility dentist. Review of R49's clinical record reflected the contracted facility dentist took dental impressions for new dentures on 12/29/22, there was no documentation that R49 had received them, nor was there any follow documentation from SW J pertaining to the delay in obtaining the dentures and or R49's request and frustration due to the delay. On 04/12/23 T 10:28 AM, during an interview SW J agreed that 4 months was a long wait time for dentures. When queried why she had not contacted the facility Dentist on R49's behalf and or why their was no documentation other than from the dental group on 12/29/22 pertaining to R49's concern SW J offered no explanation. Resident #62: According to the clinical record, including the Minimum Data Set (MDS) with Assessment Reference Date (ARD) 03/28/23, Resident # 62 (R62) was admitted to the facility on [DATE] with diagnoses that included cerebral infarction affecting the left side, major depression and hypertension and kidney disease. R62 scored 7 out of 15 (severely impaired cognition) on the Brief Interview for Mental Status (BIMS), R62 was coded as having zero behavior problems, including but not limited to refusal of care. Further review of the MDS reflected R62 required extensive assistance with assist from one person for combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands. On 04/03/23 at 02:01 PM, R62 was observed sitting in her room in a wheelchair R62 was observed to have missing teeth both upper and lower, remaining teeth were observed to be heavily coated with debris. Further record review reflected R62 was evaluated prophylactic by the facility dental group on 5/03/22 and the findings were heavy calculus, heavy plaque scaling and hand polishing was completed and the Dentist recommended staff assist R62 with brushing. The facility dental group saw R62 again, on an emergency basis with pain on 12/29/22 the Dentist recommended all of R62 upper teeth be extracted and all lower root tips be extracted. There was no further documentation that pertained to R62's dental status. On 04/12/23 T 10:28 AM, during an interview SW J she stated she sent referral to a local hospital for dental extractions. It was requested and the record review done with SW J who was asked to provide documentation that the referral was sent nor was there documentation that R62 or legal representative refused the recommendations. SW J was unable to provide documentation that a referral was sent to any hospital or dentist and had no information as to when or where R62 will receive dental care/extractions.

Based on observation, interview, and record review the facility failed to follow infection control guidelines for one resident (Resident #48) of one resident reviewed during urinary catheter care and contact isolation resulting in the potential to spread infection to all 114 residents in the facility. Findings Included: Resident #48 (R48): Review of the medical record revealed R48 was admitted to the facility 01/15/2020 with diagnoses that included chronic obstructive pulmonary disease (COPD), depression, type 2 diabetes, benign hyperplasia (enlarge prostate), obstructive and reflux uropathy (obstruction of urine flow), panic disorder, hypertension, cerebral infarction (ischemic stroke), obstructive sleep apnea, stage 4 kidney disease, coronary artery disease, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2023, revealed R48 had a Brief Interview for Mental Status (BIMS) of 11 (moderately impaired cognition) out of 15. During observation and interview on 04/05/2023 at 10:02 a.m. R 48 was observed lying in bed. R48 was observed to have a urinary catheter bag hanging on the side of the bed. R48 explained that he had a urinary catheter and that the staff performed catheter care on him regularly but did not know the frequency. Prior to entering the room at this time, it was observed that R48 had a red sign posted beside his door. It stated to see the nurse prior to entering the room. On the back of the sign, it demonstrated that R48 was on contact precautions. The sign demonstrated that personal protective equipment (PPE) required was a gown and gloves only, when coming in contact with urine, soiled linen. The reason given on the sign demonstrated that R48 had a history of Extended-spectrum beta-lactamasses (ESBLs) in his urine. The sign back of the sign also demonstrated that R48 had a history of Multi-resistant organisms (MDRO) in his urine. During observation 04/06/23 at 11:06 a.m. Certified Nursing Aide (CNA) HH entered R48's room with a surgical mask on and explained to R48 inquired if he would allow her to perform urinary catheter care. R 48 consented to having catheter care provided at this time. CNA HH placed gloves on both hands and proceeded to obtain a single compliance wipe (pre-moistened perineal wipes) from a container located at the bedside. CNA HH pulled back the sheets and gown of the resident. Her body was observed to be leaning against the bed sheets of R48. CNA HH proceeded to pull back the head of R48's penis and wipe the tip of his penis with the compliance wipe in a circular motion. She then wiped the shaft of his penis, his scrotum, and bilateral groin area. She then wiped the catheter tubing itself. Then she disposed of the compliance wipe. CNA HH then proceed to empty the urinary collection bag into a graduated cylinder and discarded the urine in the toilet. Then CNA HH removed her gloves, re-covered R48 with his bed sheets, and placed compliance wipe container back in the R48's dresser. CNA HH then proceed to wash hands in bathroom. During observation and interview on 04/06/2023 at 11:10 a.m. Licensed Practical Nurse (LPN) JJ was observed standing outside of R48's room. She was asked to explain what personal protective equipment (PPE) was necessary to care for R48. LPN JJ explained that R48 was in contact precautions which meant that gown and gloves were necessary if someone had direct contact with R48. She explained that a gown and gloves would be necessary if providing catheter care to R48. In an interview on 04/06/2023 at 11:20 a.m. Infection Preventionist (IP) Registered Nurse (RN) II explained that R48 was on contact precautions related to his history of having a drug resistant organism in the past. She explained that his need for contact precautions was in following the Center for Disease Control (CDC) recommendations for the spread of drug resistant organisms. IP RN II explained that it was necessary to wear a gown and gloves when providing catheter care for R48. She also explained that a gown and gloves were to be worn if staff came in direct contact with R48 or his bed sheets. Review of policy entitled Catheter Care: Indwelling Catheter (implementation date not listed), with a most recent revision date of 04/2016, demonstrated: Number 11- Provide perineal care using a pre-moistened perineal wipes or soap, water, and wash cloth. Male: Cleanse area around catheter insertion site, from meatus outward and then wash from tip of penis down to body including scrotum and skin folds. Use alternate sits on the wipe or washcloth with each downward stroke.

Based on interview and record review the facility failed to meet educational requirements for four (K, L, M, CC) of five Certified Nursing Aides related to required in-services education of dementia management resulting in the potential for improper and/or inappropriate care for 33 residents with dementia. Finding included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) K was hired 02/24/2003. CNA K 's Inservice education record revealed that CNA K only had 5.56 training hours for the dates of 04/16/2022 through 10/06/2022. The education record demonstrated no education regarding care for resident with Dementia that had been received in the last year. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) L was hired 10/05/2012. CNA L 's Inservice education record revealed that CNA L only had 8.33 training hours for the dates of 04/13/2022 through 1/14/2023. The education record demonstrated no education on resident with Dementia that had been received in the last year. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) M was hired 01/23/2014. CNA M 's Inservice education record revealed that CNA M only had 6.57 training r the dates of 04/04/2022 through 1/9/2023. The education record demonstrated no education regarding care for resident with Dementia that had been received in the last year. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) CC was hired 01/19/2017. CNA CC 's Inservice education record revealed that CNA CC only had 8.05 training hours for the dates of 04/02/2022 through 1/13/2023. The education record demonstrated no education regarding care for resident with Dementia that had been received in the last year. Review of the Facility Assessment (dated 10/2022) entitled section Staff Competencies and sub-section Skills and Techniques Evaluation for Nursing Assistants (page 7 of 14) stated, Nursing assistants are required to complete 12 hours of in-service training per year. Below the sub-section listed above, it stated State/facility specifically training requirements based upon our patient population and care specifics identified previously include: .3. Dementia. In an interview 04/12/23 10:31 a.m. Social Worker (SW) J explained that the facility does conduct Dementia training upon new hire orientation. SW J explained that dementia training is conducted annually through a computerized educational system that Certified Nursing Aides complete annually. SW J explained that she did not monitor that this education was completed annually. During interview on 04/13/2023 at 12:39 p.m. Human Resource (HR) Director N explained that Certified Nursing Aides (CNA) education hours were tracked by the human resource department. HR Director N explained that the education reports for the Certified Nursing Aides (CNA), that had been provided, were for the last 12 months. HR Director N could not explain why dementia education was not completed for the Certified Nursing Assistants that were reviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #14: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R14 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), heart failure, stroke with hemiplegia, post traumatic stress disorder, and depression. The MDS reflected R14 had a BIMS (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required two-person assist with bed mobility and one-person physical assist with transfers, toileting, dressing, hygiene, and bathing. The MDS reflected R14 had no evidence of behaviors. During an observation and interview on 4/03/23 at 2:10 PM, R14 was in his room sitting in a personal motor chair and appeared alert and able to answer questions. R14 reported attended resident council meetings on a regular basis and had reported concerns with long call light times. R14 also reported wanted to go outside and go around facility in motor chair and staff will not allow him to leave the facility. R14 reported staff at front desk had informed him he was not allowed to leave the facility for safety reasons. During an observation and interview on 4/12/23 at around 2:00 p.m., two residents observed on side walk outside facility including one resident in motor chair and current weather was warm and sunny in the 70's. R14 was observed sitting by double door in the hall in the sun. During an interview on 4/13/23 at 9:12 AM, Activity Director (AD) O reported staff can take residents outside by picnic tables or residents can go out in courtyard. AD O reported residents are required to have staff with them unless physician order for Leave of Absence (LOA). During an interview on 4/13/23 at 10:14 AM, Social Work Director (SW) J reported residents can go outside to courtyard(interior exit) with staff if they ask. SW J reported residents can sign out LOA with responsible party to make sure they come back from the front door. SW J reported R14 was his own responsible person. During an interview and observation on 4/13/23 at 1:37 PM, R14 was sitting in hall in motor chair by windows in the sun. R14 verified had not been outside and wants to be able to drive motorized chair around building. R14 reported something about doctor. R14 reported would be happy if staff would walk with him even. R14 reported had not been able to go outside yet in over a year and stated, do they think I am going to run away? Resident #40: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R40 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), heart disease, heart failure, kidney disease, diabetes, chronic obstructive pulmonary disease, hemiplegia post intercranial bleed affecting dominate right side, bipolar disorder (manic depression), atrial fibrillation, and anemia. The MDS reflected R40 had a BIMS (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required one-person physical assist with bed mobility, transfers, locomotion on unit, toileting, dressing, hygiene, and bathing. The MDS reflected R40 had no evidence of behaviors. During an observation and interview on 4/4/23 at 11:10 a.m., R40 was in a contact isolation room in bed and appeared alert and able to answer questions without difficulty. R40 reported was admitted to the facility after an acute hospital admission stay and had a court appointed guardian that he was very unhappy with. R40 reported does not think he needs a guardian and reported VA hospital had indicated he was competent to make his own decisions. R40 reported had been working with facility Social Worker, who no longer worked at facility, related to discharge plans and revoke guardianship for several months but still has guardian and unaware of plans to transfer. R40 reported did not care for Social Worker (SW) J and stated, if it was up to her, he would never get out of this place. R40 reported had spoken with local ombudsman related to concerns and was unsure if concern form had been completed at facility for reported concerns. R40 stated, feels no senior should be treated this way because he has rights. R40 reported seen by psychiatric services at the facility and reported did not feel safe because personal items disappear all the time. During an interview on 4/13/23 at 9:44 a.m., SW J reported working at the facility as the Social Worker Director for two years. SW J reported SW W was R40's SW prior to leaving the facility in November 2022 because R40 did not care for SW J. SW J reported facility recently hired SW DD in March of 2023 who was currently worked with R40 with SW J behind the scenes. SW J reported R40 will not work with SW J because he believes SW J is why R40 is still at facility. SW J reported R40 had a court appointed guardian service and reported R40 does not feel he needs a guardian. SW J verified R40's BIMS score was 15/15. SW J reported R40 wanted guardian services terminated and R40's court appointed guardian instructed facility not to assist R40 with the guardian termination because R40 had to do it for himself if R40 wanted to be his own person. SW J reported direction from prior Administrator (NHA) R and R40's guardian group. SW J reported had to request cognitive re-evaluation for R40 and had done last week. After SW J was requested to provide evidence SW J reported after reviewing R40's Medical Record reported request was not send and would do that day. SW J reported facility physician and consulting physiologist does not feel R40 can make own medical decisions, but VA does and reported physiologist comes to the facility every two weeks. SW J was unable to answer why competency re-evaluation was not requested prior to that day. SW J reported it had been over a year that R40 wanted to discharge, and guardian did not disagree but reported was unable to move out of the state prior to finding guardian in state he preferred to move, to be closer to family. SW J reported R40 was invited to quarterly Care Conferences along with Court Appointed Guardian services and were times both R40 and guardian did not participate. SW J reported R40 comprehensive Care Plans should be updated with changes in plans for discharge and reported was not aware until three weeks prior that it was her responsibility to update Care Plans including Discharge Care Plans and verified R40 Care Plans were not up to date. SW J verified it was SW job to advocate for residents best interest. During an interview on 4/13/23 at 11:10 a.m., SW J reported prior SW W started employment 9/2022 through 2/2023, after prior NHA R was coving R40's Social Work needs. SW J reported prior to NHA R providing SW services R40 was followed by another SW who terminated employment March 2022. SW J reported prior NHA R provided R40 SW services because R40 did not care for SW J, but was overall manager, responsible for Social Work Department. SW J reported SW DD was hired about one month ago and was R40's current social worker. SW J verified R40 had wanted to transfer to another facility out of state to be closer to family for several months and that is why they requested re-evaluation for competency. This surveyor requested evidence of request. Review of the Resident incapacity to Give Informed Consent and to Exercise Resident Rights document, reflected one physician signature dated 7/11/22(document did not include required second physician signature.) Review of the VA(Veteran Affairs) Hospital Discharge records, faxed to the facility 11/9/22 at 1:25 p.m., reflected notes that included, [Named R40] is quite concerned about his guardianship status. He is not sure how he ended up with a guardian and does not think needs one. Per ICU, they were also concerned about the ethics of his guardianship, as he is consentable and expressed that he wants to be full code, but the guardian (a private company) had him as DNAR .He would like assistance .getting out of his guardianship situation. -Consult social work . Review of R40's Annual Michigan Department of Health and Human Services Comprehensive Level II Evaluation, dated 1/31/23, reflected subjective evaluation notes that included, In terms of placement, [named R40] indicated that his ECF[extended care facility] social worker, [named SW W] is working on getting him discharged to an ECF in Wintersville, Ohio called [named facility]. He noted that he has family and several friends in the [NAME] Virginia/Ohio area and he is looking forward to being closer to them .contributing factors to his depression and anxiety being being here (at the ECF) .Objective Evaluation: Assessor spoke with [named guardian staff] at Guardian Care on 1/12/23 .In terms of movement towards discharge to an ECF closer to [NAME] Virginia, [named guardian staff] reported Well he can't leave the state of Michigan since he has a guardianship here. I haven't seen or heard of anything [regarding discharge]. There aren't any upcoming court dates in the system .Assessor spoke with ECF social worker, [named SW W], on 1/12/23 .reported no major changes in [named R40] mood or behaviors, however, did note, [named R40] was actually evaluated by psychologist recently who deemed him competent. Him and I are trying to get him to [NAME] Virginia but with the guardian it's kind of tricky.' [named SW W] is working with the ECF administrator to complete the needed paperwork in order to terminate guardianship however no court date is set yet. [named SW W] stated once guardianship is terminated, [named R40] would move to a VA contracted ECF in Ohio new [NAME] Virginia .Assessor spoke with OBRA treatment services staff [named] on 1/13/23 who reported [named R40] mood, behaviors, and cognition have remained relatively stable throughout the last year. He consistently reports that he is depressed or sad related to his finances, frustration with his guardian, and his desire to transfer to a nursing facility in Ohio.Clinical Symptoms: Behaviors, Easily agitated towards ECF staff, anxiety and depression related to wanting to move, passive death wish .Affective Development .He endorsed mild depression and anxiety related to wanting to discharge to be closer to his friends/family .Recommendations .ECF Social Work .Please continue to work with [named R40] and his legal guardian to continue exploring [named R40's] desire to return to his home state of [NAME] Virginia .Cognitive Abilities Addendum: [Named] Psychology Consult on 11/14/22 Reason for referral: Facility SW requested psychologist to evaluate and determine decision making capacity. Per clt, he wants to terminate his guardian and be his own responsible party .Attending physician indicated in chart: [named R40 physician GG]. Psych order in chart dated 11/12/22 for psych consult re: reassess need for guardianship and if he is competent .Standardized testing completed: SMMSE: 11/14/22, clt scored 29/30 which indicated no cognitive/memory issues. 07/11/22, clt scored 29/30 which indicated no cognitive/memory issues .PHQ-9: 11/14/22, clt scored a 10 which indicated moderate depression. 07/11/22, clt scored an 8 which indicated mild depression .Based on the clinical structured interview, standardized testing, observations made on clt, and info in chart, psychologist determined that he is able to make informed medical and legal decisions. Review of the Clinical Psychologist Note, signed 11/14/22, reflected R40 was evaluated to assess capacity to make informed medical and legal decisions. Continued review of the document reflected, In psychologist's professional opinion, psychologist determined that [named R40] is able to make informed medical and legal decisions. Review of R40 Social Service Progress Note, dated 6/14/2021 at 7:38 a.m., reflected, Writer spoke to [named R40] and issued the new court date paperwork explaining that he has a Zoom hearing on 7/12 and stated that writer would be in to assist with the Zoom hearing. [Named R40] was agreeable for writer to assist .[named R40] had no change in mood or behaviors, he was cooperative with staffs interview and then continued to discuss the upcoming court date and how angry he is that the guardian closed his bank account and does not feel that his guardian has his best interest. Writer explained that we can discuss that at his court date with the judge and they will handle it . The Progress Note was written by SW J. Review of the Social Service Progress Note, dated 7/21/2021 at 12:05 p.m., reflected R40's court appointed guardian was changed to [named guardian services]. Review of R40 Care Plan Progress Note, dated 8/18/2021 at 8:37 a.m., reflected, Writer spoke to [named R40} and informed him that his care conference will be rescheduled r/t not hearing back from his guardian. [named R40] stated that they have not returned his calls either. Writer explained that since he wants to go to Florida, writer wants his guardian to be in attendance or at least via phone. [named R40] gave writer a card for admissions for a Brookdale facility in Florida stating that he wants to go to. Writer stated that she has to have permission from his guardian in order to send him out of state. Writer explained that she would try and call his guardian after morning meetings and see if we can get it rescheduled. Will continue to monitor, provide support and address any issues/concerns as they arise. Review of R40 Social Service Progress Note, dated 8/26/2021 at 9:12 a.m., reflected, Writer received a phone call from [named R40] this morning stating that he wanted to return to [NAME] Virginia. Writer stated that she received a voicemail from the guardian stating that she's unable to transfer him out of state because he's under the guardian care, however she would be able to transfer him to an assisted living facility. [named R40] stated that the guardian never said that to him. Writer stated that she would contact the guardian this morning and see what can be done. Will continue to monitor, provide support and address any issues/concerns as they arise. Review of R40 Social Service Progress Note, dated 8/26/2021 at 2:00 p.m., reflected, [named R40] stopped writer in the hall, writer explained that she left his guardian a voicemail requesting a call back r/t his transfer. Writer explained to [named R40] again that she's unable to transfer him out of state, because of his guardianship. [named R40] became angry and started yelling at writer in the hall, and called her names. Writer explained that she will not be called names and will wait to hear from the guardian about transfer. Will continue to monitor. Note was written by SW J. Review of R40 Social Services Progress Note, dated 8/31/2021 at 3:29 p.m., reflected, Writer received a voicemail on Friday around 5 pm and another voicemail on Monday around 2:30 pm from [named R40] requesting a call back to speak to him. Writer went to speak with him and he stated that he wants to go to [NAME] Virginia. Writer explained that she can't transfer him out of state without the guardian's permission, however if he wanted to transfer in the [NAME] Arbor area that can be accomplished. [named R40] stated that he does not want to do that, he wants to go to [NAME] Virginia. [NAME] became agitated that writer was ignoring him. Writer explained that she's not ignoring him, she was off on Monday, [named R40] stated that writer never calls him back. Writer explained that she does not call him, but she comes down to see him when she can. [named R40] denied writers statement and then became agitated again and said he wants to go to [NAME] Virginia. Writer explained that she can't do that unless she has permission from the guardian. [named R40] became agitated and defensive stating that writer does not do anything for him, writer explained that she does what she can, but its inappropriate for him to be yelling, swearing and calling writer names .Writer stated she would contact the guardian about the transfer, [named R40] then stated that he wanted a court date because he does not feel he needs a guardian. Writer explained that she can't make that determination but would reach out to the guardian. Will continue to monitor, provide support and address any issues/concerns as they arise. Note written by SW J. Review of R40 Social Work Note, dated 11/15/2021 at 10:07 a.m., reflected, admitted on [DATE][date after note], for Long Term Care services .[named R40], who prefers to be called [named R40]; was readmitted to [Named facility]. [named R40] is a DNR, alert and oriented x 3, although he does have a guardian in place prior to admission to the facility. [named R40] goal is to go to [NAME] Virginia, however at this time [named R40] will remain LTC at this facility, until guardianship can be switched to a company in [NAME] Virginia. [named R40] stated that his lawyer in [NAME] Virginia is working on switching the guardianship. Will continue to monitor and address any issues/concerns as they arise. Note written by SW J. Review of R40 Social Service Progress Note, dated 4/28/2022 at 12:41 p.m., reflected, .admitted on [DATE], for Long Term Care services .Annual assessment completed with [named R40]. BIMS score of 15 indicates cognitively intact, PHQ-9 score of 8 indicates potential for mild depression. Guardianship has been granted and Guardian's Care Inc is the responsible party. [named R40] is a DNR, alert and oriented x 3, able to make needs known, can be pleasant and cooperative with staff at times and can also be irritable at times. [named R40] ultimate discharge goal is to return to the community in [NAME] Virginia, facility and Ombudsman are assisting with possible transfer. [named R40] has a dx of bipolar disorder and receives Zoloft 75mg Qday and Valproic Acid 250mg Qday for dx of Bipolar d/o. Mood appears stable overall, no behaviors noted this quarter. Will continue to monitor, provide support and address any issues/concerns as they arise. Review of the Care Conference Note, dated 5/20/2022 1:10 p.m., reflected, Care conference held. Those in attendance include Activities Dietary Nursing Social Services The patient attended. The discharge planning process in not active at this time. DNR at this time .There is no current acute illness present. There are no current changes to pain management. No significant changes in activities of daily living at this time .Physical Therapy is not being received. Occupational Therapy is not being received. Speech Therapy is not being received .The patient is not their own decision maker. Guardian's Care Inc.[named]. Patient is not exhibiting behavioral symptoms. No ancillary services provided Audiology Dental Podiatry Vision Patient/Family education and/or follow up is not indicated at this time .The patient/responsible party did not request a copy of the current care plan. The patient/responsible party did not request a copy of the current physician orders. [Guardian not present] Comments: Quarterly care conference held with [named R40], he stated that he's doing fine, but wants to be seen by his doctor. He declined any other issues/concerns. Guardian did not attend via phone as she did not answer the phone when staff called her. Will continue to monitor, provide support and address any issues/concerns as they arise. Review of R40 Social Services Note, dated 7/27/2022 at 4:32 p.m., reflected, Quarterly MDS completed with a BIMS score of 15 indicating no cognitive impairments and a PHQ-9 score of 2 indicating minimal depressive symptoms. Resident voiced he feels depressed because he does not feel he needs a guardian and would like to discharge to [NAME] Virginia. Writer to continue to work with resident on discharge planning. Writer to also continue to provide support as needed. Note written SW W. (One year after resident requested to transfer and concerns about need for guardian). Review of R40 Social Services Progress Note, dated 9/15/2022 at 10:53 a.m., reflected, Resident called writer to discuss concerns with not getting his mail. Writer explained d/t him having a guardian, all of his mail goes directly to the guardian. Writer explained if he was waiting for specific pieces of mail, he can contact the guardian to ask for them to be mailed back. Writer attempted to give resident the phone number and resident stated he already had it. Resident started to get angry and yell at writer over the phone stating, this is criminal, you cannot send my mail to my guardian, I don't even need a guardian . Review of R40 Social Services Progress Note, dated 9/19/2022 at 9:14 a.m., reflected, Writer called a facility of choice for resident to discuss transfer. The facility told writer there is an application process and a wait list. Will discuss with resident to complete application. Spoke with resident's guardian regarding discharge planning to [NAME] Virginia. Resident's guardian stated she has no concerns with him transferring, but will have to confirm there is a guardian in place in the location of the transfer prior to the transfer occurring .When writer got off the phone, resident's community social worker was in the office to discuss resident. Writer explained current discharge planning progress. Social worker stated no other questions or concerns. Writer to continue to follow and provide support. Note written by SW W. Review of R40 Social Services Progress Note, dated 9/21/2022 1:17 p.m., reflected, Writer emailed back and forth with VA SW regarding resident's request to transfer. Discussed transferring to a VA contracted facility and then to the community. Writer also asked if the VA would be able to assist with guardianship for resident to transfer. VA SW stated the VA does not assist with guardianship, but to call the county probate court where resident will be residing. Writer to continue to follow and provide support. Review of R40 Social Services Progress Note, dated 9/27/2022 3:19 p.m., reflected, Writer spoke with resident regarding update with transfer. Writer told resident that the VA SW stated a transfer to a different SNF with a VA contract would be easiest and then transfer to the community once in [NAME] Virginia. Resident was agreeable to this plan. Writer to continue to follow and provide support. Note completed by SW W. Review of R40 Social Service Note, dated 10/6/2022 8:11 a.m., reflected, Writer called and spoke with the VA in PA regarding resident's transfer. VA SW pulled resident up in system and stated she would start the process to transfer resident's service down there. PA SW will be sending an email to AA SW and writer to discuss the steps that needs to happen moving forward on resident's transfer. Will continue to follow and provide support as needed. Note completed by prior SW W. Review of R40 Care Conference Note, dated 11/3/2022 3:56 p.m., reflected, Resident is currently out at hospital for quarterly care conference. IDT called and left message with resident's guardian and reviewed plan of care among IDT. Reviewed resident's code status, advance directives and ancillary services. Writer reported transfer to a different SNF and actively working on the discharge . Review of R40 next Care Conference Note, dated 1/26/2023 1:50 p.m., reflected, Care conference held. Those in attendance include Activities Dietary Social Services The patient attended. [No mention of Guardian services]. The discharge planning process is active at this time. Plans to discharge to a Nursing Home. Currently working on transferring to a SNF in Ohio. Full code status at this time .Physical Therapy is not being received. Is not receiving Occupational Therapy. Is not receiving Speech Therapy .The patient is not their own decision maker. Guardian Care Inc. Patient is not exhibiting behavioral symptoms . Review of the Electronic Medical Record (EMR), dated 1/26/23 through 4/11/23, reflected no evidence of progress or efforts towards resident request for transfer to another facility closer to family that had been in the progress for almost two years. Review of the Social Services Progress Notes, dated 3/18/2023 at 11:05 a.m., reflected, Writer received a phone call from [named R40] while he was in the hospital asking writer about a medication list while he's at the hospital. writer explained that he's been gone for so long that his medications are discontinued from the system, so she's unable to determine which meds he's referring too . Note completed by SW director J. Review of R40 Social Services Progress Note, dated 4/11/2023 at 8:35 a.m., reflected, SW met with Resident per his request (per concern form) re: f/u on Resident's desire to terminate legal Guardianship, move out of state, and live his best life. Resident states he would like to first move to Ohio for a while, and then move to [NAME] Virginia. In Ohio, he states former SW informed him that he would not have VA coverage until he officially became a Resident of the state of Ohio which would take 45 days. Then he would be able to apply for the coverage/have it transferred to OH, to that particular service area . Note completed by SW DD. (After R40 interview with surveyor on 4/4/23 related to mentioned concerns). Review of Concern Form, dated 4/10/23, reflected R40 contacted NHA A via telephone and requested to speak with facility Social Worker related to concerns. The document reflected SW DD met with R40 to discuss process for ongoing concern related to terminating Legal Guardian and moving away. The form included section labeled, Results of action taken: with handwritten note that included, ongoing issue, will cont. to assist Res. as able. The form reflected section labeled, Resolution of Concern, was concern resolved? The form was marked, No, with handwritten note, This is an ongoing issue, and the process is time consuming. Continued review of the form reflected section labeled, Was the complainant satisfied with the resolution? The form was marked, No, with written note, ongoing issue w/ legal system entanglement. (R40 had competency re-evaluation, dated 11/14/22, that reflected able to make own informed medical and legal decisions.) During an interview on 4/13/23 at 2:51 p.m., located in R40 room with both R40 and local Ombudsman (OMB) FF, R40 provided verbal permission to discuss R40 concerns with OMB FF. OMB FF reported aware of ongoing concerns related to delay with process to terminate R40 court appointed Guardian Group and delayed plans to transfer to facility out of state, closer to family. OMB FF reported facility had frequent Social Service Department staff turnover with no overall follow-up or resolution to R40's request to terminate Guardianship or discharge to another state for over a year. OMB FF reported was under the impression that R40 was deemed competent to make own decisions several months ago and was unsure why facility had not assisted R40 schedule court hearing to terminate Guardianship as requested by R40. During an interview on 4/13/23 at 4:08 p.m., SW DD reported followed up with R40 as requested by R40 Concern Form, dated 4/10/23. SW DD reported had been employed at the facility for about one month as the SW. SW DD reported R40 reported concerns with ongoing process relating to terminating court appointed Guardian Services and transferring to another facility out of state. SW DD reported was not aware R40 had requested assistance with both for over a year from the facility. SW DD reported R40 was currently not his own responsible party and had a court appointed guardian and was under the impression that NHA A had provided R40 with documents to terminate guardianship. SW DD reported resident competencies can change related to many factors and reported a role of Social Worker is to advocate for residents and request re-evaluation and assist as needed. SW DD reported R40 alert and oriented and able to make needs known. During an interview on 4/13/23 at 4:29 p.m., NHA A reported R40 currently had a court appointed Guardian Service and had knowledge R40 was unhappy about having a Guardian and requests to transfer to another facility. NHA A reported had recently provided R40 with paperwork related to process for termination guardianship and reported R40 refused to allow staff to assist with completing documents. NHA A was unable to reported when documents were provided or provided evidence. NHA A reported would expect Social Services to assist residents with discharge planning and resident concerns with guardianship and expect staff to document in resident medical record including updated to Care Plans. Based observation, interview and record review the facility failed to preserve the dignity of 5 residents (Resident #14, Resident #31, Resident #36, Resident #40 and Resident #76) of eight residents reviewed for dignity, resulting in feelings of anger, embarrassment, and decreased self-worth. Findings include: Resident #31: According to the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/23, Resident # 31 (R31) was admitted to the facility on [DATE] with diagnoses that included anxiety, bi-polar disorder and depression. Further review of the MDS reflected R31 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). During an interview with R31 on 04/04/23 at 1:30 pm, she reported staff often talk on phone while providing care, they use an ear piece. R31 went on to say that recently one of the nursing staff was in R31's room providing care and the staff person started talking into their wrist. R31 stated she had not realized the facility employees watch could be used as a phone until she asked the unidentified staff to repeat herself (R31 thought the staff member was speaking to her.) R31 stated the girl snapped at her and told me to mind my business she was on the phone. R31 stated she was embarrassed for not realizing the watch could be used as a phone then angry for being snapped at treated like a child. When queried how frequently this occurs, R31 stated it was daily common occurrence that staff talk on the phone during care or have ear buds in an listen to music. Resident #36 According to the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/23 Resident # 36 (R36) was a [AGE] year old resident with diagnoses that included major depression and anxiety. Review of the Brief Interview for Mental Status (BIMS) R36 scored 15 out of 15 (cognitively intact). On 04/04/23 at 09:02 AM, during an interview with R36, it was reported that Certified Nursing Assistants (CNA) K, L and Mconstantly talk to each other about their personal lives, talk over resident, have a bad attitude, constantly wear their ear buds all while providing care to R36 or her roommate. When queried if R36 had

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains To Intake Number MI00130725. Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse and neglect for one resident (Resident #239) of three residents reviewed for abuse, resulting in allegations of abuse and neglect not being thoroughly investigated and the potential for further allegations not being thoroughly investigated. Findings include: Resident #239: According to the clinical record, Resident # 239 (R239) was a [AGE] year old male admitted to the facility 06/14/22 and transferred to the hospital on 6/18/22. R239 was admitted to the facility with multiple medical comorbidities and received nutrition through a feeding tube and had a tracheostomy. Review of the Facility Reported Investigation (FRI) reflected R#239's relative (family member) X emailed former Social Worker (SW) W on 6/20/22, the email read in part.the first night the tech came in and yelled at him, complained didn't have time for him, banged on the table and left him . The email went on to say family member X and R239 had complained to Respiratory Therapist (RT) Y but requested RT Y not reveal R239's name due to their fear of retaliation. Later in the same email it alleged former Licensed Practical Nurse (LPN) V intentionally withheld oxygen from R239 and according to the Emergency Medical Service staff , former LPN V was not acting right. Further review of the FRI, including witness statements reflected there had been not been an interview or documented attempts in identification of the Tech that verbally abused, slammed his hand on the table and allegedly neglected R239 on 6/14/22 . Further review of the FRI did not have a statement or any form of documented interview with Respiratory Therapist Y whom allegedly took the first complaint from R239 and family member X, nor was their documented evidence that former LPN V was suspended pending investigation of abuse. On 04/12/23 04:07 PM former SW W was contacted via phone and had no recollection of R239 or family member X, on 4/12/23 at 04:10 PM and 4/13/23 at 9:31 am former employees LPN V and Certified Nursing Assistant (CNA) AA both assigned to R239 the during the alleged time frame of neglect and withholding of oxygen. Neither former employees returned the calls. On 04/13/23 09:12 AM RT Y was interviewed and had no recollection of R239 or family member X, nor did she recall being interviewed by former Nursing Home Administrator ( NHA) R or former Director of Nursing (DON) S whom completed the facility reported incident. RT Y stated she was fairly certain that she had not provided a written statement. On 04/13/23 08:59 AM, during an interview with NHA A the facility reported incident investigation and documents were reviewed, NHA A acknowledged there was no evidence that former NHA R had not documented any attempt in identification of the Tech that verbally abused, slammed his hand on the table and allegedly neglected R239 on 6/14/22 . NHA A also was not able to locate documentation to support that Respiratory Therapist Y had ever been interviewed for the investigation or documentation that former LPN V was suspended pending investigation of abuse. On 04/13/23 09:47 AM Human Resource Director ( HR) N reviewed former LPN V personnel file and reported LPN V was not suspended in June of 2022. A request of former LPN V time sheet beginning on 6/14 thru 6/25 was requested at that time. On 4/17/23. NHA A reported on 4/17/23 at approximately 10:00 am that she obtained former LPNV time sheet for June 2022 and some dates read sus indicating he had been suspended. A second request was then made to review former LPN Vs time sheet beginning June 14 2022 but was not received by the exit date of 4/17/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to revise care plans for 8 residents (#12, #15, #22, #28, #34, #48, and #92) of 24 residents reviewed resulting in the potential of unmet care needs. Findings included: Resident #12 (R12): Review of the medical record revealed R12 was admitted to the facility 12/5/2020 with diagnoses that included congestive heart failure (CHF), hypertension, chronic respiratory failure, type 2 diabetes, atherosclerotic heart disease, occlusion (blockage) and stenosis (narrowing) of carotid artery, atrial fibrillation, vascular dementia, anxiety, psychotic disturbances, mood disturbance, insomnia, gout (buildup of uric acid in bone joints) , dysphagia (difficulty swallowing), and anemia (low blood count). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/2023, revealed R12 had a Brief Interview for Mental Status (BIMS) of 99 (unable to participate in assessment). During observation on 04/05/2023 at 08:00 a.m. R12 was observed setting on the side of her bed eating breakfast. She repeatedly was making grunting sounds and saying help. R12 did not respond to verbal stimulation. In an interview on 04/10/2023 at 10:34 a.m. Certified Nursing Aide (CNA) CC explained that R12 did have behaviors of grunting and saying help repeatedly. CNA CC explained that the behaviors had been getting worse. She also explained that she was not aware of any interventions that would help R12 during these behaviors. She explained that she only knew to place an alert in the point of care documentation that would notify the nurse. Review of the medical record revealed R12 had the problem statement cognitive loss as evidence by dx (diagnosis) of vascular dementia with behaviors. No identification of R12 resent behaviors or interventions to assist the resident. In an interview on 04/12/23 at 10:31 a.m. Social Worker (SW) J explained that she was aware of behaviors that had been observed for R12. SW J explained that she was made aware by alerts when residents have behaviors. She also explained that she was made aware by a progress note (04/04/2023) that R12 had been yelling. SW J was asked to review the plan of care for R12. She confirmed that the new behaviors were not located in the plan of care and no new interventions were present for the new behaviors that had been exhibited. SW J explained that she should have placed those behaviors in the plan of care and included interventions to assist the staff in providing care to R12. SW J could not explain why the plan of care was not updated. Resident #15 (R15): Review of the medical record revealed R15 was admitted to the facility 03/26/2016 with diagnoses that included seizures, stage 3 kidney disease, right knee pain, mood disorder, adjustment disorder, depression, traumatic brain injury, hydrocephalus (buildup of fluid in the brain), adult failure to thrive, osteoporosis (brittle/fragile bones), macular degeneration (degenerative condition affecting the retina), glaucoma (buildup of fluid in eye), gastro-esophageal reflux, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/16/2023, revealed R15 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. During observation and interview on 04/04/2023 at 11:38 a.m. R15 was observed lying in bed. R15 explained that wanted to be discharged from the facility but no one had assisted him with that plan. R15 explained that he had talked with Social Worker (SW) DD and SW J about his desire to be discharged . Review of the medical record demonstrated care plan problem statement Patient does not show potential for discharge to the community due to need for 23/7 medical care and supervision for medical issues, memory deficits and physician debility. That problem statement was revised 04/10/23 by SW J. In an interview on 04/10/2023 at 09:48 a.m. Social Worker DD explained that he had knowledge that R15 had a desire to be discharge in the past. He explained that he had not spoken with R15 regarding his discharge plan. In an interview on 04/12/2023 at 10:57 a.m. Social Worker J explained that R15 desired to be discharged from the facility. She explained that she had not assisted R15 with this plan because he was not able to be discharged . When asked why he could not be discharged , she explained that R15 had a guardian who had been appointed to him in 2019 after he was determined to be incompetent. SW J explained that she had spoken to the guardian regarding discharge but could not provide any documentation. SW J could not explain why R15's discharge plan did not explain that he wanted to go home or any interventions to assist him in meeting his goal of discharge. SW J agreed that the plan of care did not provide any interventions on how to assist R15 with his desire for discharge. Resident #22 (R22): Review of the medical record revealed R22 was admitted to the facility 02/16/2023 with diagnoses that included depression, anemia (low amount of blood), hyperlipemia (high fat content in blood), neuropathy (nerve damage), insomnia, anxiety, seizures, urinary retention, malignant neoplasm of breast (breast cancer), hypertension, dysphagia (difficulty swallowing), tremors, and dizziness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/22/2023, revealed R22 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 04/03/2023 at 02:08 R22 was observed lying down in bed. R22 explained that she was going to be discharged soon but did not know what the plan was to be. She explained that she had requested to talk with a social worker but she no one has talked with her as of this date. Review of the medical record demonstrated plan of care that stated, Patient shows potential for discharge and patient, relative, or representative expresses with for discharge. The plan of care for discharge had been updated since 2/20/2023. In an interview on 04/06/2023 at 01:43 p.m. Social Worker (SW) J was asked to review the discharge plan of care for R22. SW J reviewed the plan of care and explained that it was her understanding that R22 would be discharged home with her daughter. SW J was asked why the plan of care did not reflect that information. SW J explained that she had been told by the previous facility cooperation that owned the facility that the care plan was not to be specific and individualized. In an interview on 04/10/2023 at 09:37 a.m. Social Worker (SW) DD explained that R22 had different discharge plans during her stay at the facility. He explained that each family member of R22 had different plans for their mother's discharge, while R22 wanted something totally different. SW DD explained that the current plan was that R22 wanted a referral made to an assisted living facility and was to be discharged [DATE]. When asked where that documentation was present, SW DD explained that he had e-mails with that information but had not recorded anything in the medical record. SW DD agreed that the discharge plan of care was not accurate and should have been updated. SW DD could not explain why the plan of care was not updated. Resident #34 (R34): Review of the medical record revealed R34 was originally admitted to the facility 08/10/2022 and most recently re-admitted [DATE] (following a recent hospital stay on 02/19/2023) with diagnoses that included chronic ischemic heart disease, congestive heart failure (CHF), atherosclerotic heart disease of coronary artery, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation, gastro-esophageal reflux, hypercholesteremia, chronic viral hepatitis C, hypertension, anxiety, depression, and benign prostatic hyperplasia (prostate enlargement). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2023, revealed R34 had a Brief Interview for Mental Status (BIMS) of 10 (moderately impaired cognition) out of 15. During observation and interview on 04/05/2023 at 09:43 a.m. R34 was observed laying on his bed. R34 explained that he recently had a short stay at the hospital sometime in February of this year and explained that he was happy to be back at the facility. During review of R34's medical record it was revealed that R34 had a care plan that stated, At risk for behavior symptoms r/t (related to) Alzheimer's disease/dementia. No specific types or behaviors that had been exhibited were list on R34's plan of care. In an interview on 04/12/2023 at 10:57 a.m. Social Worker J explained that R34 does exhibit certain behaviors such as walking around with his front wheel walker when he is anxious and can be verbally aggressive when the facility staff. Social Worker J could not explain why R34's behaviors had not been included on his plan of care or what why interventions had not been listed. Resident #48 (R48): Review of the medical record revealed R48 was admitted to the facility 01/15/2020 with diagnoses that included chronic obstructive pulmonary disease (COPD), depression, type 2 diabetes, benign hyperplasia (enlarge prostate), obstructive and reflux uropathy (obstruction of urine flow), panic disorder, hypertension, cerebral infarction (ischemic stroke), obstructive sleep apnea, stage 4 kidney disease, coronary artery disease, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2023, revealed R48 had a Brief Interview for Mental Status (BIMS) of 11 (moderately impaired cognition) out of 15. During observation and interview on 04/05/2023 at 09:57 a.m. R48 was observed lying in bed. R48 explained that he was to be discharged to another facility, but the facility was doing nothing to assist him with his discharge plan. Review of the medical record revealed R48 had a plan of care that stated, Patient shows potential for discharge and patient, relative, or representative expresses wish for discharge. That discharge plan was last revised on 02/20/2023. The medical record also revealed that R48 had a plan of care that stated, Patient does not show potential for discharge to the community due to long term stay. Requires 24-hour care/supervision. That discharge plan was last revised 01/20/2023. R48's medical record also demonstrated a progress note that was entered 01/20/2023 that stated, Resident still is hoping to transition to a long-term care facility in [NAME]. Writer is working on transfer. In an interview on 04/13/2023 at 11:00 a.m. Social Worker (SW) J explained that R48 had expressed a desire to transfer to another facility in [NAME], Michigan. She explained that a previous Social Worker had been assisting him with that transfer. She explained that Social Worker left the facility the middle of March 2023. SW J reviewed R48's discharge plan and agreed that the discharge plan of care was not accurate. SW J could not explain why the discharge plan of care had not been updated to reflect R48's current discharge plan. Resident #92 (R92): Review of the medical record revealed R92 was admitted to the facility 06/17/2019 with diagnoses that included pulmonary embolism, abnormal heart beat, cardiac murmurs (abnormal sound of blood in heart), fatigue, restless leg syndrome, pulmonary nodule (mass), dysphagia (difficulty swallowing), muscle wasting and atrophy, subdural hemorrhage (brain bleed), anxiety, psychotic disorder with delusions, psychotic disorder with hallucinations, polyosteioarthritis (joint pain and stiffness), diverticulosis (abnormal pouch in intestinal wall of the intestines), stage 2 kidney failure, neuropathy (nerve damage), Parkinson's disease, type 2 diabetes, insomnia, gastro-esophageal reflux, hyperlipidemia, and Lewy body dementia. ). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/05/2023, revealed R92 had a Brief Interview for Mental Status (BIMS) of 11 (moderately impaired cognition) out of 15. During observation and interview on 04/10/2023 at 08:29 a.m. R92 was observed sitting up in a chair was the side of her bed eating breakfast. R92 was unable to answer questions and just kept saying doing good. Review of the medical record revealed R92 had a plan of care that stated, Paranoia/Suspiciousness and hallucinations as evidenced by: she stated that she believes people are trying to force her to go to the hospital, someone is forcing her to have a brain procedure, related to: unknown cause, my be related to her reading books. A lot of her feeling things are reality to her. She sites from recent books she has read or when she is listening to her roommates TV shows. She will make comments about the person is coming after her from the show. This care plan problem statement was last updated 04/12/2023. The only intervention listed of for that problem was to administer medication per physician orders, which was last updated 04/12/2023. In an interview on 04/12/2023 at 10:54 a.m. Social Worker J explained that R92 had delusions that her dad was supposed to pick her up. SW J could not demonstrate that those delusions were in R92's plan of care. SW J explained interventions for those delusions were that R92 was easily redirectable, and that staff should take her back to the room and set and talked with her. SW J could not demonstrate that that any intervention was listed on R92's plan of care other than administer medication per physician orders. Resident #28 (R28): In an observation and interview on 4/03/2023 at 2:41 PM, with Resident #28 (R28) it was observed that in a medication cup (small plastic cup used to place medications in) there was a purple scored (dented line to break apart pill) oval shaped pill with an M on one side and L10 on the other side, and another round scored white pill with the number 120 on it. The two pills were identified be a thyroid pill and a Baclofen (muscle relaxer) pill. R28 stated that the two pills were brought in to her at around 6:00 AM this day (4/3/2023). R28 stated that she finished her lunch at approximately 2:00 PM and needed to wait three hours after she ate to take her thyroid pill, and said she did not know when she would take the Baclofen pill. R28 the stated that the Baclofen pill was brought in to her around 1:00 PM. In a continued interview R28 stated stated that she did not know when she would take the Baclofen pill, but may not take it so she probably will flush it down the toilet. Further observation of R28's room drawer (that was open) revealed a bottle of medicated nasal spray containing Azelstine hcl (hydrochloride) in R28's drawer. R28 stated that the nasal spray had been in her drawer for more than a month. In an interview on 4/6/2023 at 1:00 PM , LPN T stated that R28 needed to be watched taking her pills by the nurses, because she would put the pills in her mouth, and nurses would see the cup was empty, but she would pocket the pills, such as her thyroid and Baclofen, then spit them out after the nurse left her room. LPN T said then R28 would put pills into a medication cup. LPN T was asked what interventions were in place to address R28 pocketing medications. LPN T was not able to state any interventions, but stated that R28 was care planned that she did this so it was okay seems there was a care plan in place. Review of R28's care plans revealed no care plan was in place that addressed R28 needing to be watched taking her pills, pocketing of her pills, or keeping the pills in her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure sufficient nursing staff for four residents (Resident #10, Resident #14, Resident #67, and Resident #84) and the confidential residents attending Resident Council resulting in the potential of all 114 residents residing at the facility being unable attain or maintain their heights practicable physical, mental, and psychosocial well-being related to showers and unmet needs. Finding Included: Resident #10 (R10): Review of the medical record revealed R10 was admitted to the facility 02/08/2023 with diagnoses that include B-cell lymphoma (cancer of the lymph nodes), pancytopenia (problem with blood-forming stem cells in bone marrow), hypertension, hyperlipidemia (increase fat in blood), osteoporosis (brittle and fragile bones), glaucoma, and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2023, revealed R10 had a Brief Interview for Mental Status (BIMS) of 11 (moderately cognitively impaired) out of 15. During observation and interview on 04/04/2023 at 07:50 a.m. R10 was observed lying in bed. R10 explained that she knew the facility was short staffed because it takes a long time for her call light to be answered. R10 explained that she frequently must get her own water because it would just take to long. Resident #67 (R67): Review of the medical record revealed R67 was admitted to the facility 03/14/2018 with diagnoses that include lymphedema (abnormal accumulation of lymph in the body), vitamin D deficiency, polyosteoarthritis (arthritis in at least five bone joints), depression, anxiety, peripheral neuropathy (nerve damage), morbid obesity, hypertension, right hip pain, right knee pain, and asthma. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/2023, revealed R67 had a Brief Interview for Mental Status (BIMS) of 15 (Intact cognition) out of 15. During observation and interview on 04/04/2023 at 08:39 a.m. was observed lying down in bed. R67 explained that at night she would place her call light on, and the staff would come and turn it off without attending to her needs. She explained that the staff tell her that they will come back but they never return. R67 explained that many times she needs assistance after being incontinent in her brief and just needs to have her brief changed. She further explained that there are times where she would place the call light on just before 3 a.m. and does not receive assistance until well after 4 a.m. Resident #84 (R84): Review of the medical record revealed R84 was admitted to the facility 03/03/2022 with diagnoses that include benign neoplasm of cranial nerves, cardiomyopathy (enlargement of the heart), hypertension, right arm pain, atherosclerotic heart disease, ischemic cardiomyopathy (decreased ability for heart to pump blood) , congestive heart failure (CHF), right shoulder pain, hyperlipidemia, lung cancer, depression, peripheral neuropathy (nerve damage), type 2 diabetes, and orthostatic hypotension (drop in blood pressure when standing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2023, revealed R84 had a Brief Interview for Mental Status (BIMS) of 14 (Intact cognition) out of 15. During observation and interview on 04/04/2023 at 08:21 a.m. R84 was observed lying in bed. R84 explained that the facility was not good with answering the call light. R84 explained that it usually takes an hour to a hour and a half before someone comes into the room to answer the call light. Review of Resident Council Minutes, dated 03/15/2023, demonstrated concerns with the Nursing Department that was documented call light wait times, especially at night. Review of Resident Council Minutes, dated 01/24/2023, demonstrated concerns with the Nursing Department that was documented Residents waiting a long time for call light. Review of Resident Council Minutes, dated 10/11/2022, demonstrated concerns with the Nursing Department that was documented Residents waiting a long time for call lights. Review of the facility's CMS-672 Resident Census and Conditions of Residents dated 4/3/23 revealed the facility's census was 114 , of which 105 required assistance of one or two staff for bathing, 102 required assistance of one or two staff for dressing, 97 required assistance of one or two staff for transferring, 98 required assistance of one or two staff for toilet use, and 17 required assistance of one or two staff for eating. The CMS-672 also revealed 6 residents were dependent on staff for bathing, 5 were dependent on staff for dressing, 6 were depending on staff for transferring, 6 were dependent on staff for toilet use, and 2 were dependent on staff for eating. Resident #14: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R14 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), heart failure, stroke with hemiplegia, post traumatic stress disorder, and depression. The MDS reflected R14 had a BIMS (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required two-person assist with bed mobility and one-person physical assist with transfers, toileting, dressing, hygiene, and bathing. The MDS reflected R14 had no evidence of behaviors. During an observation and interview on 4/03/23 at 2:10 PM, R14 was in his room sitting in a personal motor chair and appeared alert and able to answer questions. R14 reported attended resident cousil meetings on a regular basis and had reported concerns with long call light times. R14 also reported wanted to go outsided and go around facility in motor chair and staff will not allow him to leave the facility. R14 reported staff at front desk had informed him he was not allowed to leave the facility for safety reasons. During an interview on 4/04/23 at 11:03 AM, resident in room [ROOM NUMBER] reported long call light response times that were discussed at monthly resident council meetings with no improvements. Review of the Resident Council Meeting minutes for past six months revealed four of six months with resident complaints of staffing including long call light response and missed showers and bathing with no evidence of resolution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation on 4/03/23 at 2:10 PM, prescription inhaler was observed in room [ROOM NUMBER] window bed on the bedside table. Resident in bed by door and staff reported resident in 304 window bed had been transferred to the hospital. Based on observation, interview, and record review the facility failed to ensure safe and secure medication storage for two out of 16 medication carts, and three out of three residents (Resident #28, Resident #62, and Resident #77) resulting in the potential for loss of medications, and other residents having access to medications. Findings Included: Resident #28 (R28): In an observation and interview on 4/03/2023 at 2:41 PM, with R28 it was observed that in a medication cup (small plastic cup used to place medications in) there was a purple scored (dented line to break apart pill) oval shaped pill with an M on one side and L10 on the other side, and another round scored white pill with the number 120 on it. The two pills were identified be a thyroid pill and a Baclofen (muscle relaxer) pill. R28 stated that the two pills were brought in to her at around 6:00 AM this day (4/3/2023). R28 stated that she finished her lunch at approximately 2:00 PM and needed to wait three hours after she ate to take her thyroid pill, and said she did not know when she would take the Baclofen pill. R28 the stated that the Baclofen pill was brought in to her around 1:00 PM. In a continued interview R28 stated stated that she did not know when she would take the Baclofen pill, but may not take it so she probably will flush it down the toilet. Further observation of R28's room drawer (that was open) revealed a bottle of medicated nasal spray containing Azelstine hcl (hydrochloride [for relief of congestion]) in R28's drawer. R28 stated that the nasal spray had been in her drawer for more than a month. In an interview on 4/6/2023 at 1:00 PM , LPN T stated that R28 needed to be watched taking her pills by the nurses, because she would put the pills in her mouth, and nurses would see the cup was empty, but she would pocket the pills, such as her thyroid and Baclofen, then spit them out after the nurse left her room. LPN T said then R28 would put pills into a medication cup. LPN T was asked what interventions were in place to address R28 pocketing medications. LPN T was not able to state any interventions, but stated that R28 was care planned that she did this so it was okay seems there was a care plan in place. Review of R28's care plans revealed no care plan was in place that addressed R28 needing to be watched taking her pills, pocketing of her pills, or keeping the pills in her room. Review of R28's EMR revealed no assessment was conducted for R28 to self administer her own medications. Resident #77 (R77): In an observation on 04/06/2023 at 12:50 PM, R77's lunch tray was observed to have a medication cup sitting on it that also contained four large oval white pills that were marked with J75. R77 stated the pills were his phosphorus pills that he took with every meal, and had to take them when he started eating. R77 stated the nurses would usually leave the pills with him on his tray, however stated that he was not going eat his lunch so therefore he was not going to take the pills. A staff member entered R77's room and asked if he was done with his tray, in which R77 stated yes. The staff member went to pick up the tray, but was asked to get the nurse first. In an interview on 4/06/2023 at 1:00 PM, Licensed Practical Nurse (LPN) T stated that the pills on R77's lunch tray were his Phosphorous pills. LPN T said R77 would say that he would take the pills when he started to eat. In an interview on 04/06/2023 at 2:12 PM, LPN U was made aware of the the pills that were on R77's lunch tray in a medication cup. LPN U stated she had left the pills on his lunch tray so he could take them when he ate, but stated that she was not aware R77 did not eat, and did not take the pills. Review of R77's electronic medical record (EMR) revealed no assessment was conducted for R77 to self administer his own medications. In an observation on 4/12/2023 at 10:55 AM, of the medication cart for rooms 400-403 revealed in the bottom drawer a medication cup that was unmarked, had no resident identifier, nor marked with what the pills were in the medication cup. In an interview on 4/12/2023 at 11:10 AM, LPN Z stated that the nine medications in the unmarked med cup were Acetol 600 mg (to treat epilepsy), Magnesium 250 mg (mineral), Flomax (to treat enlarged prostate), iron, Torsemide 10 mg (to treat fluid retention), Febuxostat 80 mg (to prevent gout), Bactrim 875/125 mg (to treat bacterial infections), Doxycycline 100 mg (used to treat infections), and aspirin. LPN Z stated the resident whom the medications were for was at therapy, and would take them when he returned. In an observation on 4/12/2023 at 12:30 PM, two of the 500 hall medication cart was observed to have three pills in the bottom of the drawer loose, and the second cart was observed to have one pill at the bottom of a drawer loose. None of the pills were able to be identified which resident they belonged to because the pills were not in the medication packages. Review of the facility's policy and procedure titled.Self Administering Medications dated 1/1/2008 and revised on 11/28/2016, revealed under Procedure, 2. The Nursing Center, in conjunction with the interdisciplinary team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. Review of the facility's policy and procedure titled, .Storage and Expiration Dating of Drugs, Biological's, Syringes, and Needles dated 1/1/2008, and last revised on 9/1/2022, revealed under Procedure, 2. The Nursing Center should ensure that drugs and biological's are stored in an orderly manner in cabinets, drawers, carts, refrigerator/freezers of sufficient size to prevent crowding. The policy also revealed under Procedure, 3.3. The Nursing Center should ensure that all drugs and biological's, including treatment items, are securely stored in a locked cabinet/cart or locked medication room, inaccessible by residents and visitors. According to the clinical record, including the Minimum Data Set (MDS) with Assessment Reference Date (ARD) 03/28/23, Resident # 62 (R62) was admitted to the facility on [DATE] with diagnoses that included cerebral infarction affecting the left side, major depression, hypertension and kidney disease. R62 scored 7 out of 15 (severely impaired cognition) on the Brief Interview for Mental Status (BIMS), On 04/12/23 at 12:58 PM, R62 was observed resting in bed, the over bed table was observed to have 3 white pills on the table (one round, one oval one diamond like shaped). Resident # 62 they were pills from earlier that morning and R62 did not know what the medications were for but suggested one might be a muscle relaxer. Right after the observation , R62's assigned nurse, Registered Nurse (RN) BB was interviewed, RN BB went to R62's room at 1:15 PM and made the same observation. RN BB identified the medications as losartan (medication for hypertension) , coreg (medication used to treat heart failure) and amlodipine (medication for high blood pressure). RN BB stated she administered the three pills earlier that morning and had not realized R62 spit them out. On 04/12/23 at 1:30 PM, during an interview with Director of Nursing (DON) B , she stated she was not aware of the incident and offered no explanation as to why R62's pills were on the over bed table or why RN BB did not ensure R62 swallowed the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food preferences were honored and alternative menu options were offered to Resident #489 and the 111 of 114 residents who are served food from the kitchen. This deficient practice resulted in meal dissatisfaction, decreased appetite, and frustration when disliked foods continued to be served on meal trays. Findings include: Findings include: Resident #489 (R489): Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R489 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), calculus of gallbladder with acute cholecystitis with obstruction, reduced mobility and weakness. The MDS reflected R489 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required two-person assist with bed mobility, transfers and toileting and one-person physical assist with locomotion on unit, dressing, hygiene, and bathing. The MDS reflected R489 had no evidence of behaviors. During an observation and interview on 4/04/23 at 9:35 AM, R489 observed in room and appeared able to answer question without difficulty. R489 reported concerns related to food dislikes. R489 reported was questioned by staff on admission related to food dislikes and informed staff did not like tuna fish but did like fish. Review of R489 meal ticket reflected dislike fish. Review of facility menus on 4/12/23 reflected no fish noted on menus including Friday of lent(catholic observed Good Friday on 4/7/23 as fish only). Review of the provided Optional Menu only showed option of tuna fish sandwich. Review of the 4/7/23 menus reflected Italian Soup, pepperoni pizza, pasta salad and fruit for lunch and Baked Ham, squash, green beans, and pie for dinner. During an interview on 4/12/23 at 11:45 a.m. R489 reported had not been served fish including on lent. Reported was served pizza for lunch and thought it was really unusual when she received ham for dinner on lent(4/7/23). During an interview on 4/12/23 at 2:15 p.m., R489 reported had never been provided alternative menu including when served hot dogs or sausage type protein that were disliked. R489 reported was not provided menus and only aware of what was going to be served because passed Dining Room that had menus posted outside door. R489 reported Dining Rooms were closed related to Covid outbreak. During an interview and observation on 4/12/23 at 2:30 p.m., Food Service Manger(FSM) C, Registered Dietician (RD) D, and E reported fish was prepared on 4/7/23 because they were aware that some residents would prefer it on good Friday (observed holiday for catholic during lent). Dieticians D and E reported resident who lived in room [ROOM NUMBER] would know if it was offered. Entered room [ROOM NUMBER] with Dieticians D and E who asked resident if fish was served on good Friday. Resident in room [ROOM NUMBER] stated, No, if it was I would have requested it because it was Good Friday. Observed religious items through out room including palms given to catholic members on Palm Sunday. During an interview on 4/12/23 at 3:00 p.m., (FSM) C reported different process for meals depending on location of facility. FSM C reported alternative menus posted at Nurse Stations or Residents can call or report to staff request for alternative meals. FSM C reported was unsure why R489 did not have copy of alternative meals and verified alternative menus not posted outside dining rooms. During an observation on 4/12/23 at 3:15 p.m., no evidence of alternative menus posted at either the 200 or 400 hall nurse stations.

Based on interview and record review the facility failed to ensure that five Certified Nursing Aides (K, L, M, CC, and GG) of five Certified Nursing Aides personnel records had the required annual competency evaluation in skills and techniques necessary to care for residents, resulting in the potential for staff to lack the necessary training to adequately meet the needs of the 114 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) K was hired 02/24/2003. CNA K 's last skills and techniques evaluation for Nursing Assistants was completed 03/08/2022. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) L was hired 10/05/2012. CNA L 's most recent skills and techniques evaluation for Nursing Assistants was completed 11/15/2021. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) M was hired 01/23/2014. CNA M 's last skills and techniques evaluation for Nursing Assistants was completed 01/31/2022. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) CC was hired 01/19/2017. CNA CC 's last skills and techniques evaluation for Nursing Assistants was completed 01/31/2022. The facility was unable to provide skills and techniques evaluation for Nursing Assistants for Agency CNA GG by the time of survey exit. Review of the Facility Assessment (dated 10/2022) entitled section Staff Competencies and sub-section Skills and Techniques Evaluation for Nursing Assistants (page 7 of 14) stated, Nursing Assistants document validation of technical skills completed during job-specific orientation and annually. During interview on 04/13/2023 at 12:39 p.m. Human Resource (HR) Director N explained that Certified Nursing Aides (CNA) competency are completed by the nursing department and are coordinated with their annual hire date. She explained that she informed the nursing department of their annual hire date and that it was completed near that time. She could not explain why the annual competencies were not completed for the CNA's reviewed. During an interview on 4/12/23 at 12:00 p.m., Human Resource (HR) Director N reported did not have an employee file for Agency Certified Nurse Aid GG. HR N verified CNA GG background check was completed 3/16/23 and reported after 3/1/23 new ownership with guidance to no longer provide training/competencies including abuse training to agency staff. HR N reported facility only obtains background check and request documents if needed from each agency as needed.

Based on interview and record review the facility failed to ensure that four Certified Nursing Aides (K, L, M, CC) of four Certified Nursing Aides in-service records reviewed had the 12 hours of in-service education per year, resulting in the potential for staff to lack the necessary in-service education to adequately meet the needs of the 114 residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) K was hired 02/24/2003. CNA K 's Inservice education record revealed that CNA K only had 5.56 training hours for the dates of 04/16/2022 through 10/06/2022. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) L was hired 10/05/2012. CNA L 's Inservice education record revealed that CNA L only had 8.33 training hours for the dates of 04/13/2022 through 1/14/2023. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) M was hired 01/23/2014. CNA M 's Inservice education record revealed that CNA M only had 6.57 training hours for the dates of 04/04/2022 through 1/9/2023. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) CC was hired 01/19/2017. CNA CC 's Inservice education record revealed that CNA CC only had 8.05 training hours for the dates of 04/02/2022 through 1/13/2023. Review of the Facility Assessment (dated 10/2022) entitled section Staff Competencies and sub-section Skills and Techniques Evaluation for Nursing Assistants (page 7 of 14) stated, Nursing assistants are required to complete 12 hours of in-service training per year. During interview on 04/13/2023 at 12:39 p.m. Human Resource (HR) Director N explained that Certified Nursing Aides (CNA) education hours were tracked by the human resource department. HR Director N explained that the education reports for the Certified Nursing Aides (CNA), that had been provided, were for the last 12 months. She explained that she does not monitor the compliance of the required 12 hours of education for the CNAs. HR Director N explained that she would need to start monitoring the compliance of the required 12 hours of education for the CNA's HR Director N confirmed that the CNA's that were reviewed did not have 12 continuing educational hours for the last 12 months. During interview on 04/13/2023 at 03:05 p.m. Nursing Home Administrator (NHA) A explained that it was her expectation that Human Resource Director N needed to monitor the compliance of the Certified Nursing Aides (CNA) 12-hour education. She could not explain why this was not being monitored and was not in compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) maintain physical plant drywall surfaces effecting 113 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased interior food service equipment illumination. Findings include: On 04/03/23 at 01:21 P.M., An initial tour of the food service was conducted with Food Service Manager C. The following items were noted: The Victory one-door reach-in refrigerator interior light bulb was observed non-functional. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. The Victory one-door reach-in refrigerator light bulb socket harness assembly was observed loose-to-mount. Food Service Manager C indicated he would have maintenance repair the faulty light bulb socket harness as soon as possible. On 04/03/23 at 02:05 P.M., An environmental tour of the facility unit pantries was conducted with Food Service Manager C. The following items were noted: Maple Unit Pantry (300-400): The Hotpoint refrigerator door gasket was observed worn and torn. The damaged door gasket segment measured approximately 18-20-inches-long. [NAME] Unit Pantry (600-700): The Americana refrigerator door gasket was observed worn and torn. The damaged door gasket segment measured approximately 12-inches-long. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. The hand sink basin perimeter drywall surface, located adjacent to the dish machine room, was observed etched, scored, bubbled. The damaged drywall surface measured approximately 6-inches-wide by 24-inches-long. The ceiling drywall surface, located adjacent to the return-air exhaust ventilation grill, was observed etched, scored, bubbled. The damaged ceiling drywall surface measured approximately 12-inches-wide by 30-inches-long. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. The Univex stand mixer was observed soiled with accumulated and encrusted food residue. The spindle gear assembly and backsplash plate were also observed soiled with accumulated and encrusted food residue. On 04/03/23 at 02:05 P.M., An environmental tour of the facility unit pantries was conducted with Food Service Manager C. The following items were noted: Meadows Unit Pantry (500): The interior of the Sharp Carousel microwave oven was observed soiled with accumulated and encrusted food residue. [NAME] Unit Pantry (600-700): The interior of the Sharp Carousel Microwave Oven was observed soiled with accumulated and encrusted food residue. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The two-compartment vegetable preparation sink faucet assembly was observed leaking water. The 2017 FDA Model Food Code section 5-205.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. One of two Dish Machine Room fresh air supply grills and adjacent ceiling drywall surfaces were observed soiled with accumulated dust and dirt deposits. The 2017 FDA Model Food Code section 6-501.14 states: (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. (B) If vented to the outside, ventilation systems may not create a public health HAZARD or nuisance or unLAWful discharge. On 04/03/23 at 02:05 P.M., An environmental tour of the facility unit pantries was conducted with Food Service Manager C. The following items were noted: Cypress Unit Pantry (100-200): One plastic container of single service disposable spoons was observed uncovered without a protective lid. Maple Unit Pantry (300-400): One plastic container of single service disposable spoons was observed uncovered without a protective lid. Meadows Unit Pantry (500): One plastic container of single service disposable spoons was observed uncovered without a protective lid. [NAME] Unit Pantry (600-700): One plastic container of single service disposable spoons was observed uncovered without a protective lid. The 2017 FDA Model Food Code section 4-903.11 states: (A) Except as specified in ¶ (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under ¶ (A) of this section and shall be stored(1) In a self-draining position that allows air drying; and (2) Covered or inverted. (C) SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored as specified under ¶ (A) of this section and shall be kept in the original protective PACKAGE or stored by using other means that afford protection from contamination until used. On 04/05/23 at 04:45 P.M., Record review of the Policy/Procedure entitled: Dietary Cleaning Schedules dated 11/2020 revealed under Policy: Cleaning schedules help frame a plan for cleaning tasks. Staff use and follow cleaning schedules to make sure that all areas, equipment, and food contact surfaces are given a thorough cleaning on a routine basis, in addition to the clean as you go approach during day-to-day operations. On 04/05/23 at 05:00 P.M., Record review of the Policy/Procedure entitled: The Maintenance and Cleaning of Kitchen Equipment dated 02/2023 revealed under Policy: The Food Service Department will adequately clean and maintain dietary equipment in accordance with the State and US Food Codes, OSHA, and best practices in order to minimize the risk of foodborne illness and employee safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 114 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 04/05/23 at 08:50 A.M., a common area environmental tour was conducted with Director of Maintenance F and Director of Housekeeping and Laundry Services G. The following items were noted: Cypress Unit (100-200) Cypress Lounge: 9 of 23 overhead recessed light assemblies were observed non-functional. Director of Maintenance F indicated he would have staff replace the faulty bulbs as soon as possible. The overhead light assembly directly outside of the Central Bath was observed non-functional. Maple Unit (300-400) Central Bath Restroom: The toilet seat was observed etched, scored, particulate, and worn. Director of Housekeeping and Laundry Services G indicated she would have maintenance replace the worn toilet seat as soon as possible. Occupational Therapy/Physical Therapy: One round stool cushion was observed etched, scored, worn. The inner Styrofoam padding was also observed protruding from the vinyl cushion cover. The hand sink faucet assembly hot and cold-water valves and actuating handles were observed out-of-adjustment. The hot water valve handle was also observed to rotate approximately 135 degrees into the goose neck water supply stream upon actuation. Meadows Unit (500) (900) Central Bath Shower Room: The shower stall acrylic base was observed etched, scored, corroded. The damaged entry platform surface measured approximately 6-inches-wide by 24-inches-long. Central Bath Storage Room Closet: The room was observed in disarray. Miscellaneous items (white plastic bucket, vinyl gloves, paper towels, goggles, etc.) were also observed within the closet space. Central Bath Entrance Foyer: One of two overhead light assemblies were observed non-functional. [NAME] Unit (600-700) Central Bath Restroom: The hand sink faucet assembly was observed loose-to-mount. The hot and cold-water supply valves and actuating handles were also observed out-of-adjustment. Soiled Utility Room: Two 4-inch-wide by 4-inch-long ceramic tiles were observed missing on the waste hopper support podium. Director of Housekeeping and Laundry Services G indicated she would have maintenance replace the two missing ceramic tiles as soon as possible. Janitor Closet: Numerous dead insect carcasses were observed resting within the overhead light assembly. Director of Housekeeping and Laundry Services G indicated she would have maintenance remove the dead insect carcasses as soon as possible.

This citaiton pertains to inake: MI00131044 During observation, interview, and record review the facility failed to ensure residents receive showers according to their personal preferences for two residents (#6 and #7) of four residents reviewed for hygiene and grooming, resulting in missed showers and the potential for inadequate hygiene and feelings of embarrassment. Findings Included: Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility 06/19/2011 with diagnoses that included chronic respiratory failure, adjustment disorder, anxiety, depression, bipolar disorder (causes swings of mania and depression) , diverticulosis (small bulging pouches in the intestines), hemorrhoids, lower back pain, shoulder pain, hypernatremia (high levels of sodium in blood), pain left knee, pain right knee, gastro-esophageal reflux, chronic pain, hypertension, type 2 diabetes, atrial fibrillation, hypothyroidism (low thyroid levels), hyperlipidemia (high fat in blood), and chronic obstructive pulmonary disease (COPD). The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/2023 demonstrated R6 had a Brief Interview for Mental Status (BIMS) of 12 (mildly impaired cognition) out of 15. Section G0120A: bathing of the MDS with the same ARD demonstrated that R6 required total dependence. During observation and interview on 03/28/2023 at 03:41 p.m. R6 explained that there are many times that she has not received her shower twice every week. She explained that her hair is not always washed when she has had her showers. R6 explained that many times in the past she only receives a shower because she has a friend that is her senior companion. Her senior companion helps her take a shower. R6 explained that she does not prefer to have a bed bath but really preferred a shower so that she could have her hair washed. She explained that she never refused a shower but had occasionally refused bed baths. R6's hair appeared to be unkept and oily. During review of R6's medical record her care plan demonstrated that she required assistance for bathe/showers as needed. The plan of care did not demonstrate the frequency or preferences of R6 for a shower or a bath. R6's Point of Care (POC) task documentation (computerized document recording task to be completed by certified nursing aides) demonstrated that R6 tasks which stated Shower/Bath: Saturday Evenings and Shower/Bath: Wednesday Evenings. Review of R6's POC documentation completion of Shower/Bath: Wednesday Evenings demonstrated: refused on 02/01/2023, shower on 02/08/2023, no shower/bath on 02/15/2023, and shower on 02/22/23 after a bed was refused and no shower/bath on 03/01/2023, bed bath on 03/08/2023, no shower/bath on 03/15/2023, no shower on 03/22/2023, Review of R6's POC documentation completion of Shower/Bath: Saturday Evenings demonstrated: bed bath refused 02/04/2023, bed bath 02/11/2023, no shower/bath 02/18/2023, and bed bath refused 02/25/2023. bed bath 03/04/2023, shower 03/11/2023, refused 03/19/2023, no shower/bath and 03/25/2023, Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility 03/03/2021 with diagnoses that included end stage renal disease, bilateral cataracts, low back pain, major depression, congestive heart failure (CHF), hypothyroidism (low thyroid levels), morbid obesity, gout (increase uric acid in bone joints), type 2 diabetes, hypertension, charcot's arthropathy (progressive condition of the musculoskeletal system characterized by joint dislocations, pathologic fractures, and debilitating deformities), atrial fibrillation, adjustment disorder, anxiety, and obstructive and reflux uropathy (obstruction of ureter, bladder, or urethra). The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/2023 demonstrated R7 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. Section G0120A: bathing of the MDS with the same ARD demonstrated that R7 required total dependence. During observation and interview on 03/28/2023 at 03:47 p.m. R7 explained that she had just received a shower today. She explained that many times she has not received her shower twice every week. R7 explained that she prefers to have a shower and not a bed bath. She explained that she goes to dialysis several times per week, so she likes to look presentable. R7 explained that in her opinion the facility does not have enough staff so that she may be giving her showers. During review of R7's medical record her care plan demonstrated that she required assistance for bathe/showers as needed. The plan of care did not demonstrate the frequency or preferences R7 had for a shower or a bath. R7's Point of Care (POC) task documentation (computerized document recording task to be completed by certified nursing aides) demonstrated that R7 tasks which stated Shower/Bath: Saturday Evenings and Shower/Bath: Tuesday Days. Review of R7's POC documentation completion of Shower/Bath: Tuesday Days demonstrated: no shower/bath 02/07/2023, bed bath 02/14/2023, shower 02/21/23, no shower/bath 03/07/2023, shower 3/14/2023, and bed bath 03/21/23. Review of R7's POC documentation completion of Shower/Bath: Saturday Evenings demonstrated: bed bath refused 02/04/2023, refused 02/11/2023, no shower/bath 02/18/2023, and no shower/bath 02/25/2023, bed bath refused 03/04/2023, shower 03/14/2023, refused 03/17/2023, and no shower/bath 03/25/2023. In an interview on 03/29/2023 at 07:44 a.m. the Director of Nursing (DON) B explained that is her expectation and the facility practice that all residents receive a bed bath or a shower twice every week. She explained that a schedule is posted on the nursing units so that direct care staff knew who wanted a bed bath/shower that day and that shift. DON B was reviewed R6 and R7 POC documentation completion Shower/Bath task and could not provide and explanation why showers or baths were not completed for R6 and R7 twice every week.

This citation pertains to intakes: MI00129659, MI00131044, MI00134799 Based on observation, interview, and record review the facility failed to ensure sufficient nursing staff for two residents (#6 and #7) and confidential residents attending resident council resulting in all 125 residents residing at the facility to attain or maintain their heights practicable physical, mental, and psychosocial well-being related to showers and unmet needs. Findings Included: Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility 06/19/2011 with diagnoses that included chronic respiratory failure, adjustment disorder, anxiety, depression, bipolar disorder (causes swings of mania and depression) , diverticulosis (small bulging pouches in the intestines), hemorrhoids, lower back pain, shoulder pain, hypernatremia (high levels of sodium in blood), pain left knee, pain right knee, gastro-esophageal reflux, chronic pain, hypertension, type 2 diabetes, atrial fibrillation, hypothyroidism (low thyroid levels), hyperlipidemia (high fat in blood), and chronic obstructive pulmonary disease (COPD). The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/2023 demonstrated R6 had a Brief Interview for Mental Status (BIMS) of 12 (mildly impaired cognition) out of 15. During observation and interview on 03/28/2023 at 03:41 p.m. R6 explained that there are many times that she has not received her shower twice every week. She explained that her hair is not always washed when she has had her showers. R6 explained that many times in the past she only receives a shower because she has a friend that is her senior companion. Her senior companion helps her take a shower. R6 explained that she does not prefer to have a bed bath but really preferred a shower so that she could have her hair washed. She explained that she never refused a shower but had occasionally refused bed baths. R6's hair appeared to be unkept and oily. R6 explained that she thinks they do not always take her down to the shower because they do not have enough staff to help her get into the shower chair. She explained that it also took a very long time for any staff the answer the call light. She explained that sometimes it can take up to five hours to answer the call light. R6 explained that when she attends activities she is brought back to her room and has had to wait 5 hours be assisted back to bed. During review of R6's medical record her care plan demonstrated that she required assistance for bathe/showers as needed. The plan of care did not demonstrate the frequency or preferences of R6 for a shower or a bath. R6's Point of Care (POC) task documentation (computerized document recording task to be completed by certified nursing aides) demonstrated that R6 tasks which stated Shower/Bath: Saturday Evenings and Shower/Bath: Wednesday Evenings. Review of R6's POC documentation completion of Shower/Bath: Wednesday Evenings demonstrated: refused on 02/01/2023, shower on 02/08/2023, no shower/bath on 02/15/2023, and shower on 02/22/23 after a bed was refused and no shower/bath on 03/01/2023, bed bath on 03/08/2023, no shower/bath on 03/15/2023, no shower on 03/22/2023, Review of R6's POC documentation completion of Shower/Bath: Saturday Evenings demonstrated: bed bath refused 02/04/2023, bed bath 02/11/2023, no shower/bath 02/18/2023, and bed bath refused 02/25/2023. bed bath 03/04/2023, shower 03/11/2023, refused 03/19/2023, no shower/bath and 03/25/2023. Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility 03/03/2021 with diagnoses that included end stage renal disease, bilateral cataracts, low back pain, major depression, congestive heart failure (CHF), hypothyroidism (low thyroid levels), morbid obesity, gout (increase uric acid in bone joints), type 2 diabetes, hypertension, charcot's arthropathy (progressive condition of the musculoskeletal system characterized by joint dislocations, pathologic fractures, and debilitating deformaties), atrial fibrillation, adjustment disorder, anxiety, and obstructive and reflux uropathy (obstruction of ureter, bladder, or urethra). The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/2023 demonstrated R7 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 03/28/2023 at 03:47 p.m. R7 explained that she had just received a shower today. She explained that many times she has not received her shower twice every week. R7 explained that she prefers to have a shower and not a bed bath. She explained that she goes to dialysis several times per week, so she likes to look presentable. R7 explained that in her opinion the facility does not have enough staff so that she may be giving her showers. R7 explained that the time it took to answer call lights was a problem. She expressed that the facility did not enough staff to assist her with her needs at night. R7 explained that she has laid in her own bowel movements for almost 5 hours. She explained that the greatest time that she had to wait for her call light to be answered was on the night shift and especially on the weekends. Review of R7's POC documentation completion of Shower/Bath: Tuesday Days demonstrated: no shower/bath 02/07/2023, bed bath 02/14/2023, shower 02/21/23, no shower/bath 03/07/2023, shower 3/14/2023, and bed bath 03/21/23. Review of R7's POC documentation completion of Shower/Bath: Saturday Evenings demonstrated: bed bath refused 02/04/2023, refused 02/11/2023, no shower/bath 02/18/2023, and no shower/bath 02/25/2023, bed bath refused 03/04/2023, shower 03/14/2023, refused 03/17/2023, and no shower/bath 03/25/2023. Review of Resident Council Minutes, dated 03/15/2023, demonstrated concerns with the Nursing Department that was documented call light wait times, especially at night and also didn't receive shower. Review of Resident Council Minutes, dated 01/24/2023, demonstrated concerns with the Nursing Department that was documented Residents waiting a long time for call light. Review of Resident Council Minutes, dated 10/11/2022, demonstrated concerns with the Nursing Department that was documented Residents waiting a long time for call lights. In an interview on 03/28/23 at 04:27 a.m. Nursing Home Administrator (NHA) A explained that answering call lights in a timely manner would be within 15 minutes or less. She explained she was aware that timeliness of call light response was a issue at the facility. She explained that the facility does do on random audits of call light response times but provided any audits by the time of survey exit. NHA A could not detail any current plans to improve the facility call light response time. In an interview on 03/29/2023 at 07:44 a.m. the Director of Nursing (DON) B explained that is her expectation and the facility practice that all residents receive a bed bath or a shower twice every week. She explained that a schedule is posted on the nursing units so that direct care staff knew who wanted a bed bath/shower that day and that shift. DON B was reviewed R6 and R7 POC documentation completion Shower/Bath task and could not provide and explanation why showers or baths were not completed for R6 and R7 twice every week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #102 (R102): Review of the medical record reflected R102 admitted to the facility on [DATE], with diagnoses that included multiple sclerosis, muscle weakness, diabetes, unstageable pressure ulcer (obscured full-thickness skin and tissue loss) of the left buttock, unstageable pressure ulcer of the sacral region, unstageable pressure ulcer of the left heel and pressure-induced deep tissue damage (persistent non-blanchable deep red, maroon or purple discoloration) of the right heel. The Admission/5 day Medicare Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/25/23, reflected R102 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had three unstageable pressure ulcers present on admission and one deep tissue injury present on admission. On 5/2/23 at 2:47 PM, R102 was observed in his room, doing therapy, with a visitor present and assisting. R102's pressure relieving air mattress hose was not plugged in. The therapist left the room at 2:51 PM. R102's visitor was unsure when the mattress was unplugged, as they had just arrived. At 2:54 PM, Physical Therapy Assistant (PTA) D re-entered the room. R102's visitor asked about the mattress hose not being plugged in. PTA D was unaware that it was unplugged and was not sure why. The admission skin assessment for 4/20/23 reflected pressure wound to the left heel, right heel and left buttock and pressure to the right toes. There was no documentation of wound characteristics or measurements. No Baseline Care Plan interventions were selected on the assessment. A Skin and Wound Evaluation of the right heel, dated 4/20/23, reflected a deep tissue injury that was present on admission and measured 0.9 centimeters (cm) in length by (x) 0.8 cm in width. The wound was documented as having 100% epithelial tissue, with the surface intact. Review of the April 2023 Treatment Administration Record (TAR) reflected treatment for the right heel was started 4/25/23 (six days after admission). A Skin and Wound Evaluation of the right heel, dated 4/28/23, reflected a deep tissue injury that was present on admission. The wound was documented as having 100% epithelial tissue, with the surface intact. The wound was documented as resolved, with a treatment that would continue for protection. A Skin and Wound Evaluation of the left heel, dated 4/20/23, reflected an unstageable pressure ulcer due to slough (non-viable yellow, tan, gray, green or brown tissue) and/or eschar (dead, devitalized tissue that is usually black, brown or tan in color) that was present on admission. There were no documented measurements. The wound bed was documented to have 80% granulation tissue (pink-red moist tissue that fills an open wound when it starts to heal), 10% slough and 10% eschar. The April 2023 TAR reflected treatment to the left heel was started 4/21/23 (two days after admission). A Skin and Wound Evaluation of the left heel, dated 4/28/23, reflected an unstageable pressure ulcer due to slough and/or eschar that was present on admission and measured 4.0 cm in length x 3.2 cm in width. The wound bed was documented to have 100% granulation tissue. A Skin and Wound Evaluation of the left buttock, dated 4/20/23, reflected an unstageable pressure ulcer due to slough and/or eschar that was present on admission. There were no documented measurements. The wound bed was documented to have 30% granulation tissue, 40% slough and 30% eschar. The April 2023 TAR reflected treatment to the buttock was started 4/21/23 (two days after admission. The order reflected, Cleanse wound to buttock with NS [normal saline], dry thoroughly. Apply skin prep to surrounding area apply foam dressing every day shift for wound care. The order was discontinued 4/25/23. A Skin and Wound Evaluation of the left buttock, dated 4/28/23, reflected an unstageable pressure ulcer due to slough and/or eschar that was present on admission and measured 5.4 cm in length x 4.4 cm in width. The wound bed was documented to have 90% slough and 10% eschar. A Skin and Wound Evaluation of the sacrum, dated 4/20/23, reflected an unstageable pressure ulcer due to slough and/or eschar that was present on admission. There were no documented measurements. The wound bed was documented to have 50% granulation tissue and 50% slough. The April 2023 TAR reflected treatment to the sacrum was started 4/26/23 (seven days after admission). A Skin and Wound Evaluation of the sacrum, dated 4/28/23, reflected an unstageable pressure ulcer due to slough and/or eschar that was present on admission and measured 2.6 cm in length x 1.0 cm in width. The wound bed was documented to have 50% granulation tissue and 50% slough. The wound was documented as deteriorating. Progress Notes from 4/19/23 through 5/2/23 at 11:12 AM did not reflect any additional wound assessments or measurements. A Physician Progress Note for 4/20/23 and Nurse Practitioner Progress Notes for 4/21/23 and 4/24/23 did not reflect wound assessments or measurements. During an interview on 5/2/23 at 2:50 PM, Registered Nurse (RN) C reported being part of the wound team. RN C reported wound assessments would have typically included a description of the wound and measurements. RN C confirmed the left heel, left buttocks and sacrum wounds did not have measurements on the assessments dated 4/20/23. RN C confirmed that measurements were documented for those wounds on 4/28/23. She denied that wound measurements would have been documented elsewhere. RN C stated the wound to the sacrum was deteriorating from the 4/20/23 assessment to the 4/28/23 assessment. She reported on 4/20/23, a treatment was ordered to start on 4/21/23 (referring to the buttock treatment that was in place 4/21/23 to 4/25/23). When asked how the nurse would know the order for the buttock treatment was to include the wound to the sacrum, RN C stated she did not know and did not have an answer. RN C confirmed treatment to the buttocks and left heel started 4/21/23. When asked what was in place for wound management between admission and 4/21/23, RN C reported that according to their records, there was no treatment (during that time). Review of the facility's audits for F-686 reflected R102 was not audited for the facility's plan of correction. Based on observation, interview, and record review the facility failed to effectively carry out a plan of correction to correct deficiencies related to pressure ulcers resulting in continued noncompliance with the potential for negative outcomes to facility residents including Resident #100, #101, and #102. Findings include: Review of the facility's Plan of Correction revealed an alleged compliance date of 4/18/23. Resident #100 (R100) Review of the medical record revealed R100 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes, schizophrenia, chronic kidney disease stage 4, and dementia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/30/23 revealed R100 scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening too) and had a stage 4 pressure ulcer that was acquired at the facility. On 5/2/23 at 11:37 AM, R100 was observed lying in bed. Review of the Physician's Order dated 3/29/23 revealed cleanse/irrigate R [right] buttock with NSS, pat dry, skin prep the peri wound, pack wound to [sic] iodoform packing strip then cover with foam dressing BID and PRN [twice per day and as needed]. Review of the Nurse Practitioner's Note dated 4/12/23 revealed Cleanse wound bed with NS, Pat dry Pack wound with iodoform packing strip, skin prep to peri wound then cover with foam dressing BID and PRN. Review of the Skin & Wound Evaluation dated 4/28/23, revealed R100 had a stage 4 facility acquired pressure ulcer to his right buttock. The pressure ulcer measured 0.8 centimeters (cm) long x 0.5 cm wide x 3.2 cm deep. Review of R100's Treatment Administration Records for April and May 2023 revealed the right buttock pressure ulcer treatment was ordered to be completed twice per day but was only scheduled and completed once per day. In an interview on 5/2/23 at 12:52 PM, Registered Nurse (RN) C reported she was the facility's wound nurse. RN C agreed that R100's pressure ulcer treatment was scheduled and completed once per day. When asked about the order for twice per day, RN C reported she was unsure why there was a discrepancy. In a telephone interview on 5/2/23 at 2:00 PM, Director of Nursing (DON) B was read R100's treatment order. DON B reported the treatment was ordered for twice a day. When informed the treatment was scheduled and completed once per day, DON B reported she was unsure why and would have to check with RN C. DON B reported she performed the pressure ulcer audits for the plan of correction which included care plan audits to make sure interventions were appropriate for the person and that we were preventing pressure ulcers for that patient. DON B reported she would not have caught that R100's treatment was not completed per physician's order because she was not looking at orders, only preventative measures. Review of the facility's audits for F-686 revealed R100 was audited on 4/20/23 and 4/24/23. The facility did not identify that R100's treatment was being completed once per day instead of twice per day as ordered. Resident #101 (R101) Review of the medical record revealed R101 was admitted to the facility on [DATE] with diagnoses that included unstageable pressure ulcer to the right heel, unstageable pressure ulcer to the left heel, and severe protein-calorie malnutrition. The MDS with an ARD of 4/20/23 revealed R101 scored 13 out of 15 (cognitively intact) on the BIMS and had two unstageable pressure ulcers present on admission. On 5/2/23 at 11:35 AM, R101 was observed sitting in a wheelchair in his room. R101 reported he had a pressure ulcer on each heel. Review of the Skin & Wound Evaluations revealed, wound evaluations were completed on 4/14/23 and 4/28/23. On 4/14/23, R101's left heel unstageable pressure ulcer measured 1.2 cm x 0.7 cm and on 4/28/23 the same pressure ulcer measured 4.2 cm x 3.2 cm. On 4/14/23 R101's right heel unstageable pressure ulcer measured 2.9 cm x 1.8 cm and on 4/28/23 the same pressure ulcer measured 4.2 cm x 3.8 cm. Wound assessments were not completed between 4/14/23 and 4/28/23. Review of the late entry Progress Note dated 4/21/23 and entered 4/24/23, revealed patient away on LOA [leave of absence] for appt [appointment] thus far this shift as well as previous day. Images to heels to be completed with next wound rounds for tracking . In an interview on 5/2/23 at 12:52 PM, RN C reported wound assessments were completed weekly. RN C reported she was not sure why R101's wound assessments were not completed on 4/21/23. RN C reported she was unable to locate an assessment between 4/14/23 and 4/28/23. RN C reported typically, the wounds would be assessed when a resident returned from their appointment. In an interview on 5/2/23 at 2:00 PM, DON B reported if a wound assessment were missed due to a resident being out of the building for an appointment, the wound should be assessed the next day. Review of the facility's audits for F-686 revealed R101 was not audited. Review of the facility's Skin Management Guidelines dated 2/2022 revealed Wound rounds are completed weekly on pressure injuries and complex wounds .One member of the wound team documents wound evaluations in a Pressure Ulcer Weekly Note in [electronic medical record system] or within the Skin/wound application of [electronic medical record system] (if enabled). Documentation should include wound location, etiology, presence of exudate/odor, tissue type, measurements, presence of undermining or tunneling, description of peri-wound, PUSH score, indications of pain or infection, notifications to medical practitioner and patient/responsible party, education provided and any changes in treatment or care plan interventions. In an interview on 5/2/23 at 3:05 PM, Nursing Home Administrator (NHA) A reported she had only been in the building for one day; therefore, Assistant Administrator (AA) E was more familiar with the facility's QAPI process related to the Plan of Correction. AA E reported since the survey, the facility had two QAPI meetings on 4/21/23 and 4/28/23. NHA A then read the QAPI minutes and reported the facility did not identify any concerns related to pressure ulcers during their meetings.