**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake 1210578.Based on interview and record review, the facility failed to provide care and services to promote dignity and respect in 4 of 5 residents (Resident #31, #3, #17, #16) reviewed for dignity/respect, and 7 of 12 residents from the confidential group meeting, resulting in the potential for unmet care needs and feelings of diminished self-worth, sadness, and frustration.Findings include:Resident #31 Review of an “admission Record” revealed Resident #31 was a male, with pertinent diagnoses which included: need for assistance with personal care; major depressive disorder, recurrent severe without psychotic features; difficulty walking, not elsewhere classified; and muscle weakness (generalized). Review of a Minimum Data Set (MDS) assessment for Resident #31, with a reference date of 6/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #31 was cognitively intact. Further review of said MDS revealed Resident #31 was “always incontinent of bowel and bladder” and required “substantial/maximal assistance” (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) for “toileting hygiene” (The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement…) In an interview on 8/18/25 at 2:10 PM Resident #31 reported call light wait time was at least a half hour and sometimes the wait had been up to 2-3 hours. Resident #31 reported he has had to wait extended periods for staff to change his brief after having a bowel movement and “it is uncomfortable to say the least.” In an interview on 8/19/25 at 11:59 AM, “Licensed Practical Nurse” (LPN) “D” reported residents have complained to her about long call light wait times. In an interview on 8/20/25 at 9:01 AM, “Certified Nurse Aide” (CNA) “X” reported residents complained to her about long call light wait times. In an interview on 8/20/25 at 9:02 AM, CNA “FF” reported residents sometimes complained about long call light wait times. According to https://journals.lww.com/ regarding call light use, “It is one of the few means by which patients can exercise control over their care on the unit. When patients use the call light, it is usually to summon the nurse…Patients expect that when they push the call light button, a nursing staff member will answer or come to them.” Resident #3: Review of an admission Record revealed Resident #3 was a female with pertinent diagnoses which included paralysis affecting right dominant side, need for assistance with personal care, weakness, and difficulty in walking. In an interview on 08/18/2025 at 12:11 PM, Resident #3 reported “things haven’t changed.” Resident #3 reported over the weekend she had to wait from 6:15 PM to 8:00 PM for them to come and answer the call light. Resident #3 reported she knew the times because the long call light waits happened “quite a bit” and she wanted to make sure she had the time down on how long it took Resident #17: Review of an admission Record revealed Resident #17 was a male with pertinent diagnoses which included paraplegia (affects all or part of the trunk area, legs, and pelvic organs), and need for assistance with personal care. In an interview on 08/18/2025 at 3:59 PM, Resident #17 reported he had concerns with call lights times being usually 45 minutes to an hour. Resident #17 reported he had the most issues with his call light being answered during the evening and nighttime shifts. Resident #17 reported at night the staff were not emptying his urinal. Resident #17 reported a few nights ago the urinal was not emptied from 10:00 PM until 4:30 AM and it was full. Resident #17 reported he had [NAME] his concerns with call light wait times to the previous two nursing home administrators and he felt they tried to placate him and nothing changed. Resident #16: Review of an admission Record revealed Resident #16 was a male with pertinent diagnoses which included muscle weakness, and cognitive communication deficit (communication impairment stemming from difficulties with thinking processes like attention, memory, and reasoning, and problem solving). In an interview on 08/18/2025 at 1:45 PM, Family Member (FM) “OO” reported waiting long periods of time for call lights to be answered and when staff do respond, the staff would turn off the call light prior to completing the request. FM “OO” reported sometimes the staff would forget to come back. FM “OO” reported the call light had been turned on at 1:20 PM today, the CNA came in and turned it off and reported she would be back with someone to assist. FM “OO” reported Resident #16 had a bowel movement and had been sitting in it since then (25 minutes upon my entry to the room, no staff entered the room when this writer was present approximately 10 minutes). FM “Betty” expressed worry the staff would return as the door was closed and she wanted to ensure Resident #3 would get his brief changed. In an interview on 08/20/2025 at 1:57 PM, Certified Nursing Assistant (CNA) K reported she attempted to answer the call light as soon as possible. CNA K reported if unable to complete the requested task she would tell the resident she would return to assist them. CNA K reported she does turn off the light but does return to the resident as soon as she was able to. u In an interview on 08/20/2025 at 2:01 PM, [NAME] President of Clinical Services JJ reported the staff were educated during orientation to leave the light on until the need was met. Review of “Call Lights” received on 08/20/25 from employee orientation, revealed, “…Response to Call Lights: If you see an activated red light in the hall, you are expected to answer the call light…Assist with the need if it is within your scope or to advise the resident you will get assistance, do not turn off the call light unless you have met the resident’s need…”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00152539 Based on interview and record review the facility failed to ensure that a therapy evaluation (a process to determine a resident's need for therapy services) was completed at the time of re-admission to the facility following an inpatient hospital stay for 1 (Resident #2) of 3 residents reviewed for therapy evaluation at the time of re-admission, resulting in the potential for the inability to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #2 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: muscle weakness, need for assistance with personal care, and stiffness of the right and left shoulders. Review of a Minimum Data Set (MDS) assessment for Resident #2, with a reference date of 2/3/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #2 was cognitively intact. In an interview on 5/12/25 at 1:15 pm Resident #2 reported she had been very sick with a UTI (urinary tract infection) and was hospitalized in April 2025. Resident #2 reported she did not know why she did not receive therapy services when she returned to the facility. Resident #2 reported she was weak and tired more quickly after completing tasks since she returned. Resident #2 reported she was not yet back to her old self. Review of Census for Resident #2 revealed she was discharged from the facility on 4/21/2025 and readmitted on [DATE]. Review of Order Summary Report for Resident #2 revealed .ADMIT to skilled care . with a start date of 4/25/2025. In an interview on 5/12/25 at 1:10 pm Therapy Manager (TM) Y reported when a resident was admitted to the facility as skilled (skilled care, skilled nursing care, or rehabilitation services are care and services provided by licensed health professionals such as nurses and physical therapists and services are ordered by a physician) they were picked up by therapy for services. TM Y reported Resident #2 was at her baseline when she returned to the facility and was not evaluated by therapy for services. TM Y reported hospitalization alone was not a reason for a resident to be screened for therapy services. In an interview on 5/12/25 at 3:16 pm Clinical Care Coordinator/Registered Nurse (CCC/RN) N reported when a resident returned to the facility at their baseline, the resident did not receive therapy services. CCC/RN N reported the hospital would complete an evaluation for therapy services and would communicate any further need by the resident for therapy services to the facility. CCC/RN N stated Resident #2 went out to the hospital, and she came back to the building at her baseline and had no need for therapy services. CCC/RN N stated a hospital stay is not a reason to be evaluated by therapy, it can contribute to a need for therapy, but if a resident returns to the facility at their baseline there is no need for a referral to therapy and they would not be referred. Review of Occupational Therapy Evaluation for Resident #2, provided by (Name Omitted) hospital with a date of service as 4/22/25 revealed .Discharge Disposition: Return to prior level of care. At baseline, patient dependent with LB (lower body) ADL's (Activities of Daily Living), max/mod (maximum/moderate) assist with UB (upper body) ADLs, mod 1 (moderate of 1) assist with feeding. At this time patient is requiring total assist/max assist indicating further Occupational Therapy is required. Clinical Impression: Patient to benefit from skilled OT (occupational therapy) to address the following impairment balance, cognition, endurance/activity tolerance, grasp/prehension, coordination, motor planning, strength, trunk/postural control. Provide patient with education regarding Occupational therapy role and plan for care as well as mobility techniques and ADLs . Review of Occupational Therapy Evaluation for Resident #2, provided by (Name Omitted) hospital with a date of service as 4/24/25 revealed .Today's OT session focused on ADL. At this time, patient is demonstrating decreased strength/endurance/ROM (range of motion) with bed mobility/ADL tasks, indicating continued need for ongoing skilled Occupational Therapy . Review of Discharge Orders for Resident #2 provided by (Name Omitted) hospital with a date of service as 4/25/2025 revealed .Occupational Therapy Evaluate and Treat at receiving Facility .Physical Therapy Evaluate and Treat at receiving Facility . Review of After Visit Summary for Resident #2 with a date of 4/25/2025, retrieved from Resident #2's facility medical record on 5/12/25 revealed .Discharge Instructions . Occupational Therapy Evaluate and Treat at receiving Facility .Physical Therapy Evaluate and Treat at receiving Facility . In an interview on 5/13/25 at 2:55 pm Regional Clinical Support/Interim Director of Nursing (RCS/IDON) B reported her expectations were that every resident admitted or readmitted should be evaluated by the therapy department for any therapy needs. RCS/IDON B confirmed that Resident #2 was not evaluated by therapy for services when she returned to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop person centered care plan for 2 Residents (#8 & #32) of 16 residents reviewed for person centered care plans. Findings include: Resident #8 Review of an admission Record revealed Resident #8 had pertinent diagnoses which included: need for assistance with personal care and bed confinement status. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 7/30/24 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated Resident #8 was unable to participate in the assessment. Observations were made on 8/20/24 at 10:27 AM., 8/21/24 at 8:37 AM., and 8/21/24 at 12:07 AM., where Resident #8 was observed unkempt, and unshaven, with facial hair that varied in length, and growth and did not appear to be indicative of a beard or other shaped facial hair. In an interview on 8/21/24 at 2:13 PM., Certified Nursing Assistant (CNA) K reported Resident #8 required total care for activities of daily living. CNA K reported Resident #8 required staff to shave his face for him. CNA K reported Resident #8 should be shaved during his shower. CNA K reported Resident #8's shower was due to be given on second shift. Review of Shower List dated 8/21/24 indicated Resident #8 was to be showered weekly on Wednesday and Friday on second shift. In an interview on 8/21/24 at 2:20 PM., CNA L reported shaving was to be completed when the resident received a shower. In an interview on 8/21/24 at 2:26 PM., Director of Nursing (DON) B reported her expectations were, residents were shaved during their scheduled showers and/or as needed. On 8/22/24 9:19 AM., Resident #8 remained unshavena nd had received a shower on 8/21/24 at 9:59 PM., per the Shower Assignment. Review of Care Plan for Resident #8 revealed Focus .bed bound .goal .will receive required assistance for ADL (activities of daily living) care needs . revised on 7/24/24 .ADLs Dependent for ADLs .Bathing . one person assists with bathing . During an interview and observation on 8/22/24 at 9:22 AM., DON B confirmed the Shower Assignment sheet for Resident #8 indicated a shower was completed. DON B was present at the bedside of Resident #8 with this surveyor and stated yes, (Resident #8's) face was not shaved during his shower. DON B reported Resident #8 does refuse to let staff shave him. This surveyor asked to see the documentation that Resident #8 refused to be shaved during his shower. During an interview and observation on 8/22/24 at 9:29 AM., Regional Clinical Consultant (RCC) QQ was present with this surveyor and DON B at the bedside of Resident #8 and acknowledged Resident #8's face needed to be shaved. RCC QQ reported her expectation was, shaving should be done during the resident's shower. RCC QQ reported Resident #8 preferred not to be shaved during his shower and it was in his care plan. During an interview on 8/22/24 at 9:36 AM., DON B reported Resident #8 preferred to be shaved by a family member. DON B reported Resident #8's preference should be in his care plan but was unable to locate this intervention. During an interview on 8/22/24 at 9:46 AM., Licensed Practical Nurse (LPN) BB reported Resident #8 refused to be shaved during care many times. LPN BB reported she believed Resident #8 preferred to have his face shaved by a family member. When this surveyor asked LPN BB if Resident #8's preferences were updated on his care plan, LPN BB stated I did not update Resident #8's care plan to reflect his preferences or that he will refuse care. Review of Care Plan for Resident #8 revealed no noted intervention related to Resident #8's preferences or refusals for care related to shaving facial hair. Resident #32 Review of an admission Record revealed Resident #32, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: major depressive disorder, post-traumatic stress disorder, and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #32, with a reference date of 5/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #32 was cognitively intact. Review of a Care Plan for Resident #32, with a reference date of 3/17/21, revealed a focus/goal/interventions of: (Resident name omitted) has the potential for an acute condition change related to his diagnosis of PTSD(post traumatic stress disorder) . Goal: (resident name omitted) will have early identification, management, treatment and resolution of an acute condition change. No interventions related to Resident #32's diagnosis of PTSD were present. In an interview on 8/21/24, at 3:55 p.m., Social Services Director (SSD) DD reported Resident #32 did not have PTSD. When made aware of Resident #32's PTSD diagnosis, SSD DD reported she was not aware of any triggers the resident had related to his PTSD but the resident was prone to angry outbursts. In an interview on 8/22/24 at 10:37 a.m., Licensed Practical Nurse (LPN) I reported she regularly cared for Resident #32, who struggled to trust others, became angry very quickly, and needed to have his his needs met immediately upon request to avoid him becoming stressed. LPN I reported she referred to the care plan to gain information about each resident's mental, physical and psychosocial needs. LPN I reported she was not aware Resident #32 had PTSD and it would be important for his triggers to be outlined in his care plan in order to avoid potential retraumatization and additional angry outbursts. Review of a facility policy titled Care Planning Process: Admission, Comprehensive & Short Term with a reference date of 11/2017 revealed: Purpose: to ensure .delivery of high standard Person-Centered Care and to communicate resident needs .Definition: Person Centered Care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident .and having an understanding of the resident(sic) life before coming to reside in this center. Within a section labeled Comprehensive, statement 4 revealed: in situations where a residents (sic) choice to decline care(e.g., due to autonomy or preferences) poses a risk .the comprehensive care plan will identify the care or service being declines (sic) . Section 5 stated: interventions are listed to provide the necessary care and services to accomplish the goal .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00146198. Based on interview and record review, the facility failed to update the transfer status of one resident (Resident #268) of 16 residents reviewed for comprehensive care plans resulting in a skin tear. Findings include: Resident #268 (R268) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R268 admitted to the facility on [DATE] with diagnoses of unsteadiness on feet, need for assistance with personal care and difficulty walking. Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which indicated R268 was cognitively intact (13 to 15 cognitively intact). The most recent MDS completed on 7/18/2024 indicated a BIMS couldn't be completed. She passed away under Hospice care on 7/19/2024. Review of the Investigation Summary of the Facility Reported Incident (FRI) revealed On 7-8-2024 (R268) was sent to the hospital and had an inpatient stay and readmitted to the facility on [DATE]. Upon readmission her care plan transfer status was a 1 (person) assist as it was prior to her transfer out on 7-8-2024. On 7-15-2024 therapy did complete a screen on her and given her increased weakness and the therapist indicated that her transfer status had changed, and she required more assistance for transfers. Her care plan was not revised to reflect their recommendation. On 7-18-2024 she sustained a skin tear to her right lower leg during a transfer .The plan of care was followed as it was at that time. However, given her weakness and based on therapys screen completed on 7-15-2024, her transfer status should have been changed to a 2 (person) assist but was not. Post incident the Nurse (RN G), did change her plan of care to reflect her transfer status as a 2 assist. During an interview on 8/22/2024 at 7:35 AM, Registered Nurse (RN) G stated on 7/18/2024, CNA J went to him and said that CNA MM was working with R268 and she noticed R268 had a skin tear while she was sitting on the toilet. RN 'G said he observed R268 was on the toilet and CNA MM transferred her there by himself. RN G stated at that point it wasn't communicated to nursing that R268 was a 2 person transfer but they knew she needed more help. RN 'G said R268's care plan indicated she was a 1 person assist and he changed the care plan on 7/18/2024 after the incident to a 2 person assist, per therapy's recommendation on 7/15/2024. During an interview on 8/21/2024 at 11:53 AM, CNA MM said R268 was a 1 person assist per the care plan and that's what he was following. He stated R268's care plan like all other resident care plans were kept inside the closet. CNA MM stated they should be updated and the CNAs rely on the nurses to tell them about any immediate changes. Review of R268's care plan revealed R268 was a 1 person assist for transfers which was initiated on 1/18/2024 and she was changed to a 2 person assist with transfers with a revision date of 7/18/2024 after the skin tear occurred. During an interview on 8/21/2024 at 12:33 PM, Therapy Director (TD) VV stated R268 was able to transfer herself prior to her fall with injury on 7/8/2024 and then when she came back from the hospital on 7/11/2024 therapy reevaluated her. TD VV said she verbally communicated to RN G and told him and a CNA that R268 changed to a 2 person assist with transfers and she wasn't sure if they communicated that to other staff. TD VV stated that the therapy to nursing communication process changed after the skin tear incident to communicate changes better to nursing staff and so they make sure the care plan is updated. During an interview on 8/22/24 at 10:10 AM, Interim Director of Nursing (DON) B stated R268 was a 1 person assist and then therapy changed her to a 2 person assist which was communicated to nursing and nursing didn't update the care plan. DON B stated now whenever there is a transfer status change, it is emailed to her. Review of the Care Planning Process: Admission, Comprehensive & Short Term Policy with an effective date of 11/2017 revealed, Comprehensive 5. Format d. Interventions are listed to provide the necessary care and services appropriate to accomplish the goal. i. Vital information is communicated to staff via the Safety / ADL plan of care ii. A copy of this vital information is posted at the point of service (typically in the door of the closet or in a manner that otherwise protects the confidentiality of the information.) e. Disciplines responsible for the application of the interventions are listed. f. Alterations to the plan of care are electronically recorded. g. The licensed nurse will review the resident care plan with treatment changes and determine if updates to the plan of care are indicated.

Based on observation, interview, and record review the facility failed to provide nail care to dependent residents in 1 of 16 residents (Resident #8) reviewed for activities of daily living needs. Findings include: Review of an admission Record revealed Resident #8 had pertinent diagnoses which included: need for assistance with personal care and bed confinement status. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 7/30/24 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated Resident #8 was unable to participate in the assessment. Observations were made on 8/20/24 at 10:27 AM., 8/21/24 at 8:37 AM., and 8/21/24 at 12:07 AM., where Resident #8 was observed unkempt, and unshaven, with facial hair that varied in length, and growth and did not appear to be indicative of a beard or other shaped facial hair. During an observation and interview on 8/21/24 at 2:13 PM., Certified Nursing Assistant (CNA) K reported Resident #8 required total care for activities of daily living. CNA K reported Resident #8 required staff to provide nail care. CNA K reported Resident #8's nail care was to be done during showers. CNA K reported Resident #8's shower was due to be given on second shift. Resident #8 was noted to be in his bed, resting with his eyes closed, and his fingernails were noted to be long and soiled. Review of Shower List dated 8/21/24 indicated Resident #8 was to be showered weekly on Wednesday and Friday on second shift. In an interview on 8/21/24 at 2:20 PM., CNA L reported nail care was to be completed when the resident received a shower. In an interview on 8/21/24 at 2:26 PM., Director of Nursing (DON) B reported her expectations were resident's nail care was completed during their scheduled showers or as needed. During an observation on 8/22/24 at 9:19 AM., Resident #8 was in bed, with his breakfast tray on an over the bed table in front of him. Resident #8's fingernails were noted to be long and dirty. Review of the Shower Assignment for Resident #8 dated for 8/21/24 at 21:59 (9:59 PM) revealed a shower was documented as completed. Review of the Care Plan for Resident #8 revealed Focus .bed bound .goal .will receive required assistance for ADL (activities of daily living) care needs . revised on 7/24/24 .ADLs Dependent for ADLs .Bathing . one person assists with bathing . During an interview and observation on 8/22/24 at 9:22 AM., DON B confirmed the Shower Assignment sheet for Resident #8 indicated Resident #8's shower was completed. DON B was present at the bedside of Resident #8 with this surveyor and stated yes, (Resident #8's) nails are very long, they should have been cut when she picked up Resident #8's hand and looked at his fingernails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00146198. Based on observation, interview, and record review the facility failed to implement gait belt use for safety during transfers of 2 of 8 residents (Resident #268, Resident #61) reviewed for transfer status resulting in the potential for injury during transfer. Findings include: Resident #268 (R268) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R268 admitted to the facility on [DATE] with diagnoses of unsteadiness on feet, need for assistance with personal care and difficulty walking. Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which indicated R268 was cognitively intact (13 to 15 cognitively intact). The most recent MDS completed on 7/18/2024 indicated that a BIMS couldn't be completed. She passed away under Hospice care on 7/19/2024. Review of the Investigation Summary of the Facility Reported Incident (FRI) revealed On 7-8-2024 (R268) was sent to the hospital and had an inpatient stay and readmitted to the facility on [DATE]. Upon readmission her care plan transfer status was a 1 (person) assist as it was prior to her transfer out on 7-8-2024. On 7-15-2024 therapy did complete a screen on her and given her increased weakness and the therapist indicated that her transfer status had changed, and she required more assistance for transfers. Her care plan was not revised to reflect their recommendation. On 7-18-2024 she sustained a skin tear to her right lower leg during a transfer The plan of care was followed as it was at that time. However, given her weakness and based on therapys screen completed on 7-15-2024, her transfer status should have been changed to a 2 (person) assist but was not. Post incident the Nurse (RN G), did change her plan of care to reflect her transfer status as a 2 assist. During an interview on 8/21/2024 at 9:20 AM, Certified Nursing Assistant (CNA) V stated that on 7/18/2024 she heard R268 say Ouch in the shower room so she went in there and noticed that CNA MM was with R268 and that he transferred R268 from her wheelchair to the shower chair and he didn't have a gait belt with him. She said when she asked CNA MM where his gait belt was, he said I know. CNA V said R268 was sitting on the edge of the shower chair and she was afraid R268 was going to fall so she helped CNA MM transfer her without a gait belt. During an interview on 8/21/2024 at 11:53 AM, CNAMM said that on 7/18/2024 CNA WW who no longer works at the facility dressed R268 in the shower room after her shower and they both transferred her into her wheelchair. CNA MM stated that he always uses a gait belt during transfers. During an interview on 8/22/2024 at 7:35 AM, Registered Nurse (RN) G stated that on 7/18/2024, CNA J went to him and said that CNA MM was working with R268 and she noticed R268 had a skin tear while she was sitting on the toilet. RN 'G said he observed R268 was on the toilet and CNA MM and didn't notice a gait belt around her, so he asked CNA MM where the gait belt was and he said, I don't know. Review of the FRI Attachment 1, pg. 2 witness statement handwritten by CNA MM revealed .Underarm 2 person transfer no gait belt in use for this transfer indicating when he transferred R268 with CNA WW from the shower chair to her wheelchair. During an interview on 8/21/2024 at 2:00 PM, Therapy Director (TD) VV stated that a gait belt is expected at every transfer whether it is a 1 or 2 person assist, unless staff is using a mechanical lift. During an interview on 8/21/2024 at 2:00 PM, Interim Director of Nursing (DON) B stated that they don't have a gait belt policy. DON B said it is a standard of care so it's expected. Review of the gait belt education list that was provided to nursing staff after the incident on 7/18/2024 revealed that 5 staff members didn't receive current gait belt training. Of the 5 staff, 1 was a Registered Nurse, 1 a Licensed Practical Nurse and 3 were CNAs. 1 CNA didn't receive gait belt education since 10/14/2008. Review of CNA MM's Annual CNA Performance Review and Skills Checklist revealed that his date of hire was 6/12/2024 and he completed gait belt education at orientation on 6/13/2024. He had another skills checklist completed on 7/29/2024 after he returned from suspension. During another interview on 8/22/24 at 10:10 AM, DON B stated that she went over the whole skills check list with CNA MM upon his return from suspension since he did not use a gait belt with R268. Resident #61 Review of an admission Record revealed Resident #61 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: neurocognitive disorder with lewy bodies( dementia characterized by changes in sleep, behavior, cognition, and movement), and history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #61, with a reference date of 6/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 05/15 which indicated Resident #61 was severely cognitively impaired. Section GG of the MDS revealed Resident #61 required maximal assistance (helper does more than half the effort) for transferring to a standing position and for transferring to the toliet. Section J of the MDS revealed Resident #61 had 2 falls during the quarter. Review of a Care Plan for Resident #61, with a reference date of 3/20/24, revealed a focus/goal/interventions of: Focus: Altered functional mobility .Goal: (Resident name omitted) will be assist(sic) with ADL's(activities of daily living) to his highest functional capability .Interventions: .Ambulation: Non-ambulatory . During an observation on 8/20/24 at 12:49pm, Certified Nursing Assistant (CNA) O entered Resident #61's room and was told by Resident #61's spouse that the resident needed to use the restroom. CNA O assisted Resident #61, who sat in his wheelchair, to the doorway of the bathroom. CNA O then place her arms around Resident #61's upper torso and assisted him with standing while he held on to a grab bar with one hand. CNA O then pulled down Resident #61's pants and brief, then pivoted him to the toliet while both of her arms were around Resident #61's torso. In an interview on 8/20/24 at 12:54pm, Family Member (FM) XX reported she had regularly observed staff transfer Resident #61 without the use of a gait belt. In an interview on 8/22/24, at 12:48pm, Clinical Care Coordinator (CCC) N reported staff should always use a gait belt when transferring a resident who had impaired mobility. CCC N not using a gait belt with a resident who had impaired mobility could result in injury either from improperly supporting the residents body and/or the resident suffering a fall during the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify PTSD (Post Traumatic Stress Disorder) triggers and implement interventions to mitigate triggers for 1 of 1 residents (Resident # 32) reviewed for trauma informed care, resulting in the potential for previous traumas to be retriggered causing mental distress. Findings include: Review of Trauma-Informed Care in Behavioral Health Services, U.S Department of Health and Human Services, 2014, revealed: Beyond identifying trauma and trauma-related symptoms, the initial objective of TIC(Trauma-Informed Care) is establishing safety .safety has a variety of meanings. Perhaps most importantly, the client has to have some degree of safety from trauma symptoms .trauma reactions can be triggered by sudden loud noises, tension between people, certain smells, or casual touches . Review of an admission Record revealed Resident #32, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: major depressive disorder, post-traumatic stress disorder, and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #32, with a reference date of 5/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #32 was cognitively intact. Review of a Care Plan for Resident #32, with a reference date of 3/17/21, revealed a focus/goal/interventions of: (Resident name omitted) has the potential for an acute condition change related to his diagnosis of PTSD(post traumatic stress disorder) . Goal: (resident name omitted) will have early identification, management, treatment and resolution of an acute condition change. No interventions related to Resident #32's diagnosis of PTSD were present. Review of a Trauma Informed Care Life Event Screening for Resident #32 with a reference date of 3/10/21 revealed the resident had experienced the following traumatic events: a transportation accident, and a serious accident at work, home or during a recreational activity. No other traumatic events were identified and no additional trauma assessments by facility staff were present. In an interview on 8/21/24, at 3:55pm, Social Services Director (SSD) DD reported Resident #32 did not have PTSD. When made aware of Resident #32's PTSD diagnosis, SSD DD reported she was not aware of any triggers the resident had related to his PTSD but the resident was prone to angry outbursts. Review of a Psychiatry Progress Note for Resident #32 with a reference date of 5/13/24 revealed: (Resident #32) was playing a game with peers. He became frustrated with a female resident. He made a comment to her. A male resident told (Resident #32), you cant' talk to her like that. (Resident #32) became angry .got up from the table and slammed his chair into the table .(staff member) approached (Resident #32) .(Resident #32) came at (staff member) aggressively with his fists raised . In an interview on 8/22/24, at 11:27am, Social Services Director (SSD) DD confirmed Resident #32 did have a diagnosis of PTSD, had a longstanding history of physical violence toward those he lived with, and had experienced physical and sexual abuse by his father as a child, the loss of both parents at [AGE] years old, and the death of a teenage son. SSD DD reported Resident #32 had displayed physical aggresion at the facility by breaking a window, throwing a chair, and approaching staff in a threatening manner with clenched fists. SSD DD reported she did not know if Resident #32 had any triggers related to his PTSD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that Quality Assessment and Process Improvement (QAPI) meetings had the Medical Director as a mandatory attendee at least quarterly resulting in the potential for the Medical Director to not be notified of quality deficiencies occurring in the facility. Findings include: Review of the [NAME] Woods of [NAME] Quality Assurance/Process Improvement Meeting sign in sheets dated 1/17/2024 and 2/14/2024 revealed that the Medical Director did not attend. Review of the [NAME] Woods of [NAME] Infection Control Meeting that was used as the sign-in sheet for the Quality Assurance/Process Improvement Meeting dated 3/13/2024 and 4/14/2024 revealed that the Medical Director did not attend. During an interview on 8/22/2024 at 11 AM when discussing the QAPI Program, Nursing Home Administrator (NHA) A acknowledged the Medical Director didn't attend the meetings for 4 consecutive months and failed to attend at least 1 meeting in the quarter. Review of the Quality Assurance Performance Improvement Plan Policy with a review date of 5/10/2024 on page 14 revealed Appendix A-QAPI Committee Team Members Attendees: Medical Director .

Based on observation, interview, and record review the facility failed to ensure proper use of personal protective equipment (PPE) for enhanced barrier precautions in 2 (Resident #1 and Resident #18) of 8 residents reviewed for implementation of enhanced barrier precautions, resulting in the potential for the spread of infection, cross contamination and disease transmission. Findings include: Resident #1 Review of an admission Record revealed Resident #1 had pertinent diagnoses which included: cerebral infarction (stroke), need for assistance with personal care and type 2 diabetes (disease that does not allow the body to regulate blood sugar) mellitus without complications. Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 8/5/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident # was cognitively intact. Resident #18 Review of an admission Record revealed Resident #18 had pertinent diagnoses which included: cerebral palsy (a neurological (brain) disorder that appears in early childhood and permanently affects body movement and muscle coordination) and aphasia (inability to understand or to communicate). Review of a Minimum Data Set (MDS) assessment for Resident #18, with a reference date of 6/10/24 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated Resident #18 was unable to participate in the assessment. Review of Order Summary for Resident #1 dated 8/20/24 revealed .enhanced barrier precautions during high contact resident care activities every shift for routine care . Review of Order Summary for Resident #1 dated 8/21/24 revealed .wound to coccyx and left buttock: Cleanse with normal saline, apply chamosyn Honey with each incontinent episode .for every shift for wound care . During an observation on 8/21/24 at 11:20 AM., Certified Nurse Assistant (CNA) L was observed assisting Resident #1 into her room. Noted signage posted on Resident #1's room door indicated that enhanced barrier precautions were in place and that PPE was to be worn during care. CNA L did not apply PPE before entering Resident #1's room. During an observation on 8/21/24 at 11:22 AM., CNA S knocked on Resident #1's closed room door and entered. CNA S did not apply PPE before entering the room. During an observation on 8/21/24 at 11:22 AM., CNA L and CNA S were providing incontinent care to Resident #1 in her bed and neither CNA L nor CNA S were wearing a gown. In an interview on 8/21/24 at 11:37 AM., CNA S reported that she did not know what the enhanced barrier precautions signage on Resident #1's room door meant. In an interview on 8/21/24 at 11:38 AM., CNA L reported that the signage on Resident #1's door meant the staff needed to wear a gown and gloves when performing care. When asked CNA L reported that she did not wear a gown during care. Review of Order Summary for Resident #18 dated 2/2/24 revealed .Gastrostomy tube (PEG) (tube in the abdomen to provide nutrition) . Review of Order Summary for Resident #18 dated 4/1/24 revealed .Enhanced Barrier Precautions during high contact resident care activities every shift for routine care . During an observation on 8/20/24 at 9:45 AM and 8/21/24 at 7:35 AM., Resident #18 did not have enhanced barrier signage on the door to his room to indicate that staff were required to use PPE when providing direct resident care. In an interview on 8/22/24 at 7:35 AM., Licensed Practical Nurse (LPN) BB stated (Resident #18) has a PEG tube that he receives his medications and feedings. PPE should be worn when performing cares while handling the tube for infection control prevention. In an interview on 8/21/24 at 3:24 PM., Clinical Care Coordinator/Registered Nurse (CCC/RN) N reported that her expectation for enhanced barrier precautions was that staff wore the PPE indicated on the signage when providing care to residents. CCC/RN N reported that Resident #1 and Resident #18 were on enhanced barrier precautions. In an interview on 8/21/24 at 4:08 AM., Director of Nursing (DON) B reported that the expectation was the enhanced barrier precautions be implemented if the resident met criteria. Review of facility policy Enhanced Barrier Precautions with an effective date of March 2024, revealed .it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .high-contact resident activities include: transferring, providing hygiene, changing briefs .device care .feeding tube . post clear signage on the door or the wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00143833 Based on interview and record review the facility failed to ensure residents received care in accordance with professional standards of nursing practice to ensure accurate transcription of medications and monitoring of potentially dangerous medications in 1 of 2 residents (Resident #84) reviewed standards of practice, resulting in an overdose of blood thinner medication and potential bleeding. Findings include: Review of an admission Record revealed Resident #100 was a male with pertinent diagnoses which included atrial fibrillation and high blood pressure. Review of current Care Plan for Resident #100, revised on 1/19/24, revealed the focus, .Potential with acute condition change with cardiopulmonary, metabolic, or infectious complications . (Resident #100) has a history of hypertension and atrial fibrillation . with the intervention .Review hospital discharge to determine baseline upon admission .Review of residents medication regime to identify a possible ADR (adverse drug reaction) . Review of current Care Plan for Resident #100, revised on 1/19/24, with the focus, .Potential risk for falls or injury related to: Thromboprophylaxis therapy (treatment that prevents blood clots from forming in the blood vessels), (Resident #100) has a history of falls in the community . Review of the facility transcribed Orders dated 1/19/24, revealed, .Warfarin 2.5 mg tablets .Take 1 tablet by mouth at bedtime for to prevent blood clots .Warfarin 1mg tablet, 2 tablets by mouth at bedtime for to prevent blood clots . Review of Telehealth Encounter dated 1/19/24 at 00:00 AM, revealed, .1/19/2024 00:00, revealed, .New admission: Communication received regarding a new admission. Facility and medication orders have been reviewed and compared to discharge medication reconciliation, medications have been verified, and communication to nursing has been completed. Care team updated .Provider: (Nurse Practitioner (NP) O) .Addendum Details: 1/25/24 .Late entry: Reviewed hospital D/C medications over the phone with the nurse and the D/C summary was reviewed via fax . Note: This writer attempted to contact the admitting nurse practitioner with no return phone call prior to exit. In an interview on 5/29/24 at 4:47 PM, Nurse Practitioner (NP) N reported she was in the building on 1/21/24 and was not there to see Resident #100 on the warfarin prescription as she reported the pharmacy completed the dosing of warfarin and everything relevant at admission would be faxed to the pharmacy. NP N reported she took for granted everything was done and did not pay attention to the warfarin orders as the pharmacy dosed and the discharge medication were reviewed by the nurse and admitting provider. NP N reported she would go in and do the physical assessment of the resident and determine their needs. Review of Hospital Physician Discharge Summary dated 1/19/24, revealed, .warfarin sodium 2.5 mg Oral Daily; Patient taking differently: Take 1 tablet by mouth 3 (three) times a week Sunday, Wednesday, Friday at 4pm 2 mg Oral Daily .Patient taking differently: Take 2 tablets by mouth 4 (four) times a week Monday, Tuesday, Thursday, Saturday at 4pm . Review of Interdisciplinary Documentation dated 1/22/24 at 11:00 AM, revealed, .(Family Member T) who wanted to share some concerns since (Resident #100)'s admission to (Facility) .(Family Member T) as concerned with medications that had been ordered .Would send the provider to discuss all medications administered and to answer any questions she may have . Review of Concern Form dated 1/22/24, submitted by Family Member T revealed, .What is your complaint about? .Care & oversight of (Resident #100) and medication regimen .Concerned with warfarin medication administration . In an interview on 5/30/24 at 10:07 AM, Licensed Practical Nurse (LPN) M reported for the admission process the nurse would receive the packet of information from the attendants who brought the resident from the hospital, sometimes would get a call from the hospital nurse to give report on the resident, which would have the orders and past medical history information. In an interview on 5/30/24 at 12:34 PM, Clinical Care Coordinator (CCC) D reported an admission was a multiple nurse process, the second nurse verified the medications with the discharge summary with the medication list in the computer. Typically, orders were reviewed by the next shift nurse. The third check was completed by her, DON (Director of Nursing) or the next shift. During the week would be the DON or CCC. CCC D reported there was an admission checklist for the nurses to complete and it would be checked off by the second and third nurse who checked the medications. CCC D reported this was the only place the checks of medications were documented. Those checklists were not kept as they were an internal document. In an interview on 5/30/24 at 12:5 PM, Licensed Practical Nurse (LPN) F reported the facility used an admission checklist for admissions. LPN F reported the nurses worked together to complete a new admission most times. When orders were entered, there were triple checks of the accuracy of the orders. Usually, the second check was completed by the nurse who worked that evening, and the third check was completed by the clinical care coordinators (CCCs), on Monday if a weekend entry. LPN F reported the checklist, medications and other pertinent information was placed in a purple folder for the CCCs to review. In an interview on 5/30/24 at 4:39 PM, LPN G reported during admission if there were inconsistent orders, the nurse would contact the doctor at the hospital and contact the facility provider as well to let them know and seek direction on how to proceed. In an interview on 5/30/24 at 10:05 AM, Clinical Support, RN (CS) C reported for Resident #100 the nurse did not send to pharmacy the orders for an INR when entered medications and forwarded to pharmacy for dosing review. CS C reported the primary nurse practitioner did not review the medications as close as she should've and when she saw the resident on 1/21/24, she should have ordered an INR to be done. The order for pharmacy to dose coumadin didn't get entered until CCC D did it on 1/21/24 when she did her admission review. Review of the Fundamentals of Nursing revealed, Patient care requires effective communication among members of the health care team. The medical record is an important means of communication because it is a confidential, permanent, legal documentation of information relevant to a patient's health care. The record is a continuing account of a patient's health care status and is available to all members of the health care team. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 24088-24091). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00143833 Based on interview and record review, the facility failed to ensure medications were administered at the correct dose per the physician's order for 1 of 2 residents (Resident #100) reviewed for significant medication errors, resulting in the potential for adverse effects of an overdose of an anticoagulant medication. Findings include: Review of Intake dated 4/9/24, revealed, .However, the much greater concern is that this facility did not follow the prescribing instructions provided to them by (Local Hospital) for dosing (Resident #100)'s Warfarin and overdosed him causing him to have to be transported by Ambulance, put through additional examinations and tests, unknown physical damage, by having his blood way too thin. In addition, the facility and medical professionals did not follow standard protocol for Warfarin overdosing and were extremely slow to respond to this overdose when brought to their attention . Review of an admission Record revealed Resident #100 was a male with pertinent diagnoses which included atrial fibrillation and high blood pressure. Review of current Care Plan for Resident #100, revised on 1/19/24, revealed the focus, .Potential with acute condition change with cardiopulmonary, metabolic, or infectious complications .(Resident #100) has a history of hypertension and atrial fibrillation . with the intervention .Review hospital discharge to determine baseline upon admission .Review of residents medication regime to identify a possible ADR (adverse drug reaction) . Review of current Care Plan for Resident #100, revised on 1/19/24, with the focus, .Potential risk for falls or injury related to: Thromboprophylaxis therapy (treatment that prevents blood clots from forming in the blood vessels), (Resident #100) has a history of falls in the community . Review of Physician Discharge Summary from (Local hospital) dated 1/19/24, revealed, .warfarin sodium 2.5 mg Oral Daily; Patient taking differently: Take 1 tablet by mouth 3 (three) times a week Sunday, Wednesday, Friday at 4pm 2 mg Oral Daily .Patient taking differently: Take 2 tablets by mouth 4 (four) times a week Monday, Tuesday, Thursday, Saturday at 4pm . Review of facility transcribed Orders dated 1/19/24, revealed, .Warfarin 2.5 mg tablets .Take 1 tablet by mouth at bedtime for to prevent blood clots .Warfarin 1mg tablet, 2 tablets by mouth at bedtime for to prevent blood clots . Coumadin (Warfarin Sodium) is a narrow therapeutic range drug and anticoagulation must be carefully monitored during Coumadin therapy. Adjust the Warfarin dose to maintain a typical target INR of 2.5 for deep vein thrombosis, pulmonary embolism and atrial fibrillation with an INR range of 2.0-3.0 for all treatment durations. (Bristol-[NAME] Squibb Company, [NAME], New Jersey, October 2011) Review of Telehealth Encounter dated 1/19/24 at 00:00 AM, revealed, .1/19/2024 00:00, revealed, .New admission: Communication received regarding a new admission. Facility and medication orders have been reviewed and compared to discharge medication reconciliation, medications have been verified, and communication to nursing has been completed. Care team updated .Provider: (Nurse Practitioner (NP) O) .Addendum Details: 1/25/24 .Late entry: Reviewed hospital D/C medications over the phone with the nurse and the D/C summary was reviewed via fax . Note: This writer attempted to contact the admitting nurse practitioner with no return phone call prior to exit. Review of Medication Administration Record (MAR) for January 2024, revealed, Resident #100 was administered at 08:00 PM, 2mg by mouth at bedtime for to prevent blood clots on 1/19/24, 1/20/24, 1/21/24 .2.5 mg by mouth at bedtime for to prevent blood clots on 1/19/24, 1/20/24, 1/21/24 . This inciated Resident #100 received 4.5mg Coumadin daily instead of the 2mg or 2.5mg's ordered by the discharge physician. In an interview on 5/29/24 at 4:47 PM, Nurse Practitioner (NP) N reported she was in the building on 1/21/24 and was not there to see Resident #100 on the warfarin prescription as she reported the pharmacy completed the dosing of warfarin and everything relevant at admission would be faxed to the pharmacy. NP N reported she took for granted everything was done, and did not pay attention to the warfarin orders. Review of Interdisciplinary Documentation dated 1/22/24 at 11:00 AM, revealed, .(Family Member T) who wanted to share some concerns since (Resident #100)'s admission to (Facility) .(Family Member T) as concerned with medications that had been ordered .Would send the provider to discuss all medications administered and to answer any questions she may have . Review of Concern Form dated 1/22/24, submitted by Family Member T revealed, .What is your complaint about? .Care & oversight of (Resident #100) and medication regimen .Concerned with warfarin medication administration . Review of (Name of Laboratory) results dated 1/22/24, revealed, .Collected date & time: 1/22/24 00:28 .INR 8.19 (CH- critical high) .1. Oral Anticoagulant therapeutic range: 2.00 - 3.00 .Prothrombin time: 79.2 (CH-critical high) .Normal range: 9.6 - 12.2 . The laboratory document indicated the critical high results were reported to the facility on 1/22/24. Note: Faxed to Pharmacy noted on results. Initialed on 1/23/24 by Nurse Practitioner (NP) N. According to Mayo Clinic, The prothrombin time test is a test to evaluate blood clotting .Prothrombin is a protein produced by your liver. It is one of many factors in your blood that help it to clot appropriately . https://www.mayoclinic.org/tests-procedures/prothrombin-time/about/pac-20384661 Review of Warfarin Dosing Program: Pharmacy to Facility Communication document dated 1/24/24 at 11:25 AM, revealed, .Additional Comments: On 1/22/24 - Informed (RN K), to contact prescriber for VITAMIN K administration (Last Lab on 1/15 INR 2.4) . Review of Interdisciplinary Documentation dated 01/22/2024 at 5:08 PM, revealed, .Received lab results via fax. INR was critical at 8.19. Results faxed to pharmacy. Received a call from pharmacist with order to draw INR tomorrow, hold coumadin pending result, and call provider to ask if they want to order vitamin k . In an interview on 5/20/24 at 11:15 AM, Registered Nurse (RN) K reported she saw the fax come in (1/22/24) and it was critical, and she faxed the results to pharmacy. When pharmacy called she was the one who answered the phone and got those recommendations from pharmacy for dosing the coumadin and to contact the provider if they wanted Vitamin K administered. RN K reported relayed the information to the nurse assigned to Resident #100. Review of the medical record showed no conversation with the provider on the Critical lab result of 8.19 and how the provider wanted to proceed with the pharmacy recommendation. No progress note was entered the provider was contacted. Review of Interdisciplinary Documentation dated 1/23/24 at 10:12 AM, revealed, .(Local lab) was called regarding lab draw stat PT/INR. They will be here in four hours or less . Review of Orders dated 1/23/24, revealed, .PT/INR Stat .Verbal . Review of Interdisciplinary Documentation dated 1/23/24 at 5:01 PM, revealed, .Spoke with (Family Member T), Resident 100's daughter regarding concerns with medication orders .(Family Member T) stated she had a list of (Resident #100)'s medications and was confused that what we reviewed was not what she had stated was his medication regimen . Review of (Name of Lab Company) blood draw form indicated blood drawn on, .1/23/24 at 3:45 PM .Completion time: 4:00 PM .report given to (LPN E) .Notes: Arrived at 11:30 no tubes available, ordered tubes, will return when tubes arrive. Returned at 1545 (3:45 PM), labs drawn from L (left) . Review of (Local Hospital Lab) results revealed, .Results: Critical!! .INR 7.2. Specimen Collected: 01/23/24 3:53 PM .Last Resulted: 01/23/24 7:04 PM . Review of medical record for Resident #100 revealed no follow up on 1/23/24 of the Critical lab results. In an interview on 5/30/24 at 1:44 PM, Lab Testing Manager (LTM) S reported the laboratory hours of operation were 8:00AM to 6:30PM Monday -Friday. On Saturday and Sunday, hours of operation were 08:00AM to 12:30PM. LTM reported if the laboratory was unable to fulfill the request for a stat lab that would be completed by the local hospital. If the lab was unable to fulfill the order, the facility would be contacted and the nurse who cared for the resident would be informed the lab was unable to complete the stat order. LTM S reported the lab would not just cancel the request and not notify the nurse. If they were not able to get a stat lab in the AM, they would get to it in the PM. LTM S reported they were at the facility on 1/5/24, 1/8/24, 1/15/24, 1/22/24, and 1/25/24. If a stat lab was submitted, someone would be dispatched to complete the request. There was a log sheet for the lab and the requisition, the phlebotomist would get a copy to the lab with her sample. LTM S reported for any critical labs the facility would be contacted by phone. Review of faxed (Local Hospital Lab) resulted revealed, .1/24/24 Faxed to (Name of Pharmacy) 10A . Review of Interdisciplinary Documentation dated 1/24/24 at 10:09 AM, revealed, .Resident's PT/INR results from 1/23: 68.6/7.2, Faxed results to pharmacy for coumadin dosing . Review of Warfarin Dosing Program: Pharmacy to Facility Communication document dated 1/24/24 at 11:25 AM, revealed, .Current INR 7.2 on 1/23/2024 (lab delayed) .Warfarin Orders: Hold Dose Until Back Within the Range .PT/INR Order: Please schedule next INR on 1/24/24 - Daily . Note: Handwritten Sent to ER 1/24/24. Fax received by facility on 1/24/24 at 12:33 PM. Review of Interdisciplinary Documentation dated 1/24/24 at 12:04 PM, revealed, .Spoke with daughter upon her arrival to the facility .(Family Member T) expressed frustration regarding her dad, (Resident #100)'s INR and why Vitamin K was not administered .I would call our provider to inquire and I would let her know as soon as I had more information .Placed a call to (Name of Medical Doctor) gave a verbal order for vitamin K and stated to send the resident out to hospital for evaluation . Review of Orders dated 1/24/24, revealed, .hold coumadin until back in range and give vitamin K stst (sic) pt/inr today . Review of Orders dated 1/24/24, revealed, .Transport to (Local hospital) ER . Review of Interdisciplinary Documentation dated 1/24/24 at 12:50 PM, revealed, .Resident's pharmacy recommendation for vitamin K and labs redrawn on 1/24 and coumadin on hold until back in range. MD called order to give Vitamin K 5 mg and send to ER for evaluation now . Review of Interdisciplinary Documentation dated 1/24/24 at 1:06 PM, revealed, .Spoke with (Medical Doctor U) gave verbal order to give Vit K 5 mg sub q (under the skin injection) STAT and send out to ER due to unmanageable INR . Review of Interdisciplinary Documentation dated 1/24/24 at 1:33 PM, revealed, .family wanted him sent based on INR results of 7.8 . Review of ED Provider Notes dated 1/24/24 at 1:18 PM, revealed, .(Resident #100) presents for complaint of elevated INR .States the patient received [NAME] the dose of Coumadin over the weekend and his INR was 8.9. His INR was most recently 7.2 last night. He was not given any vitamin K until today, received just prior to the facility calling 911 .He did have a fall on Sunday .Discharge home with outpatient f.u. (follow up) .strict return precautions .Medications changes: Vitamin K 100 mcg oral daily for 5 days, starting Wed 1/24/24, until Mon. 1/29/24, normal . In an interview on 5/29/24 at 4:59 PM, Licensed Practical Nurse (LPN) E reported she worked every other weekend, for stat labs or critical labs like the PT INR results were sent to the pharmacy to review and make recommendations for the warfarin dosing. The pharmacy would call to let know sending over a fax for recommendations. Once the recommendations were received, the nurse would contact the doctor/provider to let them know what the results were for the lab. In an interview on 5/30/24 at 10:07 AM, Licensed Practical Nurse (LPN) M reported for the admission process the nurse would receive the packet of information from the attendants who brought the resident from the hospital, sometimes would get a call from the hospital nurse to give report on the resident, which would have the orders and past medical history information. In an interview on 5/30/24 at 12:34 PM, Clinical Care Coordinator (CCC) D reported an admission was a multiple nurse process, the second nurse verified the medications with the discharge summary with the medication list in the computer. Typically, orders were reviewed by the next shift nurse. The third check was completed by her, DON (Director of Nursing) or the next shift. During the week would be the DON or CCC. CCC D reported there was an admission checklist for the nurses to complete and it would be checked off by the second and third nurse who checked the medications. CCC D reported this was the only place the checks of medications were documented. In an interview on 5/30/24 at 12:5 PM, Licensed Practical Nurse (LPN) F reported the facility used an admission checklist for admissions. LPN F reported the nurses worked together to complete a new admission most times. When orders were entered there were triple checks of the accuracy of the orders. Usually, the second check was completed by the nurse who worked that evening, and the third check was completed by the clinical care coordinators (CCCs), on Monday if a weekend entry. LPN F reported the checklist, medications and other pertinent information was placed in a purple folder for the CCCs to review. LPN F reported for coumadin Monday labs were usually ordered in the electronic medical record (EMR). LPN F reported pharmacy was the one to dose coumadin, send to the pharmacy via fax and note that they were sent. LPN F reported we usually dose it and order the labs and then the pharmacy takes it from there. LPN F reported if there was a critical lab result, faxed the results to pharmacy, and notified the provider. LPN F reported the faxed come on the weekends to the medication room fax, pharmacy calls and let facility know sent a fax, if not your resident, let your peer know there was a critical lab. In an interview on 5/30/24 at 10:42 AM, Pharmacist R reported when the pharmacy received the order, would ask if the INR was drawn and how long ago, obtained medication history, drug list at that point. We asked for medications to determine if there was anything that would interact and create fluctuations. For those on coumadin, we would recommend to have an INR drawn in a day or two even if the resident was a weekend admission. Pharmacist R reported clinical monitoring on a discharge summary would be the monitoring of the residents INR/PT. In an interview on 5/30/24 at 4:39 PM, LPN G reported during admission if there were inconsistent orders, the nurse would contact the doctor at the hospital and contact the facility provider as well to let them know and seek direction on how to proceed. In an interview on 5/30/24 at 10:05 AM, Clinical Support, RN (CS) C reported for Resident #100 the nurse did not send to pharmacy the orders for an INR when entered medications and forwarded to pharmacy for dosing review. CS C reported the primary nurse practitioner did not review the medications as close as she should've and when she saw the resident on 1/21/24, she should have ordered an INR to be done. The order for pharmacy to dose coumadin didn't get entered until CCC D did it on 1/21/24 when she did her admission review. CS C reported when the lab was drawn on 1/22/24 and it was resulted at 8.19 Critical, not sure why the provider was not contacted, and the recommendation of vitamin K to be administered not followed up on. Reviewed the lab results for 1/23/24, CS C reported an order to do an INR stat was entered and resulted at Critical at 7.2 and was unsure as to why the results were not faxed over on 1/23/24 and did not happen until 1/24/24, as the provider should have been contacted right when the results were received and taken care of immediately. The critical lab should have been addressed the day of the result as it could have had consequences for the resident. Review of document submitted to this writer on 5/30/24, revealed, .Coumadin order education .When a resident is on Coumadin, they need routine PT/INR lab levels drawn and the dosing is managed by the pharmacy. There needs to be an order for the pharmacy to dose the Coumadin. Then the day the lab is to be drawn there needs to be an order for that day to do so, with supplementary documentation where the INR result will be recorded on the MAR before administration of the Coumadin on the lab day .This is an order that we have a template for already. Under orders, next to new order, there is a search bar, on that line type PT/INR and it will pop up, click on it and the order will open and you simply need to change the date at the bottom of the order for the day the lab is ordered for . Review of policy, Medication Monitoring received on 5/30/24, revealed, .Appropriate laboratory monitoring of all residents should be done to ensure optimal therapeutic outcomes., decrease the risk of adverse events .1. Laboratory monitoring is recommended during the medication regimen review to comply with manufacturer specifications, current standards of practice .3. Certain drugs (i.e. IV medications and Clozaril) require lab values be reviewed by the pharmacist prior to dispensing, and facility will provide laboratory information as requested by the pharmacy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain dignity for one resident (R17) of 18 residents reviewed for dignity, resulting in the likelihood of feelings of embarrassment and humiliation based on the reasonable person concept. Findings include: According to the Minimum Data Set (MDS) 6/12/2023, R17 had a BIMS (Brief Interview Mental Status) of 99 indicating that he was not capable of making decisions on his own. Required total dependence of two-plus persons physical assistance to transfer. Resident was always incontinent of bowel and bladder dependent on staff for ADL care. His diagnoses included cerebral palsy (a condition marked by impaired muscle coordination/spastic paralysis and/or other disabilities typically caused by damage to the brain before or at birth, aphasia (disorder that affects how you communicate), seizure disorder/epilepsy, anxiety, and depression. During an observation and interview on 6/26/2023 at 11:08 AM, Certified Nursing Assistant (CNA) Z pulled R17 backwards in a Broda chair (gives resident ability to tilt back and recline) to his room banging him into the double doors. This made the resident [NAME] forward in his chair. CNA Z stated, I'm going to take him to do a check and change(brief change) in his room. I can do it. The CNA then pulled R17 into his room and closed the door. This Surveyor entered R17's room observing CNA Z had leaned the resident back in the Broda chair and had started to change his urine soaked brief while still in the chair. At 11:17 AM, CNA Z exited R17's room with him, pushing him to the middle of the hall. There, the CNA left the resident in middle of the hall, put dirty linen in Home Care-S, went back to the resident, pushed him to the Nursing Station 2, placing him next to the railing and left him by himself. During an interview on 6/27/2023 at 1:59 PM, Director of Nursing (DON) B shook her head, stating, A resident that needs a brief change or incontinence care should be transferred to their bed to make sure they are thoroughly cleaned. A resident should not be changed in a Broda chair. They cannot be thoroughly cleaned while sitting that way. Review of R17's Care Plan Functional Incontinence as evidenced by resident's altered mobility, cognitive communication deficit, and anarthria (complete loss of speech). He was dependent on staff to anticipate and intervene for his toileting needs. Any continence achieved was through direct staff intervention. Other risk factors of incontinence included fall revision on 2/22/2023. Goal to meet R17's needs included maintain an adequate output without evidence of an infection. To meet goal, interventions included incontinence care with protective barrier ointment as indicated, incontinence supplies (disposable briefs) used.

Based on interview and record review, the facility failed to notify a Responsible Party of a change in care/condition for 1 of 18 residents (Resident #71) reviewed for notification of change, resulting in the Responsible Party not participating in medical decisions regarding care and treatment. Findings included: Resident #71: Review of an admission Record revealed Resident #71 was a male with pertinent diagnoses which included Korsakoff syndrome (memory disorder results from vitamin B1 deficiency, damages nerve cells, part of the brain involved with memory), traumatic head injury, Wernicke's encephalopathy (life threatening illness which affects the peripheral and central nervous system), adult failure to thrive, depression, and history of falls. Review of a Minimum Data Set (MDS) assessment for Resident #71, with a reference date of 5/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated Resident #7 was moderately cognitively impaired. Review of current Care Plan for Resident #71, revised on 5/2/2023, revealed the focus, .Altered functional mobility and ADLs (activities of daily living) related to: (Resident #71) admitted with primary diagnosis of Korsakoff syndrome, malnutrition, chronic subdural hematoma .He is alert and oriented to himself only. He wanders the halls and requires redirecting. Wanderguard in place . with the intervention .EXIT SEEKING ALERT: Exit seeking alarm band protection device applied dated 4/28/23 .With history of exit seeking and mobility independence apply interventions as indicated and reassess prn (as needed) .4/28/23 . In an interview on 06/28/23 at 08:49 AM, Guardian MM reported when Resident #71 had exited the building without supervision on 5/14/23 she was not contacted as his guardian as to what had occurred. In an interview on 06/28/23 at 3:25 PM, Director of Nursing (DON) B reported during review of the record, the notification of the representative should have been entered in the risk assessment. Review of the progress notes did not reveal a notification provided to the guardian. Review of the incident report showed no notification to the guardian. DON B concurred the record did not contain notification of the responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00134009 and MI00136319 Based on interview and record review, the facility failed to immediately report allegations of abuse for one resident (R38) of three residents reviewed for abuse, resulting in allegations of abuse that were not reported to the Nursing Home Administrator and the State Agency timely, and the potential for further allegations of abuse to go unreported, and not thoroughly investigated. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], R38 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status) and required a wheelchair for mobility. The resident did not exhibit behaviors including verbal/communicated outbursts. Diagnoses included cancer, stroke, anxiety, and depression. Review of MI-FRI ID: 00049615 reported an incident alleging staff to R38 verbal abuse occurred on 12/29/2022 at 9:15 PM. Review of MI-FRI Incident Summary reported the incident between staff and R38 was discovered 12/30/2022 at 3:30 PM. During an interview on 6/28/2023 at 12:28 PM, the Nursing Home Administrator (NHA) A stated, I am not the abuse coordinator the DON (Director of Nursing) is. At the time of the incident for (R38) another nurse was the DON. (R38's) incident, occurred on 12/29 (2022) and administration was not notified until the next day, 12/30 (2022), when a CNA said something to the then DON. It should have been reported within two hours. During an interview on 6/28/2023 at 12:35 PM, Director of Nursing (DON) B stated, The incident with (R38) and staff, (Licensed Practical Nurse/LPN NN) happened before I became the DON. I am currently the abuse coordinator. When any type of abuse is observed or heard about it should be reported to myself or the Administrator immediately. Staff has received abuse training through in-services since I've been here. There are signs around the building telling staff who to contact when they see or hear about abuse, any kind of abuse. During an interview on 6/28/23 at 11:40 AM, Certified Nursing Assistant (CNA) M stated, During my rounds, (R38) was telling (LPN NN) about her medications. They argued. (LPN NN) started calling (R38) a B**** and acting liking a F****** 2-year-old. The LPN shoved (R38) in her wheelchair into the door. (R38) looked shook up. I felt (R38) was in danger. The RN (Registered) Charge Nurse PP said the incident needed to be reported and had all staff write statements. I am to report abuse immediately but first try to intervene. I would report to the nurse. The RN Charge Nurse PP witnessed the incident. Review of facility policy Identification of Abuse, revised March 2019, revealed, .It is the policy of this facility to encourage any employee who has reasonable cause to believe that a resident has been subject to abuse .or endangerment to report it to the facility Administrator and/or Director of Health Care Services (DON) .Abuse: Intentional (non-accidental) harm or threatened harm to a resident's health or welfare. Abuse is defined at 483.5 as the willful infliction of injury, unreasonable .intimidation or punishment with resulting .mental anguish .It includes . verbal abuse . Psychological, Mental or Verbal Abuse: Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability.

Based on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 1 residents of 18 (Resident #8) reviewed for care planning resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual V1.17, Chapter 4, revealed, .the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #8: Review of an admission Record revealed Resident #8 was a female with pertinent diagnoses which included stroke, dementia, need for assistance with personal care, muscle weakness, legal blindness, repeated falls, difficulty in walking, anxiety, and delusional disorder. Review of current Care Plan for Resident #8, revised on 1/24/22, revealed the focus, .(Resident #8) has altered functional mobility and ADL's (activities of daily living) related to: history of strokes and is blind in both eyes .She needs reminded to remain calm as she is safe . with the intervention .AMBULATION: non-ambulatory .Fall - RISK MANAGEMENT, 10/3/21 - Fall mat at bedside . During an observation on 06/26/23 at 11:27 AM, Resident #8 was observed lying in her bed with a fall mat next to her bed. Her bed was not low to the ground. During an observation on 06/26/23 at 12:33 PM, Resident #8 was observed lying in her bed. A gray fall mat was folded up in the far right corner of the room with the wheelchairs. During an observation on 06/26/23 at 02:49 PM, Resident #8 was observed lying in her bed and there was not a gray fall mat next to her bed. It was folded in half placed in the far right corner of the room. In an interview on 6/28/23 at 10:15 AM, CNA T reported the CNAs would find the care plan information on the rounds sheets and also look in the resident's room and it tells you their level of care, diets, etc. In an interview on 6/28/23 at 11:32 AM, Licensed Practical Nurse (LPN) C reported following an incident the nurse would add an intervention to the care plan. When there was a fall, nurses contact the supervisor on duty and they do at times assist with interventions. LPN C reported the IDT team reviews the care plans and made any changes they felt necessary. In an interview on 6/28/23 at 10:53 AM, CNA Y reported the CNAs look for the ADL Care plan which was placed in the resident's closet, this informed them of the interventions needed to care for the resident. In an interview on 6/28/23 at 3:43 PM, Director of Nursing (DON) B reported the nursing staff would find the ADL Care Plan which is what was used a the care guide for Residents in the resident's room, in the closet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 1) follow professional standards of nursing practice for physician notification of a change in condition, 2) complete assessments when an injury occurs, 3)notify of incident to nursing staff and kitchen personnel and 4) administer treatment with an order for 1 of 18 residents (Resident #42) reviewed for accidents, resulting in the potential for further injury and the affected resident not maintaining or achieving their highest practical physical well-being. Findings include: Review of the Fundamentals of Nursing revealed, Patient care requires effective communication among members of the health care team. The medical record is an important means of communication because it is a confidential, permanent, legal documentation of information relevant to a patient's health care. The record is a continuing account of a patient's health care status and is available to all members of the health care team. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 24088-24091). Elsevier Health Sciences. Kindle Edition. Resident #42: Review of an admission Record revealed Resident #42 was a male with pertinent diagnoses which included ataxic gait (unsteady, staggering gait, poor balance, widened base of support), diabetes, muscle weakness, need for assistance with personal care, kidney disease, dysphagia (impairment in the production of speech resulting from brain disease or damage), and cognitive communication deficit, and unsteadiness on feet. Review of current Care Plan for Resident #42, revised on 2/21/23, revealed the focus, .(Resident #42) has altered functional mobility and ADLs related to blindness, age-related debility. He cannot see but is aware of his surroundings, needs guidance to ambulate to bathroom . with the intervention of .ABLE TO LEAVE ON TOILET: No stand by assist (revision on 9/10/22) .SENSORY: He is legally blind - totally blind in his left eye, very low vision in his right eye. He is able to sense objects/others around him .(Revision on 12/6/20) . Review of Incident Report dated 3/18/23, revealed, .Called to North dining room. Informed by (LPN C) that (Resident #2) had spilled hot tea on himself. Removed from dining room to check him in private. Observed slight redness to abdominal fold. No blistering or open areas observed .Intervention: have dietary or rehab give him a closed lipped cup to prevent spills or accidents .Updated the care plan to lid on hot liquids . In an interview on 06/28/23 at 10:06 AM, Resident #42 reported he had a spill of his hot tea and the nurse's put cream on the areas where he had spilled his hot tea. Resident #42 reported there were no blisters and was happy for that. Review of Interdisciplinary Documentation at 3/19/2023 6:00 PM, revealed, .Clarification is was hot tea that spilled on (Resident #42) . Review of Interdisciplinary Documentation at 3/18/2023 at 6:00 PM, revealed, .Called to North dining room. Informed by (LPN C) LPN that (Resident #42) had spilled hot coffee on himself. Removed resident from the dining room to check him in private. Observed slight redness to abdominal fold/groin area. No blistering or open areas observed. Will notify all parties concerned. Will ask dietary or rehab for a closed lid cup to prevent spills . Review of Resident #42's care plan provided no mention of the intervention of adding a lid for all hot liquids due to the incident on 3/18/23. Review of Resident #42's meal ticket revealed no intervention to have a lid for all hot liquids due to his incident on 3/18/22. Review of Resident #42's medical record revealed no skin assessment was completed on the day of the incident. Review of Resident #42's medical record revealed no treatment record or medication administration record for March 2023 for a cream due to a burn. During an observation on 06/28/23 at 12:05 PM, Resident #42 was observed seated at a table in the dining room. Resident #42 has a Styrofoam cup with two tea bags in it and he reported it was hot tea. His table mate had to assist him with finding where his hot tea cup was located at on the table. Resident #42 stated, .I am blind and I needed help locating the cup on the table . In an interview on 06/28/23 at 03:15 PM, Licensed Practical Nurse (LPN) C reported a skin check would be completed, notify the DON, notify the physician and the family (if not their own person), complete an incident report to monitor for injury and develop an intervention for the care plan. In an interview on 06/28/203 at 3:43 PM, Director of Nursing (DON) B reported during review of Resident #42's medical record revealed no skin assessment was completed, no hot liquid assessment was completed, and there was only a progress note in the record. DON B reported during review of the care plan revealed no intervention in place for Resident #42 for the lid for hot liquids. DON B reported she was not aware there was no intervention on the resident's meal ticket for the hot liquids to have a lid. DON B reported the resident may have had calamine lotion applied to the area where he spilled the hot tea as it was used for burns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #42: Review of an admission Record revealed Resident #42 was a male with pertinent diagnoses which included ataxic gait (unsteady, staggering gait, poor balance, widened base of support), diabetes, muscle weakness, need for assistance with personal care, kidney disease, dysphagia (impairment in the production of speech resulting from brain disease or damage), and cognitive communication deficit, and unsteadiness on feet. Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 5/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated Resident #42 was moderately cognitively impaired. Review of current Care Plan for Resident #42, revised on 2/21/23, revealed the focus, .(Resident #42) has altered functional mobility and ADLs related to blindness, age-related debility. He cannot see but is aware of his surroundings, needs guidance to ambulate to bathroom . with the intervention of .ABLE TO LEAVE ON TOILET: No stand by assist (revision on 9/10/22) .SENSORY: He is legally blind - totally blind in his left eye, very low vision in his right eye. He is able to sense objects/others around him .(Revision on 12/6/20) . Review of Incident Report dated 3/18/23, revealed, .Called to North dining room. Informed by (LPN C) that (Resident #2) had spilled hot tea on himself. Removed from dining room to check him in private. Observed slight redness to abdominal fold. No blistering or open areas observed .Intervention: have dietary or rehab give him a closed lipped cup to prevent spills or accidents .Updated the care plan to lid on hot liquids . During an observation on 06/26/23 at 10:50 AM, Resident #42 was observed seated on the side of his bed and he was drinking his drink with no lid or straw. During an observation on 06/26/23 10:58 AM, Resident #42 was calling out to get some help, he has his light on. CNA PP asked him if he liked the tea Resident #42 was reporting he doesn't' like the water and asked for more tea. In an interview on 06/28/23 at 10:06 AM, Resident #42 reported he had a spill of his hot tea and the nurse's put cream on the areas where he had spilled his hot tea. Resident #42 reported there were no blisters and was happy for that. Review of Interdisciplinary Documentation at 3/19/2023 6:00 PM, revealed, .Clarification is was hot tea that spilled on (Resident #42) . Review of Interdisciplinary Documentation at 3/18/2023 at 6:00 PM, revealed, .Called to North dining room. Informed by (LPN C) that (Resident #42) had spilled hot coffee on himself. Removed resident from the dining room to check him in private. Observed slight redness to abdominal fold/groin area. No blistering or open areas observed. Will notify all parties concerned. Will ask dietary or rehab for a closed lid cup to prevent spills . Review of Resident #42's care plan provided no mention of the intervention of adding a lid for all hot liquids due to the incident on 3/18/23. Review of Resident #42's meal ticket revealed no intervention to have a lid for all hot liquids due to his incident on 3/18/22. Review of Resident #42's medical record revealed no skin assessment was completed on the day of the incident. Review of Resident #42's medical record revealed no treatment record or medication administration record for March 2023 for a cream due to a burn. During an observation on 06/28/23 at 12:05 PM, Resident #42 was observed seated at a table in the dining room. Resident #42 has a Styrofoam cup with two tea bags in it and he reported it was hot tea. His table mate had to assist him with finding where his hot tea cup was located at on the table. Resident #42 stated, .I am blind and I needed help locating the cup on the table . In an interview on 06/28/23 at 03:15 PM. Licensed Practical Nurse (LPN) C reported a skin check would be completed, notify the DON, notify the physician and the family, if not their own person, complete an incident report to monitor for injury and develop an intervention for the care plan. Review of Incident Report dated 2/20/23 at 1:01 PM, revealed, .Nursing Description: It was reported to this nurse that Rusty hit his head after standing up in the bathroom. He was being picked up for dialysis and had to use the bathroom before he left. Rusty is legally blind and requires staff to direct him when ambulating. Resident Description: I hit my head on something .Immediate Action Taken: Description: Assessed for injury, and then he left for dialysis. No markings noted. Will start neuros once he returns from dialysis. INTERVENTION: Educated staff to keep eyes on him due to him being legally blind when in the bathroom . In an interview on 06/28/23 at 09:52 AM, CNA D exited Resident #42's room and when this writer inquired where Resident #42 was CNA D reported he was in the bathroom. CNA D went into the shower room. Resident #42 was left in the bathroom unattended. In an interview on 06/28/23 at 3:02 PM, CNA D reported when a resident was a stand by assist the staff would wait outside the bathroom door in case the resident needed assistance. CNA D reported Resident #42 was alright to be in the bathroom by himself as he was able to call for assistance when he was finished. In an interview on 06/28/203 at 3:43 PM, Director of Nursing (DON) B reported when a resident was a stand by assist the staff member was to be in the room by the restroom door in case the Resident needed assistance. DON B reported the resident should not be left alone in the room by themselves. Resident #71: Review of an admission Record revealed Resident #71 was a male with pertinent diagnoses which included Korsakoff syndrome (memory disorder results from vitamin B1 deficiency, damages nerve cells, part of the brain involved with memory), traumatic head injury, Wernicke's encephalopathy (life threatening illness which affects the peripheral and central nervous system), adult failure to thrive, depression, and history of falls. Review of a Minimum Data Set (MDS) assessment for Resident #71, with a reference date of 5/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated Resident #7 was moderately cognitively impaired. Review of current Care Plan for Resident #71, revised on 5/2/2023, revealed the focus, .Altered functional mobility and ADL's related to: (Resident #71) admitted with primary diagnosis of Korsakoff syndrome, malnutrition, chronic subdural hematoma .He is alert and oriented to himself only. He wanders the halls and requires redirecting. Wanderguard in placed . with the intervention .EXIT SEEKING ALERT: Exit seeking alarm band protection device applied dated 4/28/23 .With history of exit seeking and mobility independence apply interventions as indicated and reassess prn (as needed) .4/28/23 . Review of Orders dated 4/28/23, revealed, .EXIT SEEKING PREVENTION TRANSMITTER CHECK PLACEMENT EVERY SHIFT (DEVICE ON LEFT ANKLE) every shift for exit seeking device function Y/N IF DEVICE ON .Exit Seeking Transmitter Device: Check Function q afternoon shift, if no positive result; replace transmitter. *every night shift for exit seeking device function . Review of Interdisciplinary Documentation dated 4/28/23 at 12:58 PM, revealed, .Resident alert with confusion. Exhibits severe STM (short term memory) impairments constantly asking the same questions, redirection unsuccessful. Res. Ambulates independently and without assistive device gait steady. Res. Wandering throughout facility looking for door to go to work and smoke a cigarette. Writer explained why res. is here at facility, he says ok and is calm and cooperative and within 5 minutes, res. asking same questions and seeking door. Exit seeking device on left ankle. No attempts to remove . Review of Wandering Risk Assessment Scale dated 4/28/23, revealed, .Score: 11.0 .11- Above High Risk to Wander .Assessment Summary: Resident with stm impairment and independent ambulatory. Constant reminders given. Wandering around facility. Exit seeking device placed on res. left ankle . Review of Interdisciplinary Documentation dated 4/28/23 at 7:27 PM, revealed, .Mr. (Resident #71) went to every door and tried to go out, staff re-direct the resident . Review of Interdisciplinary Documentation dated 4/30/23 at 1:15 PM, revealed, .Client wandering hall by nurses station . Review of Interdisciplinary Documentation dated 5/1/23 at 2:53 PM, revealed, .He has dementia and is independent with mobility. He has made several attempts to exit the facility and has been pressing on the doors and verbalizing that he want to leave. He has a wanderguard device on. Orders in place and his care plan reflects the device. He has been placed on 1:1 supervision . Review of Interdisciplinary Documentation dated 5/1/23 at 3:10 PM, revealed, .(Resident #71) as he is trying to exit the facility multiple times daily . Review of Interdisciplinary Documentation dated 5/2/2023 at 2:29 PM, revealed, .Resident alert and forgetful. He is on one:one for safety . Review of Interdisciplinary Documentation dated 5/8/2023 11:38 AM, revealed, .admission MDS note: (Resident #71) was admitted for long-term convalescent care due to Wernicke's encephalopathy, dementia with amnestic disorder related to ETOH abuse, frequent falls resulting in subdural hematoma, AFTT, BPH, and depression. (Resident #71) is disoriented at baseline. Continued decline is anticipated due to dx of Dementia. He has experienced a slow cognitive decline over time. His current BIMS score is 7/15 indicating severe cognitive impairment. He was able to repeat the 3 words that were given to him, but unable to answer the remaining questions or needed verbal cueing. Due to cognitive impairment, he is unable to recall that he now resides at the nursing home. He wanders and goes to the exit doors throughout the day, seeking a way to leave the building. Exit seeking transmitter device is in place to alert the staff when he is exceeding a safe range of movement .(Resident #71) continues to adjust to new surroundings, loss of roles, and SNF (skilled nursing facility) placement. Nursing is assessing mood, behavior, sleep, and appetite daily . (Resident #71) .independent movement/wandering .history of falling .(Resident #71) has a history of repeated falls in the community. He has a strong self-determined behavior and prefers to complete ADLs as independently. During self-determination he is at risk of exceeding his functional capabilities .Current interventions remain the most appropriate to reduce likelihood of falls or injuries . Review of Interdisciplinary Documentation dated 5/11/2023 at 1:07 PM, revealed, .1:1 discontinued due to no further attempts made to exit the facility. Continue with wanderguard . Review of Interdisciplinary Documentation dated 5/13/23 at 1:38 PM, revealed, .Client wandering hall by nurses station at this time . Review of Interdisciplinary Documentation dated 5/14/23 at 2:03 PM, revealed, .Per staff client walked out front door with people that were here visiting their family. Client had on wanderguard/intact/working properly. Alarm was going off in building. Staff had client in line of site and client started to walk into street with traffic. Staff stopped client and brought him back into facility . Review of Incident Report dated 5/14/23 at 2:00 PM, revealed, .Nursing Description: CNA reported to the nurse that (R71) was observed walking outside. The CNA had stated there were visitors leaving and he got out as well. It was about 71 degrees outside, no coat was needed. He had on shoes. He had his wanderguard on at that time and the alarm was sounding and the door alarm was as well. We are unable to determine who the visitors were he walked out with . INTERVENTION: Increased supervision when awake . Review of the care plan showed no care plan revisions for interventions to be implemented following his elopement on 5/14/23 when he made it to the street after exiting the building. Review of Intake Information form submitted on 5/23/23 at 7:46 PM, revealed, .Caller states yesterday (05/14/2023) around 2:00 PM a resident left the facility and was found in the center turning lane of (Name of Highway) Highway. Caller states she witnessed the resident in the middle of the road and staff members running after him . Note: the highway was a 4 lane highway, with a center lane for turning, with a speed limit of 35 mph which changed from 45 mph just before the facility. Review of Interdisciplinary Documentation dated 5/15/23 at 6:48 AM, revealed, .Continues exit seeking .safety measures in place . Review of Interdisciplinary Documentation dated 5/25/2023 at 1:35 PM, revealed, .(Resident #71) was observed wandering the facility and wanting to get outside to get his keys. I asked (Resident #71)if he needed help getting back to his room and he stated yes please . Review of Interdisciplinary Documentation dated 5/27/2023 at 12:40 PM, .TBP (transmission based precautions) maintained per protocol. Alert/responsive, can verbalize needs to staff with noted confusion at times with repetitive question asking; staff redirects. Client independent, and continent B&B (bowel and bladder). All meds given per MD (Medical Doctor) orders MAR (Medication Adminstration Record); no adverse effects noted. Good appetite. Wanderguard in place/working properly at this time. VS (vital signs) updated, afebrile. Client wandering coloring at nurses station. Review of Interdisciplinary Documentation dated 6/21/2023 07:14 AM, revealed, .Writer entered resident room to administer scheduled MD prescribed medications. Upon entering room writer saw resident urinating in water cups. Writer informed resident to use bathroom and not to use water cups as urinal. Staff provided resident with urinal, resident verbalized understanding, Staff will continue to monitor for safety . During an observation and interview on 6/26/2023 at 11:48 AM, Resident #71 was sitting at bedside. Dressed seasonally appropriately. Clean in appearance. Resident reported he had a wrist watch on his left ankle. Resident revealed the wrist watch that was on his left ankle under his sock. During an observation on 06/26/23 at 12:24 PM, Resident #71 was observed by the nurse's station on the 100 hallway and continued down the 100 hallway towards the therapy room. Registered Nurse (RN) F reported the resident was a wanderer. Observed LPN J was speaking with Resident #71 and he was asking her if she contacted their supervisor at El Rico. She kept reassuring him that she contacted them and he asked again. He hugged her and told her, Thank you. In an interview, LPN J reported the resident always comes to find her, always calls her [NAME], and asks about contacting his supervisor at this place of employment. Review of Minimum Data Set (MDS) dated [DATE], revealed, .Section E: Wandering - Presence & Frequency: Has the resident wandered? .3. Behavior of this type occurred daily .Wandering - Impact: Does the wandering place the resident at significant risk of getting to a potentially dangerous place? .1. Yes . In an interview on 06/27/23 at 12:20 PM, Social Services Director (SSD) K reported she was informed by staff the resident had exited the building. SSD K reported it was believed he read the sign on the door, waited the 15 seconds and went out the door. SSD K reported there were some family members who do have the code to the door. Upon exiting her office, Resident #71 was observed in the hallway attempting to get some coffee from the beverage cart in the hallway. Review of Task - Behaviors showed no documentation in the record of any recorded behaviors for exit seeking/wandering. In an interview on 06/27/23 at 02:04 PM, Registered Nurse (RN) P reported she was going off the floor as it was the end of her shift. RN P reported from what she can recall the CNA came to the nurse's station and reported she looked out, saw him and went out and got him. RN P reported from what she remembers being told, Resident #71 was getting ready to go in the street, visitors let him out the front doors, the CNA was frantic, and she contacted the Administrator. RN P stated, .Whatever happened I placed in the notes .I was going off the floor . In an interview on 06/27/23 at 02:31 PM, Housekeeper HH reported she was at the time clock at the end of the main hallway, and the alarm was sounding, the resident had made it out the front door. Housekeeper HH reported when they (visitors) opened the door, they didn't know he was a resident and he left with them out the front door. Housekeeper HH reported CNA G was observed looking out the door, and then went out the front door, and returned with Resident #71. In an interview on 06/27/23 at 03:13 PM, CNA G reported the day was Mother's day and there as a lot of traffic of visitors in the building. CNA G reported she had just finished her break and heard the door alarm going off and walked over to the front door to turn it off. CNA G stated, .I stopped and didn't observe anyone in the hallway by the front entrance, looked outside and didn't see no one, decided to step outside and observed (Resident #71) on the curb ready to step into traffic .I wasn't sure what to do .I yelled his name and he responded and asked me, Oh [NAME] where are my keys? .She said he always called her [NAME] as he couldn't say her name .I had keys in my hand and shook them to show him. Told him to come get them and met him halfway in the parking lot and took him back inside .The nurse misunderstood what I was saying .I didn't see him go out the door, I did my protocol, looked and seen (Resident #71) outside .CNA G stated, .No one seen him going out the door. He was ready to step into traffic .He was at the 2nd entrance at the street . ready to step into the street with a button up shirt on and with the cars were flying, you could see the flannel flapping in the wind from the cars. That was how fast the cars were going .it says to go slower but people don't . CNA G reported Resident #71 had tried to get out one time before, he had read that the door said to hold for 15 seconds then push, he can read and can comprehend more than you think. CNA G reported the alarm went off that time, but he was stopped before he was able to make it outside. In an interview on 6/28/23 at 10:50 AM, CNA G reported when a resident was a fall risk or an elopement risk, they were placed on checks for every 15/20 minutes. In an interview on 6/28/23 at 11:32 PM, LPN C reported when a resident was placed on increased supervision, the resident was kept in the common area and supervised all the time. LPN C reported sometimes like with elopement, the resident would be placed on one to one or 15-minute checks. In an interview on 6/28/23 at 3:23 PM, Director of Nursing (DON) reported the wandering risk assessment was completed upon admission for all residents. Those residents determined to have a high score or indicate they might try to exit the building, those would be assessed quarterly and as needed. DON B reported the facility placed a wanderguard on Resident #71, he was very forgetful, and kind of restless. DON B reported for increased supervision you would try to keep tabs on the resident and where he was. DON B reported the facility does do behavior monitoring and this was recorded in the task section of the medical record. DON B reported when a resident was wandering the staff would redirect them or redirect them to a different area. When queried why the resident was removed from one to one, DON B reported she was unsure as to why the supervision was reduced and she couldn't remember exactly what was said to take the resident off of the one to one. Review of policy Wandering Residents Exit Seeking Management revised [DATE], revealed, .It is the policy of this facility to assess residents and plan their care to prevent foreseeable accidents related to wandering and exit seeking behavior which has the potential to lead to elopement .Definition: Wandering: Aimless or purposeful motor activity that causes a social problem such as becoming lost, leaving a safe environment, or intruding in an inappropriate place .Elopement: The resident's leaving of the facility without staff observation or knowledge of the departure .b. The admission safety care plan will be utilized as a tool to conduct a comprehensive assessment of exit seeking risk upon admission .i. An alarm bracelet is placed on the W/C or resident to audibly alert staff of a resident displaying exit seeking behavior if the location is using alarm bands .ii. Maintenance of picture ID systems to assist all departments with recognition of at-risk residents .iii. Tracking of wandering behavior to assist with identification of specific individualized effective approaches .iv. Visual checks assigned Q 15, 30 or 60 minutes for a defined assessment period to develop person-centered interventions and patterning .v. Provision of activities and distractions for the resident, i.e., memory boxes, exercise, hobbies, reading, social interaction, music, written or verbal reassurances, snacks, one-to-one sitters .vi. Sensor devices to detect room exits or visual deterrents on doors . This citation pertains to intake MI00137503 Based on observation, interview, and record review, the facility failed to prevent falls for one resident (R17), implement appropriate care planned interventions for accidents/hazards for one resident (R42), and supervise and prevent one resident (R71) from leaving the facility, for three residents reviewed for accidents and hazards, resulting in multiple falls (R17), accidents/hazards potential for harm (R42) and resident (R71) leaving the facility and walking to the road, with potential for additional falls with injuries, injuries, and elopement. Findings include: R17 According to the Minimum Data Set (MDS) dated [DATE], R17 had a BIMS (Brief Interview Mental Status) of 99 indicating that he was not capable of making decisions on his own, required total dependence of two-plus persons physical assistance to transfer, and was always incontinent of bowel and bladder. His diagnoses included cerebral palsy (a condition marked by impaired muscle coordination/spastic paralysis and/or other disabilities, typically caused by damage to the brain before or at birth), aphasia (disorder that affects how you communicate), seizure disorder/epilepsy, anxiety, and depression. During an observation and interview on 6/26/2023 at 10:44 AM, R17 was in a Broda chair (gives residents ability to tilt and recline) sitting by Nursing Station 2. Certified Nursing Assistant (CNA) Z stated, Staff keep (R17) up at the nursing station until the next shift because he tries to get out of his chair. We have to keep an eye on him. We work 12-hour shifts, so he stays up here until 6 pm. We do a check and change on him every 2 hours. If he gets sleepy, he can sleep in his bed, but he tries to get out of his bed so we keep him at the nursing station. He does not like anything on his feet. Resident was observed to be barefoot with the hall chilly, making the hair on the Surveyor's arms puff up. Observed on 6/26/2023 at 11:00 AM - 11:08 AM, R17 was left alone with no staff supervision at Nursing Station 2 rocking forwards and backwards in a Broda chair. Observed on 6/28/2023 at 7:04 AM, R17 was sitting in a Broda chair in the hall across from Nursing Station 2 where the 2 South Halls and East Hall meet with no staff supervision. No staff were seen in any of the 3 halls until 7:13 AM. During an interview on 6/28/2023 at 7:28 AM, Licensed Practical Nurse (LPN) V stated, (R17) likes to sit in the hall and not in his room. He is scared to be in the room when not sleeping because he was abused. Review of R17's Care Plan revealed the resident had expressive and receptive aphasia with limited communication. He had been observed attempting independent surface-to-surface transfers in his room. He had a history of repeated falls in the community and has fallen in the facility Revision on 2/22/2022. His goal was to have individualized interventions to promote his highest functional capability while mitigating risk factors associated with acute and chronic diagnosis. The interventions used to meet these goals included to provide direction to staff via care card revised on 2/22/2022, see ADL (activities of daily living) plan of care for fall risk interventions revised on 2/17/2022. Review of R17's Care Plan focused on resident having altered functional mobility and ADLs (activities of daily living). The resident preferred to be in his wheelchair and not his bed during the day with frequent falls and required increased supervision while sitting in his wheelchair at the nurse's station listening to music. The goal was for R17 to receive assistance needed to meet ADL care needs. Interventions to meet this goal included FALL - RISK MANAGEMENT: Encourage non-skid footwear, maintain personal items within reach, perimeter mattress, bed in lowest position except with direct care, prefers to bare foot; assist with non-skid footwear as he will allow, Broda wheelchair and encourage him to be in highly visible areas while awake check and change for incontinence as needed. When restless play music for him. If awake in bed encourage him to be in his wheelchair. Assist with AM (morning) care and assist into wheelchair with last rounds of their shift. Wheelchair not to be left in room when not in use. Date initiated: 2/17/2022. Revision on: 5/11/2023. -Psychosocial .play music when restless .push him in the wheelchair around the facility revised on 2/26/2022. -Transfer: two (person) assists revised on 2/21/2022. Review of R17's Incident Report (IR) 2689 reported on 2.2.2023 at 17:30 (5:30 PM) the resident had an unwitnessed fall out of his Broda chair in his room. The immediate action taken was to encourage resident to be in common areas when up in his chair. Plan of care had been reviewed and education provided to staff to refer to the plan of care for fall interventions. Review of R17's Fall Management 2.0 (assessment) dated 2/2/2023 17:56 (5:56 PM) reported the resident was not able to attempt a balance test without physical support, was confined to a wheelchair, and had a history of falls. Review of R17's Care Plan did not include a revised fall intervention to prevent potential future falls. Review of R17's Short-Term Care Plan Assessment for Injury Initiate for a minimum of 3 days PRN (as needed) dated 2/2/2023 reported the resident had a potential for a latent injury related, with his long-term care plan reviewed and updated as indicated by assessment. A repeat Fall Assessment should be done as indicated, with a goal of the resident free from signs/symptoms of injury dated 2/6/2023. Review of R17's Fall Management 2.0 Quarterly Review dated 3/16/2023 reported a score of 6.0 behaviors that included restlessness, lethargy, resists to care, did not follow or understand direction. He was able to stand with partial support, confined to a chair, and did not follow directions. He had a history of no falls in the past 90 days. It was noted R17 had a fall on 2/2/2023, within 30 days of this quarterly review. Review of R17's Interdisciplinary Documentation Note 2/2/2023 18:17 (6:17 PM) reported, Alerted by resident walking down hallway that resident was on floor. Resident observed on floor in doorway sitting upright with legs extended outward .educated CNA to have resident out in common areas when up in chair. Resident had been in room watching tv and attempted to transfer self . Review of R17's Progress Note 2/3/2023 05:54 (AM) Interdisciplinary Documentation Note reported, Resident alert with nonverbal communication, continues follow up fall with no injuries noted. He was transferred to his bed about 2000 pm (8:00 PM). He has transferred back to his geri-hair about 0430 am but resident was some agitated, and this writer and the CNA transferred back to his bed. He is in bed resting quietly, will continues to monitor. During a review of R17's 2/3/2023 08:43 (AM) Interdisciplinary Documentation Note reported, RISK MANAGEMENT . (R17) had an unwitnessed fall yesterday when he got out of his Broda chair care plan was updated . Review of R17's IR 2723 reported on 3/23/2023 at 11:23 (AM) the resident had an unwitnessed fall in his room. He was observed lying on the floor leaning on his nightstand next to his bed with a wet brief. The immediate action taken was to change the resident and sat on his chair. R17's care plan was updated as reviewed and followed at the time of the fall. New fall interventions included third shift would assist the resident with AM care and into his wheelchair with last rounds of third shift. Review of R17's medical record did not have a Fall Management 2.0 (assessment) for the fall on 3/23/2023. Review of R17's Short-Term Care Plan Assessment for Injury Initiate for a minimum of 3 days PRN (as needed) dated 3/23/2023, reported the resident had the potential for a latent injury, his long-term care plan should be reviewed and updated as indicated by assessment, with a repeat Fall Assessment as indicated. The goal was for the resident to be free injury or signs/symptoms of injury. Review of R17's Care Plan did not include a revised fall intervention to prevent potential future falls. Review of R17's Progress Note 3/23/2023 14:49 Interdisciplinary Documentation Note reported Resident had unwitnessed fall this morning at 1030am. He was observed lying on the floor and leaning on a nightstand. Review of R17's Progress Note 3/28/2023 Interdisciplinary Documentation reported the resident had a fall in his room from the bed on 3/23/2023. Per staff interview, third shift usually assists him out of bed, and it was unusual for him to be in the bed. Review of R17's IR 2735 reported on 4/6/2024 at 08:45 (AM) the resident had an unwitnessed fall in his room. He was observed laying in a fetal position next to his bed with his head resting on the bedside table and his leg wrapped tightly in his sheets and bed pad. His brief and pants were wet. A staff member stated she had pushed his wheelchair into his room and left his room for a couple of minutes to get assistance, when she came back, he was on the floor. Immediate action taken was to not leave wheelchair in resident's room when not in use. The resident was unable to communicate his needs and had an extensive fall history. He was typically out of bed bef[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pharmacy recommended laboratory diagnostic services were followed and completed for one resident (R17) reviewed for laboratory services, resulting in the potential of delayed treatment and impaired coordination of care. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R17 was unable to complete a BIMS (Brief Interview Mental Status) to determine his cognition. Section E - Behavior indicated R17 did not experience hallucinations or delusions and did not reject cares including bloodwork. His diagnoses included cerebral palsy (a condition marked by impaired muscle coordination (spastic paralysis) and/or other disabilities, typically caused by damage to the brain before or at birth), aphasia (disorder that affects how you communicate), seizure disorder/epilepsy, anxiety, and depression. Review of R17's Order Summary 12/27/2022 reported the resident was ordered Valporic Acid Solution (an anti-seizure medication, including anxiety disorders) related to seizures. Review of R17's Pharmacist Medication Regimen Review (MMR) 2.0 5/5/2023 revealed, Irregularity refers to use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services not supported by medical evidence, and/or that impedes or interferes with achieving the intended outcome of pharmaceutical services. An irregularity also includes, but is not limited to, use of medication without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that warrant initiation of medication therapy .b. Potential Irregularity Noted. Clinically significant medication issues identified by the reviewing pharmacist are reported to the facility for clarification or resolution. Review of R17's pharmacy Note To Attending Physician/Prescriber MMR Date: 5.5.2023 revealed, Comment: (R17) is currently receiving Depakote and does not have a recent ammonia level found in the patient electronic medical record. Hyperammonemia may occur and be present despite normal LFTs (liver function test). In most cases, elevated ammonia concentrations are benign, but in other cases, lethargy and/or coma have been reported. Recommendation: Please consider obtaining a serum ammonia level on the next convenient lab day and then every 6 months thereafter .Physician/Prescriber Response: DISAGREE unable to obtain ammonia level per SNF (skilled nursing facility) lab (dated 6/2/23). Review of email received from Nursing Home Administrator (NHA) A on 6/29/2023 at 3:00 PM, revealed, We are currently using (name of facility's laboratory) for laboratory services. To get accurate ammonia levels, a specimen must be spun in a centrifuge to separate the plasma from the cells within 15 minutes of collection. (Name of laboratory) facility is further than 15 minutes from our facility and (name of facility) does not have a centrifuge onsite. I am currently working with (name of local hospital) to secure a contract for laboratory services that are local. Review of R17's Care Plan focus with diagnoses that included seizure disorder. A goal to have early identification, management, treatment, and resolution of an acute condition change required an intervention to obtain baseline labs as ordered by the physician review and compare lab value results PRN (as needed); and to assess abnormal values as indicated. .Monitoring liver function and ammonia levels should be recommended in patients taking Valporic acid (VPA).Idiosyncratic hyperammonemic encephalopathy without liver failure is rare, completely reversible, but one of the most severe, potentially fatal, adverse drug reactions to VPA. Intermittent confusional episodes due to hyperammonemia can be easily mistaken with partial seizures inducing medication error, prompting the physician to increase the dose of VPA and thus worsening the hyperammonemia. Recommendations to monitor both liver function and serum ammonia must be considered in patients taking VPA to assist in the early detection of adverse effects. Clinical pharmacists can play an important role in this area, recommending the best treatment available, considering the constraints of the pharmaceutical market, and providing patient follow-up, with evidence-based information . Valporic acid-induced hyperammonemic encephalopathy - a potentially fatal adverse drug reaction - PMC (nih.gov)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00137460 Based on interviews and record review the facility failed to follow posted menus for two residents (Resident #3 and #45), resulting in the potential for decline in nutritional intake and a potential for weight loss. Findings include: Resident #3 Review of an admission Record revealed Resident #3, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Multiple Sclerosis Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 05/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. During an interview on 06/26/23 at 1:16 PM., Resident #3 reported the food is terrible. Resident #3 reported the meat is dry and the potatoes are hard. Resident #3 reported there are no menus delivered to the rooms anymore. Resident #3 reported have no idea what is for lunch before I get to the dining room and it is placed in front of me. I require assistance with my meals. Resident #3 reported often times there is no meat served with lunch and/or dinner. Resident #3 reported its carbohydrate and vegetables, and sometimes a roll or another vegetable. Resident #45 Review of an admission Record revealed Resident #45, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: heart failure. Review of a Minimum Data Set (MDS) assessment for Resident #45 with a reference date of 5/2/23 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #45 was cognitively impaired. During an interview on 6/28/23 at 2:53 PM., Resident #45 reported he does not always get a protein source on his lunch and dinner trays. Resident #45 reported there have been times the chicken served has been covered with a gravy sauce, but the inside of the chicken was frozen. Resident #45 reported often times the vegetables such as carrots are frozen. Resident #45 reported when he is not served with a protein source he often goes down to the vending machine for a coke and snickers bar. Resident #45 reported he had lost weight when he first admitted to the facility, and does not want to lose any more weight. Resident #45 reported the coke and snickers bar are not all that healthy, but he gets the calories he needs to maintain his weight. During an interview on 6/28/23 at 3:00 PM., Certified Nurse Aide (CNA) DD reported often time residents do not have a meat source on their main meal trays CNADD reported some lunches and dinners have food items such as macaroni and cheese, a sweet potatoes and a roll but no meat/protein source. CNA DD reported this happens at least 2-3 times per week over the last few months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #44: Review of an admission Record revealed Resident #44 was a female with pertinent diagnoses which included dementia, anxiety, need for assistance with personal care, difficulty in walking, hearing loss, Alzheimer's disease, muscle weakness, adult failure to thrive, and abnormal posture. Review of current Care Plan for Resident #44 showed no intervention for a floor mat on the wall to prevent Resident #44 from hitting her head. Review of Incident Report dated 2/4/23 at 7:30 PM, revealed, .Nursing Description: CENA (YY) reported has bump on head from hitting the wall with her head during care. Reported resident very agitated. Noted quarter-size bump on top of left forehead. PERL (pupils equal, reactive to light). Able to move all extremities. Hand grasps strong. No other injury observed. Ice bag applied to head, but will not leave on head .Will notify maintenance to (add) protection to wall to prevent injury .Staff 2/4/2023 Observed resident agitated trying to get out of bed, she rolled to her side and bumped her head. (CNA YY) .2/6/2023 (Resident #44) is a long-term resident here at (Facility) is under the care of (Hospice) for end stage dementia. (Resident #44) can become agitated when care is given due to the dementia. On 2/4/23 during the time the CENA was getting(Resident #44) ready for bed, she did become agitated and rolled herself towards the wall side of her bed and proceeded to hit her head on the wall. Will have maintenance put a floor mat on the wall to prevent (Resident #44) from hitting her head on the wall . During an observation on 06/26/23 at 11:34 AM. Resident #44 was observed lying in bed. A fall mat/mattress was observed hanging on the wall on the left side of the resident's bed. The fall mat/mattress was observed to be ripped open at the left top side and the inside foam was exposed. The fall mat/mattress was secured to the wall with two bolts screwed into the wall next to her bed. Resident #44 was observed initiating bed mobility and was able to roll self and reposition her body in her bed. During an observation on 06/26/23 at 02:47 PM, Resident #44 was observed lying in bed. Observed a fall mat/mattress hanging on the wall on the left side of the resident's bed. The fall mat/mattress was observed to be ripped open at the left top side and the inside foam was exposed. The fall mat/mattress was secured to the wall with two bolts screwed into the wall next to her bed. Resident #59: Review of an admission Record revealed Resident #59 was a male with pertinent diagnoses which included COPD (chronic obstructive pulmonary disease), anxiety, sleep disorders, malnutrition, stroke, history of falling, muscle weakness, and unsteadiness on feet. Review of current Care Plan for Resident #59, revised on 11/29/22, revealed the focus, .(Resident #59) has altered functional mobility and ADL's related to: He had a CVA (stroke) in Nov (November) of last year. (Resident #59) is alert and oriented, able to make his needs known. He has a history of COPD, HTN (hypertension). He is non ambulatory, uses WC (wheelchair) to get around. At times he gets anxious and short of breath, encourage him to try to relax and utilize his prn inhaler as needed, measure Biox and use oxygen as needed to maintain comfort and saturation. Prefers bed against the wall to increase space in his room while in his w/c. He can be sexually inappropriate at times with staff and needs reminded that we are here to help . with the intervention .6/8/23: Nonskid footwear at all times as allowed by (Resident #59) .6/25/23: Resident is unable to situp on side of the bed safety. Encourage to situp in w/c (wheelchair) or elevate HOB (head of bed) .Assess and document edema, breath sounds, circumoral or nail bed cyanosis Date Initiated: 07/29/2022 .Assess and intervene as indicated for chest pain Date Initiated: 07/29/2022 .Assess heart rate and rhythm prn Date Initiated: 07/29/2022 .Check oxygen saturation levels SA02% ad capillary refill prn, initiate 02 as ordered Date Initiated: 07/29/2022 .Conduct an assessment of the resident prior to initiating health care practitioner contact . Review of Order dated 3/30/2023, revealed, .RESPIRATORY DISTRESS: Check oxygen saturation prn, start oxygen at 2L per minute per nasal cannula. Recheck oxygen saturation PRN and titrate oxygen to maintain oxygen saturation > 90%. Notify Health Care Practitioner PRN. No directions specified for order . Note: No order to utilize the nebulizer. Review of Incident Report dated 6/4/23 at 04:10 AM, revealed, .Nursing Description: Heard a loud sound from room. Observed sitting on the floor. Asked where he was going and if he needed to go to the bathroom. Stated, He didn't have to go to the bathroom. Noted SOB (shortness of breath) with wheezing. Alert & oriented times three .Immediate Action Taken: Description: Physical assessment completed. Nebulizer treatment given for SOB with relief. Blood sugar 101. Noted call light on the floor & wearing regular socks. Able to move all extremities. ROM (range of motion) WNL (within normal limits). No injury. Not incontinent. T (temp)-98.2 P (pulse)-94 R (respirations)-20 B/P (blood pressure)-150/65 Pulse ox 92% with oxygen on @ 2 liters. Intervention: Staff education to have non skid footwear on at all times as resident allows .(Resident #59) is a long term resident at this facility due to his primary diagnosis of COPD and dependent on oxygen . Review of Incident Report dated 6/25/23 at 8:00 AM, revealed, .Nursing Description: aide called this writer into room. resident was laying on his left side in front of his bed. aide stated he did not want to sit in w/c for breakfast and wanted to sit-up on the side of his bed to eat, aide assisted him sitting up on side of bed approximately 10 minutes prior to fall .Immediate Action Taken: Description: assessment initiated; neuro checks initiated. he is A&O (alert and oriented) to baseline, no confusion and responding appropriately. no shortening of his BLEs (bilateral lower extremities) .vitals obtained and WNL (within normal limits). no increased pain or change in ROM. PERRLA(sic) x2. no injury observed to his head. he did receive 2 small skin tears to L (left) arm. areas cleaned with NS (normal saline), pat dry, and drsg (dressing) applied at the time. he was assisted back up to w/c with no issues .STCP updated. orders received for skin tears . Review of Orders dated 6/25/22, revealed, .skin tears to L forearm: cleaned with NS, pat dry, apply thin layer of triple antibiotic ointment, and cover with foam drsg every 2 days and PRN if soiled or dislodged until resolved. Notify MD (medial director) if area worsens or s/s (signs and symptoms) of Infection, every night shift every other day for skin tears to L forearm . During an observation on 06/26/23 at 10:41 AM, a nebulizer mask was observed placed on nightstand while not on a barrier or in a plastic bag for infection control. During an observation on 06/26/23 at 12:01 PM, Resident #59 was observed lying in bed. The nebulizer mask was observed to be placed on nightstand while not on a barrier or in a plastic bag for infection control. Resident #59 was observed to have two tan colored self-adherent bandage wraps on his left arm with no dates. During an observation on 06/26/23 at 04:25 PM, Resident #59 was observed seated in his wheelchair, oxygen appeared off, the nebulizer mask was still placed on the nightstand while not on a barrier or in a plastic bag for infection control. During an observation on 06/27/23 at 03:57 PM, Resident #59 was observed with two tan colored self-adherent bandage wraps on his left arm with no dates on them. During an observation on 06/28/23 at 09:52 AM, Resident #59 was observed lying in his bed, the nebulizer mask was still placed on nightstand while not on a barrier or in a plastic bag for infection control. In an interview on 6/28/23 at 11:36 AM, LPN C reported for skin wounds, like skin tears, the nurse would always put the date on the bandage to ensure the bandage was being replaced and for infection control. In an interview on 06/28/23 at 11:38 AM, LPN J reported the nebulizer for Resident #59 was just a PRN as needed. LPN J reported the nebulizer mask should be placed inside a plastic to keep it clean for infection control. LPN J reported every time the nurse used the nebulizer, the mask would be cleaned with water, let dry and put in the bag. Observed on 6/26/23 at 11:17 AM outside of Home Care-C was a resident-shared (#4) Sit-to-Stand transfer device. The device had on the base, debris and was stained with a dried white substance. The rubber covered handle was dirty with light-colored dried substances. Hanging on the transfer device was a canister of bleach wipes. Observed on 6/26/2023 at 11:23 AM outside of room [ROOM NUMBER] was a resident-shared mechanical lift. The base of the lift was stained with a variety of colored dried substances. Hanging off the front of the lift was a canister of bleach wipes. Observed on 6/28/2023 at 11:30 AM outside of room [ROOM NUMBER] was #4 Sit-to-Stand transfer device and #2 Mechanical Lift, both had their bases covered with debris and stained with a dried white substance The rubber covered handle on #4 Sit-to-Stand was dirty with light-colored dried substances. On both of the resident-shared equipment was a canister of disinfectant wipes. This citation pertains to MI00130808 Based on observation, interview and record review the facility failed to ensure proper infection control measures were implemented for cleaning and disinfecting resident shared equipment, properly storing a nebulizer mask for Resident #59, and ensuring Resident #44's bedside fall mat had a cleanable surface area resulting in the increased potential for the development and transmission of communicable diseases and infection in a vulnerable population. Findings include: Review of a facility Policy with a date of 3/2020 revealed: Policy: It is the policy of this facility to implement the Infection Prevention and Control Program utilizing a systematic, coordinated and continuous approach guided by OSHA regulations, and pertinent state, federal and local regulations pertaining to infection control In an observation on 06/26/23 at 11:02 AM., room [ROOM NUMBER]'s bedside tables were soiled with dried crusted food, stuck on spillage, and multiple soiled cup ring marks. In an observation on 6/26/23 at 11:04 AM., the spa room on unit one had sit to stand lifts, and hoyer lifts stored in it. The lifts were both noted to be soiled on the handles, bases and mechanical parts with dust, dried crusted material on the blue pad (hoyer lift-area where residents hang on during transfer/lift). The sit to stand lift had dust, debris and food crumbs noted on the base where residents plant their feet. There was a shower bed with a cushioned blue pad over the mesh lining. The mesh under the blue pad was noted to be heavily soiled with dirt, debris, hair and food crumbs. A shower chair with a blue mesh backing was noted to be visibly soiled on the underside of the seat. Noted in the crevasses was a heavily accumulation of dark brown/black buildup. In an observation on 6/26/23 10:18 AM noted a hoyer lift parked next to room [ROOM NUMBER]. The frame and handle bars (where residents grab when lifted) were noted to be soiled with dust and debris. Noted on the mechanical base, a large amount of black duct tape which was tattered and torn, with dust, hair, and debris stuck to it. one of the legs was missing the cover exposing metal, which had a sticky substance on it that was coved with dirt and grime. On 06/26/23 at 10:21 AM, a hoyer lift was observed parked outside room [ROOM NUMBER] which was soiled with dust and debris, the legs had a sticky tape residue which had dirt, and hair stuck on it, one of the legs was noted to have what appeared to be a brown dried, crusted substance that resembled feces. In an observation on 6/28/23 at 2:40 PM., a sit to stand parked next to room [ROOM NUMBER] was visibly soiled on the base with dust, debris and food crumbs. In an observation on 6/28/23 at 2:42 PM., a sit to stand parked next to room [ROOM NUMBER] was visibly soiled on the base with dust, debris and food crumbs. In an observation on 6/28/23 at 2:48 PM., a hoyer parked next to room [ROOM NUMBER] was visibly soiled on the handles and blue pad residents hold on to when lifted. During an interview on 6/28/23 03:06 PM., Director of Nursing (DON) B reported all lifts should be cleaned and sanitized before and after each use. DON B reported the blue pads on the hoyer lifts should be taken off and washed when noted to be visibly soiled. DON B reported sit to stand lift bases should be clean with no dust, debris or food crumbs on them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** South Dining Room Observed on 6/25/2023 at 11:29 AM, the South Dining room had a ceiling tile in the in the middle of the room dripping water which made a large puddle on the floor approximately 2 feet by 10 inches. There was an air exchange vent in the middle of the tile. Directly next to the puddle was a dining table and chairs. There was not a Caution Wet Floor sign or towel next to the puddle, anywhere in the room, or outside of the room. During an observation and interview on 6/26/2023 at 11:34 AM of the South Dining Room with Maintenance I, he stated, That leak in the ceiling is caused by condensation up in the ceiling. I have a call in to a service to have it turned up, so condensation does not build up. Maintenance placed a Caution wet floor sign by the puddle. Resident Rooms During an observation on 6/26/2023 at 11:48 AM, room [ROOM NUMBER] had 2 residents residing within. Each resident had a bedside table that was covered with a sticky film that appeared to be built up. The floor, spanning from the door to the opposite side of the room to the window, had splatters of varied-colored dried substances and a sticky film. The room's interior window track had dirt, dust, debris, and dried bug carcasses. During an observation on 6/26/2023 at 11:39 AM, room [ROOM NUMBER] had 2 residents residing within. The room's window had a large mass of cobwebs with leaves stuck in it eye-level to the resident living next to it. The register under the window had a section of the metal covering off, lying on the floor, exposing dust, lint, and debris on the heating coils. This citation pertains to intake #MI00130808 & MI00130380 Based on observation, and interview, the facility failed to maintain a sanitary, home-like environment, resulting in the potential for pest harborage conditions and a non-home-like environment. Findings include: In an observation on 6/26/23 at 10:25 AM., noted in room [ROOM NUMBER], the window to the outside had clear packaging tape around the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had clear packaging tape around it, which appeared to be in place as a weather strip/barrier to the outside. In an observation on 6/26/23 at 10:35 AM., noted in room [ROOM NUMBER] the window to the outside had black duct tape around the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had black duct tape around it, which appeared to be in place as a weather strip/barrier to the outside. In an observation on 6/26/23 at 10:53 AM., noted in room [ROOM NUMBER] the window to the outside had clear packaging tape around the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had clear packaging tape around it, which appeared to be in place as a weather strip/barrier to the outside. In an observation on 6/26/23 at 10:55 AM., noted in room [ROOM NUMBER] the window to the outside had black duct tape around the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had black duct tape around it, which appeared to be in place as a weather strip/barrier to the outside. In an observation on 06/26/23 at 11:02 AM., noted in room [ROOM NUMBER] the window to the outside had black duct tape around the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had black duct tape around it, which appeared to be in place as a weather strip/barrier to the outside. Noted both both bedside tables to be soiled with dried crusted food, and stuck on spillage, with cup ring marks. In an observation on 6/26/23 at 11:15 AM., noted in room [ROOM NUMBER] the window to the outside had black duct tape around the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had black duct tape around it, which appeared to be in place as a weather strip/barrier to the outside. In an observation on 6/26/23 at 11:43 AM., noted in room [ROOM NUMBER] the window to the outside had black duct tape around the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had black duct tape around it, which appeared to be in place as a weather strip/barrier to the outside. In an observation on 06/26/23 at 11:45 AM., noted in room [ROOM NUMBER] the window to the outside had clear packaging tape around the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had clear packaging tape around it, which appeared to be in place as a weather strip/barrier to the outside. In an observation on 06/26/23 at 11:55 AM., noted in room [ROOM NUMBER] the window to the outside had clear packaging tape around the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had clear packaging tape around it, which appeared to be in place as a weather strip/barrier to the outside. In an observation on 06/26/23 at 12:25 PM., noted in room [ROOM NUMBER] the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had the clear packaging tape around it, which appeared to be in place as a weather strip/barrier to the outside. In an observation on 6/26/23 at 12:31 PM., noted in room [ROOM NUMBER] the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had packaging tape around it, which appeared to be in place as a weather strip/barrier to the outside. During an interview on 6/28/23 at 1:40 PM., Maintenance Staff (Mtn) S reported the windows in resident rooms are covered with duct tape/clear tape because they are old and the tape is used to prevent drafts (weather),water and pests in. Mtn S reported the windows do not close, and there was no appropriate weather strips for those types of windows due to the age of the windows. During an interview on 6/28/23 at 2:10 PM., Director of Nursing (DON)-Infection Control Preventionist (ICP) B reported the tapes (black and clear) were used as a pest control and weather stripping. DON-ICP B reported the windows are old and do not properly closed tightly, and the windows weather stripping has dry rotted off, so Mtn staff used the tape as a preventative measure. DON-ICP B reported that discussions had taken place with upper management about the conditions of the windows, and the tape not being secure, and still allowing weather, and pests in has been an ongoing issue.

Based on observations, interview, and record review the facility failed to maintain safe and sanitary conditions in the kitchen for all residents who receive food prepared or stored in the kitchen resulting in the potential for biological contamination and the potential for the development of food borne illnesses. Findings include: Review of a submitted complaint intake from a State Agency dated 06/06/23 revealed Residents are not being fed enough food. Expired food is being served. Multiple times where there has been no meat or other protein source served with meals. Facility runs out of dairy products. During the initial kitchen tour on 06/26/23 at 09:52 AM., noted an open bottle of Worcestershire sauce located on the top shelf of the middle rack in the dry storage with an open date of 01/24/22. Noted dirt, dust, and debris on the floor of the dry storage area. Subsequent observations on initial kitchen tour included . In a refrigerator next to the dietary manager office noted hard boiled eggs, ham lunch meat, and American cheese without an open date . vanilla yogurt with an open date of 06/14/23 . package of salami on the top left shelf with an open date of 5/15/23 and cheese unsealed and without an open date. Bottom shelf of refrigerator noted soiled with food crumbs and shredded cheese. The outside thermometer read 50 degrees. Inside thermometer read 38 degrees. In an interview/record review, the Dietary Manager (DM) H reported the expectation was to follow The food Keeper 4th Edition, 2014 USDA, Cornell University . and a copy was provided for reference. The reference revealed Worcestershire sauce should be refrigerated after opening and kept for one year . Lunch meats after opening refrigerated for 3-5 days . Cheese, processed slices refrigerated for 3-4 weeks . Hard boiled eggs refrigerated one week. DM H reported open products are good for 7 days. DM H reported she is unaware of when any of the unlabeled items in the refrigerator were opened. DM H reported that all refrigerators and freezers are expected to be cleaned weekly and as needed. Additional observations during initial kitchen tour included noted the walk-in cooler outside thermometer read 44 degrees. There was no inside thermometer for comparison . Noted a cart with milk, juices, and a bowl of ice cubes without a date. Noted a box of green apples and oranges with some rotten. Noted the box of fruit was dated 5/11/23. Noted dirt, trash, and a dried white substance on the walk-in cooler floor. In an interview DM H reported that the cart of beverages was used at meal services and stored in the walk-in cooler between meals. DMH reported the box of fruit should have been thrown away. Additional observations during initial kitchen tour included an empty sprite can on the floor under the juice machine table. The waterspout of the coffee machine was visibly soiled with a white residue. A four-drawer plastic bin was noted to have food debris in the drawers. The shelf on the main prep area was noted to have metal bowls stacked together that were wet to the touch. The shelf was visibly soiled. In an interview DM H reported the coffee machine should be cleaned once a week. Twice a week if the staff has time and the entire kitchen should be cleaned daily. The two refrigerators, walk-in cooler and walk-in freezer should be cleaned weekly. On a follow up tour of the kitchen on 06/27/23 at 09:15 AM., accompanied by the DM H and Registered Dietitian AA the thermometer on the outside of the walk- cooler read 44 degrees. During an observation on 06/27/23 at 09:40 AM., Noted an opened jar of bread and butter pickles with a resident's name and no open date was present in the refrigerator of the north nourishment room. In an interview on 06/27/23 at 09:40 AM., DM H' reported that any personal food items in the nourishment room refrigerators are to be dated and are only good for 3 days. On a follow up tour of the kitchen on 06/27/23 at 12:00 PM., Noted the walk-in cooler outside thermometer read 44 degrees. The thermometer inside the walk-in cooler on the top left rack read 44 degrees. During an interview on 06/27/23 at 12:00., DM H reported the walk-in cooler temperature has to be 41 degrees or less. During an observation and interview on 06/27/23 PM., RD AA reported the internal temperature of a yogurt from the walk-in cooler was revealed to be 42 degrees. During an observation on 06/27/23 at 12:00 PM., [NAME] Q moved between the tray line service area to the dry storage to retrieve a can of soup. [NAME] Q entered walk-in cooler to retrieve a sandwich. [NAME] Q returned to the tray service area and did not perform hand hygiene after moving areas. In an interview on 06/28/23 at 09:10 AM., DM H reported that the expectation during meal service was hand hygiene should be completed if there is movement from the meal service area to another area of the kitchen, including dry storage, walk-in coolers, refrigerators, and the dish area. Review of a facility policy Food Supply Storage & Dating Policy and Procedure dated September 2017 revealed .Refrigerator storage 34 degrees Fahrenheit to maximum 41 degrees Fahrenheit. Review of a facility policy Hand Hygiene Policy & Procedure September 2022 revealed . hand hygiene should be performed . during food preparation, as often as necessary . when changing tasks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #10 Review of a Minimum Data Set (MDS) assessment for Resident #10 with a reference date of 1/10/2022 revealed a Brief Interview for Mental Status (BIMS) score of 6, which indicated that Resident #10 was severely cognitively impaired. In a telephone interview on 3/30/2022 at 10:00 a.m., Resident #10's family member MM reported that while visiting on 3/29/2022 the floor was dirty and there were ants on the windowsill. Based on observation, interview, and record review the facility failed to maintain a clean comfortable environment for 2 of 16 residents (Resident #260, #10) resulting in unclean/unkempt resident rooms and the potential for cross contamination and bacterial harborage. Findings include: Review of Housekeeping & Maintenance Environmental Cleaning Guidelines effective [DATE], revealed, .Policy of this facility to provide routine cleaning of environmental surfaces and non-critical care items .Procedure: 1. Routine cleaning of environmental surfaces and non-critical items should be performed according to a pre-determined schedule .18. Organisms of epidemiological significance: b. More frequent cleaning in rooms is necessary where Clostridium difficile or antibiotic resistant organisms (e.g., MRSA, VRE, ESBL) are identified .C. The facility maintains a list of residents with infection, tracheostomy care, and respiratory care for increased frequency and priority for thoroughness of cleaning procedures . Resident #260: Review of admission Record revealed Resident #260 was a male, with pertinent diagnoses which included diabetes, diabetic ulcer, MRSA infection in the diabetic ulcer and wound vac. In an interview on 3/29/22 at 11:57 AM, Resident #260 reported the housekeeper has swept his room but has not mopped in his room. He stated he spilled cranberry juice this morning and his wife has tried to clean most of it up. Resident stated there has been staff in there to give him his medication and have not offered to change out the pillowcase. In an interview on 3/29/22 at 11:59 AM, Family Member VV stated, .The stuff around the toilet has been there since he has been there since he arrived .I have had to bag up the trash because it is overflowing and give it to staff to dispose of . In an observation on 3/29/22 at 11:56 AM, Resident #260's room has pieces of paper and dark grey foam pieces scattered on his room floor. The bathroom had 6 styrofoam cups stacked in a row of three on the right side of the sink and a small paper cup as well. The garbage was overflowing with paper towels and gloves on the floor by the trash bin. There was a bag full of trash next to the trash bin under the sink. There was debris on the floor around the toilet in his bathroom as well. There were about half dollar size splatters of cranberry juice dried on the floor next to his chair under the rolling bedside table on the right side of his recliner. Under his right foot, there was a pillow with splatters of cranberry juice along the end of the pillowcase. Beside his recliner and behind it were splotches of white powder the resident stated were baby powder. In an interview on 3/29/22 at 11:10 am, Housekeeper GG reported she was the only scheduled housekeeper today, she works every other weekend, and only 2 days per week is there another housekeeper with her. Housekeeper GG stated, .It has been this way off and on since COVID started .I have the whole building to clean .I do what I can . In an interview on 3/31/22 at 9:14 AM, Resident #260 reported the housekeepers have come in and swept the room, .But there is still a pattern over the floor of where the baby powder was spilled and over here you can see that they haven't mopped as there is the dried pattern of cranberry juice on the floor still .That my wife attempted to clean it up the other day . In an interview on 03/31/22 at 9:55 AM, Housekeeper HH stated, .There is not a checklist of any kind .the high touch points in the room are the first major concern when cleaning a room .the room and the bathroom are cleaned separately to not cross contaminate .Every day we clean every room .Every day they are cleaned no if ands or butts .High touch surfaces, dusting and other cleaning, we were helped by the previous EVS manager but he left a few weeks ago . In an email from Clinical Specialist T reported there are not checklists completed by the housekeeping staff indicating they cleaned the residents' rooms.

This citation pertains to intake: MI00126670 Based on interview and record review, the facility failed to provide and document evidence of prompt resolution of grievances for 1 of 16 residents (Resident #14) reviewed for resolution of grievances, resulting in the potential to experience frustration, apprehension, helplessness, and a negative psychosocial outcome for the residents impacting their quality of life. Findings include: Review of an admission Record revealed Resident #14 was a female, with pertinent diagnoses which included COPD, depression, involuntary movements, dysphagia (language disorder in generation of speech and its comprehension due to brain damage or disease), difficulty walking, paranoid schizophrenia (characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities), muscle weakness, diabetes, dementia, high blood pressure, high cholesterol, dependence on supplemental oxygen, asthma, COVID-19, and edema. Review of current Care Plan: for Resident #14, revised on 12/24/21, revealed the focus, .(Resident #14) has altered mobility and ADL's related to: COPD, oxygen dependent, obesity, dementia, and weakness. (Resident #14) desires to maintain her independence but requires supervision to maintain safety. She has 02 ordered and will often remove her o2 tubing and at times declines to allow staff to apply it. She has incontinence of bowel and bladder but will also ask to use toilet but will already have been incontinent, wears briefs for dignity. Will often refuse incontinence care, reapproach. She has a CPAP and declines to wear it . with the interventions .ELIMINATION: Is incontinent of bowel and bladder, Wears incontinence products, check and change before and after meals, HS with rounds and prn, assist when verbal or non-verbal indicators communicate toileting needs .Oxygen Use- (Resident #14) will exercise her right to self determination and remove her oxygen at times .PHYSICIAN ORDERS: admission orders implemented as noted on the MAR, TAR and Medication section of the E-record .PSYCHOSOCIAL: Staff will work on assessing (Resident #14's) behavior and cognition to assist in reassuring (Resident #14). The utilization of rational emotive behavior therapy is efficient to challenge her irrational thought patterns . Review of Assistance Form submitted on 2/23/22, revealed, .Information About Your Concerns: What is your complaint about? .On 2/18/22 mom was sent out to the hospital. When she arrived they took off her brief and she was soaked it weighed 7#'s .Facility Response: Care Conference set for 3/8/22 attended by Administrator, DHCS (Director of Health Care Services), SSD (Social Services Director), (Ombudsman) W .Facility has agreed to notify (Family Member SS) when (Resident #14) refuses meds, showers, and incontinence care .Facility Follow-Up .-Will notify (Family Member SS) of refusal of care and open those lines of communication . Review of Progress Notes dated 3/15/22 at 14:39, revealed, .Orders - Administration Note, Note Text: Resident refused nasal cannula oxygen . Review of Progress Notes dated 3/15/22 at 23:39, revealed, .Orders - Administration Note, Note Test: Resident refused . Review of Progress Notes dated 3/16/2022 at 06:23, revealed, .Orders - General Note from eRecord Note Text: (Resident #14) was asking me about a living will and demand to speak with a lawyer about it. she refuse to keep her nasal cannula in place which result in drop of her oxygen to 77% at about 3:38am we try to speak to her about not having on consequence then she left it on for sometimes . Review of Progress Notes dated 3/16/2022 at 14:23, revealed, .Orders - Administration Note, Note Text: refused . Review of Progress Notes dated 3/17/2022 at 09:17, revealed, .Orders - Administration Note: Note Text: attempted to give x3. refused each time . Review of Progress Notes dated 3/18/2022 at 04:16, revealed, .Orders - Administration Note: Note Text: Took it off . Review of Progress Notes dated 3/19/2022 at 13:52, revealed, .Interdisciplinary Documentation Note Text: TBP maintained per protocol. Alert/responsive; can verbalize needs to staff. No N/V/D/cough per shift. No C/O pain/SOB. All meds given per MD orders MAR; no adverse effects noted. Remains on 2000ml fluid restrictions. VS WNL; updated; afebrile. Client 3L/NC; non-compliant with cannula at times, and removes even after educating. Good appetite. Client resting bed; HOB 35'; call light within reach . Review of Progress Notes dated 3/20/2022 at 08:05, revealed, .Orders - Administration Note: Note Text: Client refused medication, writer tried to educate client and client stated, No get out of here. MD aware, will endorse to oncoming shift . Review of Progress Notes dated 3/20/2022 at 08:05, revealed, .Orders - Administration Note: Note Text: Client refused medication, writer tried to educate client and client stated, No get out of here. MD aware, will endorse to oncoming shift . Review of Progress Notes dated 3/20/2022 at 08:05, revealed, .Orders - Administration Note: Note Text: Client refused medication, writer tried to educate client and client stated, No get out of here. MD aware, will endorse to oncoming shift . Review of Progress Notes dated 3/20/2022 at 08:06, revealed, .Orders - Administration Note: Note Text: Client refused V and stated, No get out of here. MD aware, will endorse to oncoming shift . Review of Progress Notes dated 3/20/2022 at 08:06, revealed, .Orders - Administration Note: Note Text: Client refused medication, writer tried to educate client and client stated, No get out of here. MD aware, will endorse to oncoming shift . Review of Progress Notes dated 3/20/2022 at 08:07, revealed, .Orders - Administration Note: Note Text: Client refused medication, writer tried to educate client and client stated, No get out of here. MD aware, will endorse to oncoming shift . Review of Progress Notes dated 3/20/2022 at 13:08, revealed, .Interdisciplinary Documentation Note Text: TBP maintained per protocol. Alert/responsive; can verbalize needs to staff. No N/V/D/cough per shift. No C/O pain/SOB. Client refused all meds, and VS; put in MD book; will endorse to oncoming shift. Remains on 2000ml fluid restrictions. Client 3L/NC; non compliant with cannula at times, and removes even after educating. Good appetite. Client resting bed; HOB 35'; call light within reach . Review of Progress Notes dated 3/20/2022 at 18:55, revealed, .Orders - Administration Note: Note Text: CPAP at night and every time she sleeps every shift related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA (J96.11) refused to wear . Review of Progress Notes dated 3/20/2022 at 20:06, revealed, .Orders - Administration Note Note Text: Sertraline HCl Tablet 50 MG Give 50 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE (F33.1) refused x2 . Review of Progress Notes dated 3/21/2022 at 04:38, revealed, .Orders - Administration Note Note Text: check blood sugars one time a day Monday wed Friday one time a day every Mon, Wed related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) refused . Review of Progress Notes dated 3/21/2022 at 20:20, revealed, .Orders - Administration Note Note Text: resident refused . Review of Progress Notes dated 3/25/2022 at 11:27, revealed, .Orders - Administration Note Note Text: CPAP at night and every time she sleeps every shift related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA (J96.11) doesn't wear . Review of Progress Notes dated 3/28/2022 at 06:54, revealed, .Orders - Administration Note: Note Text: CPAP at night and every time she sleeps every shift related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA (J96.11) refused . In an interview on 3/31/22 at 8:57 AM, Family Member SS stated, .I have not received any calls of my mother refusing medications, showers, or incontinence cares . In an interview on 3/31/22 at 9:40 AM, Registered Nurse (RN) RR stated, .I would try at least 3 times to give them to her .After a few times you can contact her daughter, if she doesn't answer, then it should go into a progress note .It is in EMAR as well and just do at note .The progress notes are linked to the eMAR . In an interview on 3/31/22 at 1:46 PM, Director of Nursing (DON) B stated, .If we contacted her every time she refused it would be daily we would be contacting her . DON B reported the nurses who were working with her would contact the family member .

Based on interview and record review the facility failed to provide timely notification to a representative of the Office of the State Long-Term Care Ombudsman for emergency transfer in 2 of 16 residents (Resident #14, #60) reviewed for notification of transfers, resulting in the potential for residents being inappropriately discharged , residents left without an advocate to inform them of their rights, and for the Office of the State Long-Term Care Ombudsman to be unaware of the facilities practices related to transfers and discharges. | Findings include: Review of Transfer Notice form received on 3/30/22, revealed, .Notifications: Copies of this notice will be sent to the Michigan Long Term Care Ombudsman via email MTLCOP@meji.org no later than 30 days from the date of transfer .Signed and witnessed at time of transfer by a witnessing nurse .Get residents signature/representative . Resident #14: Review of Minimum Data Set (MDS) assessment list for Resident #14, revealed, .5/30/21 Discharge Return Anticipated - Entry 6/24/21; 9/2/21 Discharge Return Anticipated - Entry 9/6/21; 10/15/21 Discharge Return Anticipated - Entry 10/19/21; 10/25/21 Discharge Return Anticipated - Entry 10/29/21; 12/20/21 Discharge Return Anticipated - Entry 12/23/21; 12/30/21 Discharge Return Anticipated - Entry -- 1/7/22; 2/18/22 Discharge Return Anticipated - Entry - 2/24/22 . Review of Progress Notes dated 2/21/2022 at 14:32 revealed, .Documentation Interdisciplinary Note Text: Resident took her morning medication while sitting on her bed. she had a conversation with this writer and said that she has a new name but did not say what her new name. She appeared tired and weak.02 was checked and she was at 82- 84% on 3L.She was rechecked two hours later and was found lying back on her back from the sitting position.02 checked she was at 78-82%.Noted to be experiencing SOB. She only communicated by shaking her head for NO or yes. The order to SEND to ER was obtained. Resident left the facility at around 1035am . Resident #60: Review of Progress Notes dated 2/5/2022 at 12:49, revealed, .Interdisciplinary Documentation Note Text: called wife as resident is not responsive, not drinking or eating, mouth wide open. VS 124/66 p113, resp 36. POA present, ok to send to ER Review of Progress Notes dated 2/5/2022 at 13:23, revealed, .Interdisciplinary Documentation Note Text: Resident taken to ER via medic 1. Wife to follow. paperwork given to medics, report called into (Local hospital) . In an interview on 3/30/22 at 12:22 PM, Licensed Practical Nurse (LPN) JJ reported there was a discharge packet we send with the residents to the hospital and it also has the notice which is sent to the Ombudsman, the appeal as well .We make copies of the documents and they will be in the Documents section under Discharge in (electronic medical record) .the discharge and the checklist is under transfer notice . In an interview on 3/30/22 at 12:29 PM, Social Services Director LL reported she has not reported resident discharges to the Ombudsman. Review of Emergency Transfers - Bridgman document revealed, no discharges noted on the document since August 2021. In an interview on 3/30/22 at 4:26 PM with Administrator A reported she was responsible for reporting the discharge of residents to the Ombudsman but has not done so since September 2021.

Based on interview and record review, the facility failed to provide written notification of the facility bed hold policy upon discharge to an acute care hospital for 2 of 2 residents (Resident #14, #60) reviewed for bed hold, resulting in possible unanticipated expense or the loss of desired room placement in the facility. Findings include: Resident #14: Review of an admission Record revealed Resident #14 was a female, with pertinent diagnoses which included COPD, depression, involuntary movements, dysphagia (language disorder in generation of speech and its comprehension due to brain damage or disease), paranoid schizophrenia (characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities), muscle weakness, diabetes, dementia, high blood pressure, high cholesterol, dependence on supplemental oxygen, asthma, COVID-19, and edema. Review of Minimum Data Set (MDS) assessment list for Resident #14, revealed, .5/30/21 Discharge Return Anticipated - Entry 6/24/21; 9/2/21 Discharge Return Anticipated - Entry 9/6/21; 10/15/21 Discharge Return Anticipated - Entry 10/19/21; 10/25/21 Discharge Return Anticipated - Entry 10/29/21; 12/20/21 Discharge Return Anticipated - Entry 12/23/21; 12/30/21 Discharge Return Anticipated - Entry -- 1/7/22; 2/18/22 Discharge Return Anticipated - Entry - 2/24/22 . Review of Progress Notes dated 2/21/2022 at 14:32 revealed, .Documentation Interdisciplinary Note Text: Resident took her morning medication while sitting on her bed. she had a conversation with this writer and said that she has a new name but did not say what her new name. She appeared tired and weak.02 was checked and she was at 82- 84% on 3L.She was rechecked two hours later and was found lying back on her back from the sitting position.02 checked she was at 78-82%.Noted to be experiencing SOB (shortness of breath). She only communicated by shaking her head for NO or yes. The order to SEND to ER was obtained. Resident left the facility at around 1035am . Resident #60: Review of an admission Record revealed Resident #60 was a male, with pertinent diagnoses which included diabetes, muscle weakness, back pain, history of falling, high cholesterol, high blood pressure, chronic kidney disease stage 3, and dementia. Review of Progress Notes dated 2/5/2022 at 12:49, revealed, .Interdisciplinary Documentation Note Text: called wife as resident is not responsive, not drinking or eating, mouth wide open. VS 124/66 p113, resp 36. POA present, ok to send to ER Review of Progress Notes dated 2/5/2022 at 13:23, revealed, .Interdisciplinary Documentation Note Text: Resident taken to ER via medic 1. Wife to follow. paperwork given to medics, report called into (Local hospital) . In an interview on 3/30/22 at 12:22 PM, Licensed Practical Nurse (LPN) JJ reported there was a discharge packet we send with the residents to the hospital. If the authorized person was here, they would sign as well as the nurse who has sent the resident out. LPN JJ reported, .The bed hold is in there and it also has the notice which is sent to the Ombudsman, the appeal as well .We make copies of the documents and they will be in the Documents section under Discharge in (electronic medical record) .the discharge and the checklist is under transfer notice . In an interview on 3/31/22 at 9:19 AM, Director of Nursing (DON) B reported the discharge packet was available at the nurse's station. DON B stated, .The nurses are to fill out this whole packet, make copies so they can be scanned into the medical record. Note: Prior to exit, did not receive the requested Transfer Notice/Bed Hold documents for the residents listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #51 Review of a Face Sheet revealed Resident #51 was a male, with pertinent diagnoses which included: secondary parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), dysphagia (swallowing difficulty), need for assistance with personal care, and generalized muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #51, with a reference date of 3/8/22 revealed a Brief Interview for Mental Status (BIMS) score of 07, out of a total possible score of 15, which indicated Resident #51 was cognitively impaired. Review of Resident #51's current Care Plan revealed a focus of .He has altered functional mobility and ADL's (activities of daily living) related to: weakness and debility . with interventions which included ADAPTIVE EQUIPMENT: rimmed plate, weighted silverware last revised 7/23/21. Review of Resident #51's Lunch Tray Ticket dated 3/29/22 revealed, Diet Order: Mech Soft (mechanical soft - soft, chopped/ground food texture) *Regular Diet, Regular Liquids .Adap. Equip (adaptive equipment): Special Plate . During an initial dining observation on 3/29/22 beginning at 12:11 PM in the main dining, noted Resident #51 was seated in his wheelchair at a table. At 12:22 PM, Resident #51 was served his meal which consisted of (not an all-inclusive list) chopped/ground meat with gravy, mashed potatoes with gravy, and soft-cooked brussels sprouts on a regular (not rimmed) plate. Resident #51 was also given weighted silverware. Observed Resident #51 had hand tremors while eating and had difficulty getting his food from the plate onto the fork. In an observation/interview on 03/29/22 at 12:37 PM, Activities Aide (AA) E reported that the kitchen must have just made a mistake and given Resident #51 the wrong plate and that he needed to have a divided plate. AA K approached surveyor and AA E and reported Resident #51 did not need a divided plate, he needed to have a lip on his plate. Surveyor continued to observe until Resident #51 had finished eating. At no time during the meal did AA E or AA K provide the appropriate, adaptive Special Plate once they were alerted that Resident #51 had not received the correct plate. In an interview on 03/30/22 at 1:51 PM, Registered Dietitian (RD) S reviewed Resident #51's care plan and reported that Resident #51 was supposed to have a rimmed plate and weighted silverware. RD S reported a regular dinner plate was not a rimmed plate (special plate) that Resident #51 should have. RD S reported a rimmed plate was different than a divided plate. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 2: Assessments for the Resident Assessment Instrument (RAI), revealed .the resident ' s care plan must be reviewed after each assessment .and revised based on changing goals, preferences and needs of the resident and in response to current interventions .Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan . .A nursing care plan includes nursing diagnoses, goals and/or expected outcomes, individualized nursing interventions, and a section for evaluation findings .The plan promotes continuity of care and better communication because it informs all health care providers about a patient's needs and interventions and reduces the risk for incomplete, incorrect, or inappropriate care measures. Nurses revise a plan when a patient's status changes .The plan of care communicates nursing care priorities to nurses and other health care providers. It also identifies and coordinates resources for delivering nursing care . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing, Tenth Edition - E-Book (Kindle Location 15861 of 76897). Elsevier Health Sciences. Review of policy Person Centered Care Planning Process: Admission, Comprehensive & Short Term revised on Nov. 2016, revealed, .d. Interventions are listed to provide the necessary care and services appropriate to accomplish the goal .i. Vital information is communicated to staff via the Safety/ADL plan of care .ii. A copy of this vital information is posted at the pin tof service (typically in the door of the closet or in a manner that otherwise protects the confidentiality of the information) .f. Alterations to the plan of care are electronically recorded .g. The licensed nurse will review the resident care plan with treatment changes and determine if updates to the plan of care are indicated . Based on observation, interview, and record review, the facility failed to implement a comprehensive, person-centered care plan for 2 of 2 residents (Residents #14, #51) reviewed for care plans, resulting in a decline in functional abilities, decline in uncommunicated care needs between disciplines and unmet care needs. This deficient practice resulted in the potential for unidentified and unmet individualized care needs. Findings include: Resident #14: Review of an admission Record revealed Resident #14 was a female, with pertinent diagnoses which included COPD, depression, involuntary movements, dysphagia (language disorder in generation of speech and its comprehension due to brain damage or disease), paranoid schizophrenia (characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities), muscle weakness, diabetes, dementia, high blood pressure, high cholesterol, dependence on supplemental oxygen, asthma, COVID-19, and edema. Review of current Care Plan: for Resident #14, revised on 12/24/21, revealed the focus, .(Resident #14) has altered mobility and ADL's related to: COPD, oxygen dependent, obesity, dementia, and weakness . with the interventions .ADAPTIVE EQUIPMENT: perimeter plate, handled cup with lid, no straws. Date Initiated: 10/22/2021 Revision on: 10/22/2021 . During an observation on 3/29/22 at 10:33 AM, Resident #14 was observed in her room seated in her wheelchair. On the rolling bedside table was a styrofoam cup with a straw in it. During an observation on 3/29/22 at 1:04 PM, Resident #14 had a small paper cup on her rolling beside table with designs on the outside of it. There was a styrofoam cup on the rolling bedside table with a straw. There was a small hard plastic cup with what appears to be milk in the cup. There was no lid to the cup. During an observation on 3/30/22 at 9:19 AM, Resident #14 was seated in her wheelchair in her room and on her rolling bedside table was a stryofoam cup with a straw in it, a small hard plastic cup with a half glass full of white liquid which appears to be milk and a small paper cup with designs on the outside of it. There was a coffee mug with no lid and a bottle of Pepsi on her rolling bedside table as well. During an observation on 3/30/22 at 11:58 AM, Resident #14 had a styrofaom cup on her rolling table with a plastic lid. During an observation on 3/31/22 at 9:27 AM, Resident #14 was observed in her room seated in her wheelchair. On the rolling bedside table there was a small, patterned paper cup on her table as well as a small cup with red colored liquid in it with a plastic lid. There was also a coffee mug on the table with no lid on it. During an observation on 3/31/22 at 9:38 AM, in Resident #14's closet review of the ADL care plan did not contain interventions for a handled cup with a lid and for no straws. In an interview on 3/31/22 at 10:10 AM, Registered Dietician S reported when there was a change to the resident's adaptive equipment the kitchen would get dietary notification slip for the changes, and .The staff in the kitchen does the set up in the kitchen for the waters which are distributed each shift . In an interview on 3/31/22 at 10:11 AM, [NAME] QQ reported if the resident was not to have a straw it would say ice only on the water pass sheet. In an interview on 3/31/22 at 10:21AM, Registered Dietician (RD) S stated, .If it says ice only it is because there is a fluid restriction .It has to say no straws for them, to not get a straw .done for safety in swallowing . Review of the Water Pass updated on 3/12/22, revealed, .Ice Only: (Resident #14) . Note: no indication on the document for resident to not have a straw. Review of the Water Pass updated on 3/12/22, revealed a legend which would use .(S) - 2 handled Cup .(K) - [NAME] Cup . to show if a resident requires an adaptive cup. Note: Resident #14 was not indicated on the document to have a handled cup with a lid. In an interview on 3/31/22 at 10:26 AM, RD S reported for Resident #14's tray card it stated .She was able to have adaptive coffee cup with lid and ice only for water pass, no straws .Care plan does say that she is not to have a straw and have a handled cup with a lid . In an interview on 3/31/22 at 1:36 AM, Director of Nursing (DON) B stated, .Care Plans were reviewed weekly. DON B stated, .Whoever makes the change is responsible for printing a new ADL care plan and replacing the one in the resident's closet in their room. For other departments, like therapy, they usually inform the nurse or the Clinical Care Coordinator (CCC) and the nurse will make the change(s) . In an interview on 3/31/22 at 1:36 AM, Director of Nursing (DON) B reported audits were conducted by managers completing rounds on the units to ensure the nursing staff were implementing care plan interventions for the care of residents.

Based on interview and record review, the facility failed to provide adequate supervision and implement appropriate care planned interventions to prevent repeated falls in 1 of 3 residents (Resident #32) reviewed for falls, resulting in multiple falls which have the potential to negatively affect the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Review of policy Accident/Incident Report Fall Management revised on 6/18, revealed, .Purpose: To establish a standard for accident/incident completion and to evaluate the facility responsibility to make every effort to decrease the likelihood of a recurrence by investigating incidents, understand how they occur and applying appropriate action .6. The facility will utilize applicable elements of the systemic process of assessment, intervention, and monitoring to minimize fall risk and injury including: b. Care plan interventions .h. Behavioral and Diagnosis risk factors .i. History of falls with root cause analysis . Resident #32: Review of admission Record revealed Resident #32 was a female, with pertinent diagnoses which included dementia, abnormal posture, repeated falls, lack of coordination, muscle weakness, difficulty in walking, stroke, and need for assistance with personal care. Review of current Care Plan for Resident #32, revised on 8/27/19, revealed the focus, .(Resident #32) has the Potential risk for falls or injury related to impaired mobility, cognitive deficits with behavioral disturbances, history of falls with recent fall within past quarter. She may exercise her right to self-determination without realizing that her movements may exceed her functional capabilities . with the interventions of .FALL INTERVENTION encourage to wear nonskid soles/gripper socks at all times CNA Anti tippers to back of w/c, 8-5-2020 dycem to be placed under and on top of w/c cushion . Review of Minimum Data Set (MDS) for Resident #32 dated 2/7/22, revealed, .Transfer: Extensive Assistance, One person physical assist .Mobility Devices: C. Wheelchair (manual or electric .) Review of Incident Report dated 1/19/22 revealed .Nursing Description: It appears as though she slid out of her wheelchair to floor, landing on her buttocks, as she was sitting in front of the w/c (wheelchair) Immediate Action Taken: Education was provided to her assigned CNA as Dycem was not in chair as ordered per care plan .Notes: On 1/19/22 she was observed on the floor in her room in front of her w/c as she slid out f tit to the floor. Given her advanced dementia she is unable to state what happened. At the time of the fall her care plan was reviewed and dycem was to be on her w/c seat and was not. Post all it was applied and staff education, verbal in nature was provided to her assigned CNA for the day. No other changes were made to her care plan . Review of Incident Report dated 2/20/22, revealed, .Nursing Description: A(sic) 0845 CNA call this writer into the room. The resident was found on the floor in her room next to her chair and between the bedside table .Notes: 2/20/22: Resident had slid out of chair onto floor, resident has advanced dementia and unable to verbalize details of incident. In reviewing care plan resident wheelchair has dycem to prevent sliding and proper footwear should be worn. CNA was educated on placing proper footwear on resident and being placed in correct chair with dycem . Review of Incident Report dated 3/19/22, revealed, .Nursing Description: (Resident #32) was in her w/c in her room and was observed on the floor in front of her w/c, that she was in prior to the fall. She was in a new room, had appropriate footwear on, call light in reach, not activated .Other Info: Dycem was not in the w/c seat at the time of the fall and was care planned to be in place. It was placed in her w/c post fall . Review of Fall Assessment dated 11/10/21, revealed, .Score of 14.0 .High Risk . In an interview on 3/31/22 at 1:36 AM, Director of Nursing (DON) B stated, .Care Plans were reviewed weekly. DON B stated, .Whoever makes the change is responsible for printing a new ADL care plan and replacing the one in the resident's closet in their room for the CNAs . In an interview on 3/31/22 at 1:36 AM, Director of Nursing (DON) B reported audits were conducted by managers completing rounds on the units to ensure the nursing staff were implementing care plan interventions for the care of residents. In an interview on 3/31/22 at 1:07 PM, Therapy Staff OO reported, Resident #32 was on the case load for PT(physical therapy) and OT(occupational therapy). Therapy Staff OO stated, .We are working on ordering her a wheelchair with a deeper seat for her .She does have a dycem in her chair, but the chair needed to be cleaned on 3/18/22 and she was provided with another chair with no dycem on top . In an interview on 3/31/22 at 1:47 PM, Director of Nursing (DON) B reported Resident #32 was transferred to another room due to her room being cleaned. DON B reported Resident #32's wheelchair was unable to be moved to the new room with her due to having to be cleaned and disinfected. DON B stated, .When she was transferred to the new room, the Dycem on her wheelchair seat was not brought with her to use with the different wheelchair .

Based on interview and record review, the facility failed to ensure timely, consistent nutritional status monitoring and re-evaluation by a nutrition professional of residents at risk for altered nutrition status for 2 (Resident #55 and Resident #51) of 5 residents reviewed for nutritional care and services, resulting in the potential for undetected weight loss, nutritional status decline, and unmet nutritional needs for both residents. Findings include: Resident #55 Review of a Face Sheet revealed Resident #55 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood), dysphagia (swallowing difficulty), anemia, and heart disease. Review of a Minimum Data Set (MDS) assessment for Resident #55, with a reference date of 1/31/22 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #55 was moderately cognitively impaired. Review of Resident #55's current Care Plan revealed a focus of, Potential risk factors for nutritional concerns include: weight loss, depression, anxiety, hypothyroidism, chronic pain syndrome, DM2, anemia, and dementia with a date initiated of 08/06/2021. Review of Resident #55's medical record revealed an Admission MDS assessment was completed for Resident #55 on 8/6/21. Further review of Resident #55's medical record revealed Quarterly MDS assessments were completed for Resident #55 on 11/2/21 and 1/31/22. Review of Resident #55's medical record revealed a Nutritional Services Review assessment (also referred to as a Nutrition Assessment) was completed for Resident #55 on 8/6/21. Further review of Resident #55's medical record revealed no subsequent Nutrition Assessment was completed. Review of Resident #55's Progress Notes on 3/31/22 at 1:17 PM for the period 8/6/21 through date of review revealed documentation from RD S on 9/29/21 and on 3/30/22. No other Progress Notes from RD S or other nutrition professional for Resident #55 for the reviewed period was found. In an interview on 3/31/22 at 1:51 PM, Registered Dietitian (RD) S reported a Nutrition Assessment/Reassessment should be completed for a resident on admission, annually, quarterly, and when there was a significant change in resident status; in other words, whenever an MDS assessment was completed. In a follow-up interview on 3/31/22 at 11:44 AM, RD S reported Resident #55 should have had a Nutrition Assessment done on 11/2/21 and 1/31/22 when her Quarterly MDS assessments were completed but that they were not done because they got missed. Resident #51 Review of a Face Sheet revealed Resident #51 was a male, with pertinent diagnoses which included: secondary parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), dysphagia (swallowing difficulty), need for assistance with personal care, and generalized muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #51, with a reference date of 3/8/22 revealed a Brief Interview for Mental Status (BIMS) score of 07, out of a total possible score of 15, which indicated Resident #51 was cognitively impaired. Review of Resident #51's current Care Plan revealed a focus of, Potential risk factors for nutritional concerns include: weight loss, mechanically altered diet texture, dx (diagnosis) of: DM2 (type 2 diabetes), gout, severe protein-calorie malnutrition, major depressive disorder, hypertension, CHF (congestive heart failure), and need for assistance with personal care. History of ulcer to buttocks last revised on 7/20/21. Review of Resident #51's medical record revealed a Quarterly MDS assessment was completed for Resident #51 on 3/8/22. Review of Resident #51's medical record revealed a Nutrition Assessment was completed for Resident #51 on 12/9/21. Further review of Resident #51's medical record revealed no subsequent Nutritional Assessment was completed. Review of Resident #51's Progress Notes on 3/31/22 at 1:49 PM for the period 12/9/21 through date of review revealed no documentation from RD S or other nutrition professional for Resident #51 for the reviewed period was found. In an interview on 3/31/22 at 1:35 PM, RD S reported Resident #51 should have had a Nutrition Assessment done on 12/9/21 when his Quarterly MDS assessment was completed but that it was not done. Review of a policy Dietary Assessment last revised August, 2010 revealed, Policy: An admission dietary assessment will be conducted for each resident admitted to the facility. Dietary assessments are reviewed quarterly and revised as indicated by the resident needs. Purpose: To ensure the appropriate management of residents nutritional needs .3. Dietary Assessments must be done to complete the resident's plan of care for nutrition. Review of a policy Weight Management effective April, 2015 revealed, Policy: it is the policy of this facility that resident's weight will be monitored by the IDT team (inter-disciplinary team) in coordination with the nutritional plan of care .Procedure: 1. Residents will be weighed a minimum of monthly unless it is clinically contraindicated; deemed uncomfortable and / or is considered an irrelevant metric as in the case of the end-of-life resident .8. The nutritional plan of care is evaluated a minimum of quarterly and as indicated to determine if current interventions are being followed and if they are effective in attaining nutritional and weight goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow and implement their antibiotic stewardship program in 1 of 6 residents (Resident #10) reviewed for unnecessary medications, resulting in Resident #10 receiving unnecessary antibiotics and the potential for antibiotic resistance. Findings include: Resident #10 Review of a Face Sheet revealed Resident #10 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, delusional disorders, and urinary retention. Review of a Minimum Data Set (MDS) assessment for Resident #10 with a reference date of 1/10/2022 revealed a Brief Interview for Mental Status (BIMS) score of 6, which indicated that Resident #10 was severely cognitively impaired. Review of a progress note dated 2/19/2022 at 10:49 a.m. revealed .(Resident #10) started on doxycycline 100mg PO BID (times) 7day for (urinary tract infection) . (Resident #10) is pleasant, resting in bed . Review of a progress note dated 2/21/2022 at 11:52 a.m. revealed .INFECTION PREVENTION: Patient was on doxycycline for (urinary tract infection). Order (discontinued). Per (medical doctor) (discontinued) due to susceptibility. New order for Augmentin 500-125 mg (by mouth) every 12hrs (times)7days received . Review of Resident #10's urine culture collected on 2/17/2022 revealed that final urinalysis results were not received until 2/21/2022 at 2:50 a.m. In an interview on 3/30/2022 at 2:25 p.m., Infection Prevention Manager N reported that the facility waits for the results of the urine culture before beginning antibiotic treatment for a urinary tract infection and uses McGeer's criteria to determine if a resident should start antibiotic treatment before the culture returns. Infection Prevention Manager N reported that in most cases residents are started on antibiotics before the urine culture is complete because of symptoms being displayed. In the case of Resident #10, Infection Prevention Manager N reported that antibiotics were ordered on 2/19/2022 before the culture was complete because of symptoms that she was exhibiting. Infection Prevention Manager N referred to a short term care plan that was used to manage the urinary tract infection. In an interview on 3/30/2022 at 2:55 p.m., Infection Prevention Manager N reported that the only documented symptom for starting antibiotics prior to the results of the urine culture was confusion(more than normal for her), documented on the short term care plan. Infection Prevention Manager N reported that no other symptoms of urinary tract infection were documented. Review of Resident #10's short term care plan urinary tract infection dated 2/19/2022 revealed that Resident #10's only documented symptom on 2/19/2022 was confusion. Review of the McGeer Criteria for Long Term Surveillance dated 6/14 (no year) provided by the facility revealed 1. Constitutional criteria in LTCF's (long-term care facilities) to start antibiotics included Fever, leukocytosis, acute change in mental status, and acute functional decline. The document indicated that ALL CRITERIA MUST BE MET before antibiotics should be started without final urinalysis results to indicate what, if any antibiotics should be prescribed. For a resident with a Urinary Tract Infection (UTI) the following criteria were documented, Without Catheter (at least 48 hours before symptoms) BOTH (1 & 2) CRITERIA MUST BE MET 1. AT LEAST ONE OF THE FOLLOWING: acute dysuria or acute pain, swelling or tenderness of the testes, epididymis or prostrate Fever or leukocytosis AND at least one of the following Acute costovertebral angle pain or tenderness; Suprapubic pain; Gross hematuria; new or increased incontinence. New or increased urgency; new or increased frequency In the absence of fever or leukocytosis, then 2 or more of: Suprapubic pain; Gross hematuria; new or increased incontinence. New or increased urgency; new or increased frequency AND 2. 1 of the following sub criteria At least 10? CFU / mL of no more than 2 species of microorganisms in a voided urine sample At least 10(2) CFU /mL of any number of organisms in a specimen collected by in-and-out catheter. Review of the policy/procedure Antimicrobial Stewardship, revised March 2020, revealed .The facility will utilize antimicrobial stewardship strategies in combination with infection prevention and control efforts to limit the emergence and transmission of antimicrobial-resistant pathogens . Antimicrobial therapy should only be prescribed if clinically indicated according to signs and symptoms of infection and/or sepsis .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #11 Review of a Face Sheet revealed Resident #11 was a female, with pertinent diagnoses which included: weakness, need for assistance with personal care, major depressive disorder, and acquired absence of left leg above knee. Review of a Minimum Data Set (MDS) assessment for Resident #11, with a reference date of 1/10/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #11 was cognitively intact. In an interview on 03/30/22 at 08:42 AM, Resident #11 reported that some of the aides (certified nursing assistants) act like we (the residents) owe them something and that some of the CNAs have bad attitudes. Resident #11 reported that some aides answer the resident call lights, go into the room, shut the call light off, and leave without finishing what they were called in there for. Resident #11 stated, it makes us feel low - like you are worthless. Resident #17 Review of a Face Sheet revealed Resident #17 was a male, with pertinent diagnoses which included: major depressive disorder. Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 1/17/22 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #17 was cognitively intact. In an interview on 03/29/22 at 11:21 AM, Resident #17 reported that a staff member had made off (rude) remarks to him, and he felt belittled because of their remarks. Resident #20 Review of a Face Sheet revealed Resident #20 was a female, with pertinent diagnoses which included: major depressive disorder and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 1/25/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #20 was cognitively intact. In an interview on 03/29/22 at 11:42 AM, Resident #20 reported that two different Certified Nursing Assistants (CNAs) had refused to go in her room anymore because she had gotten upset when they shut her door against her wishes, causing her extreme anxiety because she was claustrophobic. Resident #20 reported later in the evening when they had opened her door back up, she had overheard them talking about her in the hallway. Resident #20 reported she heard them say, she's a trip and I'm not going in there anymore. Resident #20 reported it upset her that she could hear staff talking about her and that they did not go back in her room for the rest of their shift. In an interview on 03/31/22 at 12:15 PM, Nursing Home Administrator (NHA) A reported some residents have complained about staff not treating them with dignity and respect but that the facility was working on it. NHA A reported that it would never be acceptable for a CNA to refuse to care for a resident. NHA A reported that it was not acceptable for staff to be talking in a degrading way to a resident or within in earshot of a resident. In a confidential group interview 8 out of the 8 present residents reported long call wait times have caused them to soil themselves and all agreed .This is embarassing, we are adults .we don't want something like to happen, it's embarassing and it is very uncomforable to sit in your own accident (urine and bowel movement) . In a confidential group interview 8 out of the 8 present residents stated, .Lucky if I get a shower once a week .They (CNAs) wait until 8:00-9:00 o'clock at night to give a shower .I am tired . One resident stated they were lucky if they received a shower once per month .Some stated, .The aides won't give a shower on their shift .Tell you it is another shifts responsiblity, not theirs and then that shift is upset because it is the previous shifts job .They say they are too busy to give you a shower This is our home and there are things that shoudl be done for us . Review of Resident Council Minutes dated 12/21/22, it was revealed in the minutes, .Call lights not timely . Review of Resident Council Minutes dated 12/21/22, it was revealed in the minutes, .Call lights not timely . Review of Resident Council Minutes dated 2/22/22, it was revealed in the minutes, .Call lights are not timely . Review of Resident Council Minutes dated 3/11/2022, it was revealed in the minutes, .CNAs acting snotty to the residents . Resident #54 Review of admission Record revealed Resident $54 was a male, with pertinent diagnosis which included stroke, lack of coordination, convulsions, dementia, Alzheimer's disease, high blood pressure, muscle weakness, difficulty in walking, cognitive communication deficit, and need for assistance with personal care. Review of current Care Plan for Resident #54, revised on 9/15/21, revealed the focus, .(Resident #54) was admitted to the facility from (Local Hospital). He has diagnoses and history of CVA (cerebrovascular accident), TIA (transient ischemic attack), Muscle weakness, ataxia (impaired balance/coordination), and anemia. He is dependent with all needs and unable to make needs known . with the intervention .ABLE TO LEAVE ON TOILET: Does not use bathroom .ADL's: One assist with ADL's .ELIMINATION: Incontinence of B&B (bowel and bladder) .Wears incontinence products, check and change before and after meals, HS (before sleep, at bedtime) with rounds and prn . During an observation on 3/219/22 at 11:44 AM, Resident #54 was observed laying in his bed and there was an extremely strong scent of urine when this writer entered the room. Resident #54's roommate was independent and continent with elimination. Review of Task Schedule for March 2022 revealed, .ADL Toilet use: 3/27/22: 02:35, 12:34; 3/28/22: 12:16, 21.59; 3/29/2022: 02:46, 07:00 and 21:19; and 3/30/22: 04:56 11:45. In an interview on 03/31/22 at 12:36 PM, Certified Nursing Assistant (CNA) DD stated, .He does use his call light and we have to check on him . In an interview on 3/31/22 at 1:36 AM, Director of Nursing (DON) B reported audits were conducted by managers conmpleting rounds on the units to ensure the nursing staff were implementing care plan interventions for the care of residents. This citation pertains to Intake # MI00124057, # MI00124880, & MI00126670. Based on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect in 6 of 6 residents (Resident #40, #45, #11, #17, #20, & #54) reviewed for dignity/respect, and 8 of 8 residents from the confidential resident meeting, resulting in long call light wait times and the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 1589-1592). Elsevier Health Sciences. Kindle Edition.Time management, therapeutic communication, patient education, and compassionate implementation of bedside skills are just a few of the essential skills you need. It is important for your patients to leave the health care setting with a positive image of nursing and a feeling that they received quality care. Your patients should never feel rushed. They need to feel that they are important and are involved in decisions and that their needs are met . Resident #40 Review of an admission Record revealed Resident #40 was a female, with pertinent diagnoses which included stroke, diabetes, depression, anxiety, obstructive lung disease, arthritis, muscle weakness, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #40, with a reference date of 2/14/22, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact. Review of a current Care Plan for Resident #40 revealed the focus .(Resident #40) has altered functional mobility and ADLs (Activities of Daily Living) due to PMH (Past Medical History) including: history of CVA (stroke), weakness and debility, morbid obesity chronic pain and anxiety. She receives medications that could impact her functional status. She is able to communicate her needs and understand others .(Resident #40) is dependent on staff to anticipate and provide hygiene cares . revised 2/22/22, with interventions which included .ELIMINATION .assist when verbal or non-verbal indicators communicate toileting needs . revised 3/10/22 and .Encourage call light to prompt staff assistance prior to ADLs . revised 10/19/21. Review of a current Care Plan for Resident #40 revealed the focus .(Resident #40) has functional incontinence evidenced by altered mobility, inability to get to the toilet, and dependence on staff to meet her needs . revised 2/22/22. In an interview on 3/30/22 at 8:21 a.m., Resident #40 reported long call light wait times at the facility. Resident #40 reported call light wait times longer than an hour to have her brief changed after an incontinent episode. Resident #40 reported this has happened several times and stated .it bothers me. It makes me sore on the bottom . Resident #45 Review of an admission Record revealed Resident #45 was a female, with pertinent diagnoses which included respiratory failure, diabetes, depression, anxiety, chronic pain, heart failure, obstructive lung disease, muscle weakness, urge incontinence, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #45, with a reference date of 2/21/22, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated she was cognitively intact. Review of a current Care Plan for Resident #45 revealed the focus .(Resident #45) has altered functional mobility and ADL's (Activities of Daily Living) related to: increased weakness r/t (related to) COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), chronic respiratory failure. She is alert and orientated and her own person . revised 3/7/22, with interventions which included .ELIMINATION: Assist with toileting before and after meals, HS (at bedtime) and prn (as needed) . initiated 5/21/21. Review of a current Care Plan for Resident #45 revealed the focus .(Resident #45) has the potential for altered elimination relation to: Incontinence . revised 6/3/21. In an interview on 3/29/22 at 12:41 p.m., Resident #45 reported staff at the facility do not treat her with respect and stated .I think they are overwhelmed .They are very rushed and frustrated . Resident #45 reported long call light wait times, sometimes as long as two hours. Resident #45 reported yesterday she had a call light wait time over an hour to have her brief changed after an incontinent episode. Resident #45 reported she had to lay in bed with a wet brief the entire time, and stated .I shouldn't have to do that . Resident #45 stated she felt .dependent .frustrated and helpless .it really upset me, because it wasn't the first time .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was consistently provided with showers/bathing for 2 of 16 residents (Resident #59, #54) reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for isolation, psychosocial harm, skin breakdown, harboring infection, and decreased self-esteem. Findings include: Resident #59: Review of admission Record revealed Resident #59 was a male, with pertinent diagnoses which included diabetes, depression, chronic ulcer of right heel, osteoarthritis of hip, cervical disc disorder, difficulty in walking, osteomyelitis (infection in the bone), dysphagia (language disorder with speaking and understanding), and hypertrophic cardiomyopathy (thickening of walls of heart leaving less blood to fill the heart). Review of current Care Plan for Resident #59, revised on 2/24/22, revealed the focus, .(Resident #59) has altered functional mobility and ADL's related to: requires assistance with ADL, has pain in his hip. He has a suprapubic catheter . with the intervention of .Bathing: One person assist with bathing, encouraging the resident to do as much for self as able . In an interview on 3/29/22 at 1:53 PM, Resident #59 stated, .I am lucky if I get one shower a week .One a month .There is one girl here who will give me a shower otherwise I don't get one .I can't stand my own and I can't walk, and it can be difficult to get me around so they don't get me up for a shower . Review of Task: Shower for last 30 days dated 3/31/22, revealed, Resident #59 only had two bed baths completed and no showers were completed. Review of Task List Report dated 3/31/22, revealed, ADL- Bathing: Wednesday, Saturday, Q(every) Shift: Evening . Resident #54 Review of admission Record revealed Resident $54 was a male, with pertinent diagnoses which included stroke, lack of coordination, convulsions, dementia, Alzheimer's disease, muscle weakness, difficulty in walking, cognitive communication deficit, and need for assistance with personal care. Review of current Care Plan for Resident #54, revised on 9/15/21, revealed the focus, .(Resident #54) was admitted to the facility from (Local Hospital). He has diagnoses and history of CVA (cerebrovascular accident), TIA (transient ischemic attack), Muscle weakness, ataxia (impaired balance/coordination), and anemia. He is dependent with all needs and unable to make needs known . with the intervention .BATHING: Dependent upon staff for bathing needs . Review of Task: Shower for last 30 days dated 3/31/22, revealed, Resident #54 only had two showers and two bed baths completed out of eight which were scheduled for him. In a confidential group interview 8 out of the 8 present residents stated, .Lucky if I get a shower once a week .They (CNAs) wait until 8:00-9:00 o'clock at night to give a shower .I am tired . One resident stated they were lucky if they received a shower once per month .Some stated, .The aides won't give a shower on their shift .Tell you it is another shifts responsibility, not theirs and then that shift is upset because it is the previous shifts job .They say they are too busy to give you a shower This is our home and there are things that should be done for us . In an interview on 3/31/22 at 1:36 AM, Director of Nursing (DON) B reported audits were conducted by managers completing rounds on the units to ensure the nursing staff were implementing care plan interventions for the care of residents. According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition.Personal hygiene affects patient's comfort, safety, and well-being. Hygiene care included cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities which as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation foster a positive self-image, promote healthy skin, and help prevent infection and disease . Review of policy Quality of Care effective September 2021, revealed, .It is the policy of this facility that each resident receive the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the resident's comprehensive assessment and plan of care .

Based on observation, interview, and record review, the facility failed to adequately monitor and maintain proper temperatures in 1 of 2 facility medication refrigerators, resulting in the potential for the compromise of medication for a substantial portion of the facility population. Findings include: In an observation/interview on 3/31/2022 at 9:07 a.m. in the north medication room with Director of Nursing (DON) B, the medication Refrigerator Temperature Log dated March 2022 revealed two days that the temperature was not checked(March 2nd and March 7th) and three days that the temperature was above the acceptable parameter of 36 to 46 degrees Fahrenheit with no action being taken by staff to correct the temperature(50 degrees March 1st, 51 degrees March 3rd, and 51 degrees March 4th). DON B reported that third shift staff are responsible for checking the refrigerator temperature and there should have been a documented temperature for each date. DON B reported that action should have been taken and documented by staff each time the temperature fell outside of acceptable parameters. Review of the policy/procedure Medication Storage and Stability, revised April 2021, revealed .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Medications requiring refrigeration or Temperatures between 2 degrees C (36 F) and 8 degrees C (46 F) are kept in a refrigerator to allow temperature monitoring .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation contains 2 Deficient Practice Statements (DPS) DPS #1: Based on observation, interview, and record review, the facility failed to: (1) ensure proper hand hygiene was being performed for/by residents during meal times; (2) ensure proper hand hygiene was being performed by staff between resident cares for 2 residents (Resident #14 and Resident #48); and (3) ensure clean and sanitary storage of respiratory equipment for 1 (Resident #14) of 16 sampled residents, resulting in the potential for bacterial harborage, cross contamination, and the spread of disease to a vulnerable population. Findings include: During an initial dining observation on 3/29/22 beginning at 12:11 PM in the main dining room, noted 3 residents were wheeled in their wheelchairs by staff to their respective tables, 2 residents wheeled themselves in their wheelchairs to their respective tables, and 2 other residents walked with their walkers into the dining room and sat down at their tables. Two staff, Activity Aide (AA) K and AA E were in the dining room serving the already present residents their meals. At 12:40 PM, all residents in the dining room had received their meals. At no time during the observation were any of the 6 residents who entered the dining room during the observation offered hand hygiene. In an interview on 03/30/22 at 1:51 PM, Registered Dietitian (RD) S reported hand hygiene for a resident was supposed to be performed prior to the start of the meal. RD S reported did not know that the facility currently had a process in place to offer residents hand hygiene at the start of the meal. In an interview on 03/31/22 at 9:14 AM, Clinical Care Coordinator (CCC) J reported it was the expectation that residents were offered hand hygiene before they ate. CCC J reported it was important to prevent germs and possible illness. In an interview on 03/31/22 at 10:11 AM, AA K reported hadn't known was supposed to offer residents hand sanitizer prior to their meal until today. AA K stated, I was just told that today. I had been inexperienced with serving in the dining room and didn't know that until just this morning. In an interview on 03/31/22 at 11:24 AM, Infection Prevention Manager (IPM) N reported that residents should be provided with or offered hand hygiene before meals. IPM N reported it was important from an infection control standpoint because contaminated hands while eating was an easy way to pick up pathogens and put it in your mouth and it can spread. IPM N stated, To my knowledge, it was not being done. I have not done any audits on that, but it is something I will be doing now. Review of policy Hand Hygiene revised August 2020, revealed, .It is the policy of this facility to for staff members to frequently perform hand hygiene to assist with prevention/reduction of the spread of infection. The facility promotes hand hygiene using recognized techniques as the single most effective means of reducing the risk for cross-infection . Resident #14: Review of an admission Record revealed Resident #14 was a female, with pertinent diagnoses which included COPD, depression, involuntary movements, dysphagia (language disorder in generation of speech and its comprehension due to brain damage or disease), paranoid schizophrenia (characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities), muscle weakness, diabetes, dementia, high blood pressure, high cholesterol, dependence on supplemental oxygen, asthma, COVID-19, and edema. Resident 48: Review of an admission Record revealed Resident #48 was a male, with pertinent diagnoses which included stroke, dementia, sleep apnea, paralysis, high blood pressure, dysphagia (language disorder in generation and comprehension), high cholesterol, GERD, polyneuropathy (malfunction of peripheral nerves in the body), and mild cognitive impairment. During an observation on 3/30/22 at 9:22 AM, Certified Nursing Assistant (CNA) BB was observed assisting Resident #14 in the restroom. CNA BB exited the resident's restroom, went to the resident's bed area and grabbed a cloth item and placed it in a bag and then proceeded to remove her gloves, exited the room and proceeded to enter Resident #48's room and did not perform hand hygiene. CNA BB adjusted his bed, grabbed some items from the restroom, exited the room and went to the soiled linen room and exited the soiled linen room and then proceeded to use hand sanitizer. In an interview on 3/30/22 at 9:29 AM, CNA BB stated, .When you leave the bathroom and remove your gloves, you should perform hand hygiene . and .I did not perform hand hygiene when I exited her room before going to (Resident #48's) room . In an interview on 3/31/22 at 10:35 AM, CNA G reported hand hygiene was to be performed prior to entering a resident's room and at exit of a resident's room. CNA G reported as necessary hand washing would need to be performed if visibly dirty or performed personal care for a resident. During an observation on 3/31/22 at 9:27 AM, upon Resident #14's night stand next to her bed was her CPAP mask and tubing from the CPAP machine. The CPAP mask was not placed on a barrier. A nebulizer machine was next to the CPAP machine, and it had dried food material on the top of it in the gratings. In an interview on 3/31/22 at 9:32 AM, Infection Preventionist N reported the CPAP mask would be washed in the morning and put on a paper towel. Once it was dry it was to be placed in plastic bag for storage. IFP N stated, .Not following infection control at this time . DPS #2 Based on observation and interview the facility failed to properly maintain a shower room between uses, keep separation between cleaning chemicals and clean sanitary nursing items and personal hygiene products, and store linens in a manner that would minimize the risk of contamination. This resulted in a possible decrease in the satisfaction of living and an increased risk of clean linens and sanitary nursing items to become contaminated within the facility. Findings Include: During a tour of the facility, at 2:18 PM on 3/29/22, it was observed that the shower room, by resident room [ROOM NUMBER], was found with a quarter sized clump and a few dime size pieces of bowel movement on the shower floor, sitting near the drain under the shower chair. When asked if the shower room should get cleaned between residents, Environmental Services Manager (ESM) FF stated, yes. At this time observation of a metal cabinet found unpackaged briefs stored next to a dust mop on the top shelf of the cabinet, with window cleaner stored next to gloves and wash cloths on the main shelf. It was also observed that clean folded sheets were found stored on the seat of the tub that is no longer in use. Inside the tub found an accumulation of dust and debris along with a dead cricket at the bottom of the tub. During a tour of the facility, at 2:40 PM on 3/29/22, it was observed that a rack with over 30 folded sheets and linens were found stored next to the uncovered hopper in the soiled linen room (connected to the main laundry room). When asked why these folded linens were being stored next to the hopper and in a soiled linen area, ESM FF was unsure. During a tour of the facility, at 2:50 PM on 3/29/22, it was observed that the spa room, near resident room [ROOM NUMBER], was found with a metal cabinet containing unpackaged briefs next to disinfecting wipes. In the cabinet it was also observed that clean and sanitary supplies, such as tissue paper and gloves, were found intermingled with personal care items, such as body wash, shampoo, and lotions. During a tour of the facility, at 2:56 PM on 3/29/22, it was observed that empty resident room [ROOM NUMBER] was found with a large brown stain and numerous small brown stains on the bed two privacy curtain. An interview with ESM FF found that privacy curtains have been cleaned as needed with the low staff they have in housekeeping.

Based on observation, interview, and record review the facility failed to: 1. Properly date and discard food product; 2. Protect food product from possible contamination; 3. Maintain sanitizer in proper concentration; 4. Thoroughly clean food contact surfaces; and 5. Thoroughly clean portions of dry storage after the presence of pests. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 62 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, starting at 10:10 AM on 3/29/22, an interview with [NAME] UU found that food made in house were to be held and dated for three days and anything that is not dated gets discarded. During the initial tour of the kitchen, at 10:20 AM on 3/29/22, observation of the left two door True cooler found a container of sloppy joe meat with no date. [NAME] UU stated that it was probably from the night before and it should be dated. Further review of the cooler found a container of shredded lettuce with no date, and an open bag of lettuce dated 3/24 to 3/26. During the initial tour of the kitchen, at 10:25 AM on 3/29/22, observation of the walk-in cooler found a ziplock bag with four ham slices and no date, and open pack of turkey breast with no date, and an open pack of thin sliced ham with no date. During the initial tour of the kitchen, at 10:30 AM on 3/29/22, observation of the right two door True cooler found two open half gallons of chocolate milk with no open date, two open cartons of almond milk with no date, and a container of thickened apple juice with no date. A review of the manufacturer's directions on the thickened apple juice found it must be used within 7 days after opening. During the initial tour of the South Nutrition room, at 11:53 AM on 3/29/22, it was observed that an open butter pecan Ready Care 2.0 shake was dated for 3/17 with the manufacture directions stating the product should be used within 3 days. Further review of the cooler found an open container of thickened orange juice with no date. During the initial tour of the North Nutrition room, at 12:04 PM on 3/29/22, it was observed that three open containers of thickened lemon water were found in the cooler not dated. A review of the manufacturer's directions state the thickened lemon water is good for up to 7 days under refrigeration. Further review of the cooler found two mighty shakes not dated, an open Ready Care 2.0 Vanilla shake with no date, and a peanut butter and jelly sandwich dated 3/18 to 3/20. According to the 2013 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (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 . According to the 2013 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is appropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A) . 2. During the initial tour of the kitchen, at 10:25 AM on 3/29/22, it was observed that a pushcart was found in the walk in cooler full of a variety of drinks ready to be served during lunch service, roughly 40 drinks in total were sitting on the top of the cart. The drinks were found with no covering or tops leaving the drinks open and exposed while inside the walk-in cooler. According to the 2013 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 -3-306. 3. During a tour of the kitchen, at 10:49 AM on 3/29/22, it was observed that sanitizer tablets were used to make sanitizer buckets in the kitchen. Observation of one of the sanitizer buckets found that two small tablets dissolving in the bottom of the bucket and the bucket roughly half full with water. Directions on the sanitizer tablets state that 1-2 tablets in a gallon of water makes 200-400 parts per million (ppm) concentration of quaternary ammonium (quat). At this time, the concentration of the quat was tested using the facilities QT-40 test strips and was found well over the 400 ppm maximum allowed and showed a concentration near 700 ppm. According to the 2013 FDA Food Code section 7-204.11 Sanitizers, Criteria. Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions) . 4. During the initial tour of the kitchen, at 10:50 AM on 3/29/22, a review of the clean utensil bins found an accumulation of debris in two of the bins containing mechanical scoops. A review of the scoops found one green, one yellow, and one purple scoop with an accumulation of excess dried on food debris that was still stuck on after being washed and stored with clean utensils. At this time an interview with Registered Dietician (RD) S found that the bins should be getting cleaned out once a week. According to the 2013 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (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. 5. During a tour of the dry storage room, starting at 11:20 AM on 3/29/22, an interview with RD S regarding issues with pests, found that staff had observed a mouse awhile back, but our pest vendor has set our traps and we have not found any issues since. Upon reviewing the emergency food product, it was observed that mouse droppings were evident on the boxes and cases of packaged food product in this area. No evidence of mice getting in food product was found. RD S stated that staff routinely stock, stored, and clean other areas of the dry storage room as they go about their shifts, but there has not been a need to go through the emergency food, so no one probably noticed the mouse droppings. RD S stated we will get that cleaned up. According to the 2013 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.