**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00151504. Based on observation, interview and record review the facility failed to ensure an injury of unknown origin for one resident (R905) of four sampled residents reviewed for abuse was reported to the State Agency, resulting in the potential for further injury of unknown origin or abuse to go unreported and not investigated. Findings include On 6/9/25 at 3:00 P.M. R905 was observed sleeping in a low bed with a fall mat placed on the right side. On 6/10/25 at 8:30 A.M. during a meal observation R905 was observed in a low bed with bilateral fall mats on both sides of the bed. The resident appeared alert but responded to questions in short, simple words. During the interview a dark faded area was observed on the resident's left cheek area. On 6/10/25 at 1:50 P.M. review of the admission Record revealed R905 was admitted to the facility on [DATE], with pertinent diagnoses of chronic obstructive pulmonary disease, communication deficit, chronic kidney disease, vascular dementia, metabolic encephalopathy, cerebral infraction due to occlusion stenosis of cerebral artery and severe protein-calorie malnutrition. According to the Minimum Data Set (Significant change) dated 6/5/25, R905 had a Brief Interview For Mental Score (BIMS) of 6 of 15 (indicating R905 was cognitively impaired), required substantial/maximal assistance to perform Activities of Daily Living (ADL's) and was always incontinent of urine and frequently incontinent of bowel. On 6/10/25 at 2:00 P.M., review of the care plan section of R905's clinical record stated: The resident has a behavior problem r/t (related to) dementia AEB (as evidenced by) accusatory behavior against staff and other residents. Resident has a skin tear on her face and accused staff of hitting her. (initiated 5/14/25). At 2:05 P.M. the Acting Director of Nursing (ADON) was asked about the incident and whether it was determined how the resident received the facial skin tear. A request was made to review the investigation related to the incident. On 6/10/25 at 2:30 P.M. Unit Manager (UM) D was interviewed concerning what happened to R905's face. UM D stated, It was reported to me, I observed the area, it appeared to be a broken, open blister. When I observed the area, I reported it to the wound care team. No one knew how the resident got the dark area on her left cheek, and I did not want anybody to think we had done anything to her. The resident said we hit her. UM D was not able to provide any additional information as to how R905 sustained and injury on her left cheek. On 6/10/25 at 2:45 P.M. interview with Wound care nurse A confirmed UM D had requested the team to evaluate R905's skin tear to the face. Per nurse A the area in questioned was described as: Left cheek abrasion as reported given per UM D open area measures 1.0 x 1.1 cm, pale, pink base scanty serious drainage peri skin normal new treatment (TX): Apply Gentamicin ointment everyday x 14 days PO (Physician Order) Dr E. Record review of the Physician Order's dated 5/14/25, confirmed the same description and treatment indicated by nurse A. On 6/10/25 at 3:00 P.M. ADON reported he couldn't confirm or locate an investigation for R905 related to the incident involving the skin tear but would ask the Administrator for assistance. On 6/10/25 at 3:15 P.M. the Administrator confirmed the incident had not been reported to the State Agency. In retrospect the Administrator verbally acknowledged and indicated because staff did not know how R905 sustained the injury the incident should have been investigated and reported to the State Agency. The Administrator stated, Information wasn't forwarded to me until now. Review of the facility's policy dated 11/28/2017, titled: Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property including injuries of unknown sources under the subtitled: Abuse Reporting stated: . It is the policy of this facility that (abuse, neglect, exploitation or mistreatment including injury of unknown source and misappropriation of resident property) are reported per State and Federal, law. Employees must always report any abuse or suspicion of abuse immediately to the Administrator. (I). Investigation of injury of unknown origin or suspicious injuries must be investigated to rule out abuse. (I) injuries included but not limited to bruising, the inner thigh, chest, face and breast, bruises of an unusual size, multiple unexplained bruises and or bruising in an area not typically vulnerable to trauma. On 6/10/25 at 4:10 P.M. no additional information was provided upon exiting the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00151504 Based on observation, interview and record review the facility failed to ensure an injury of unknown origin was investigated for one (R905) of four sampled residents reviewed for abuse, resulting in the potential for abuse to occur. Findings include: On 6/9/25 at 3:00 P.M., R905 was observed sleeping in a low bed with a fall mat placed on the right side. On 6/10/25 at 8:30 A.M. during a meal observation R905 was observed in a low bed with bilateral fall mats on both sides of the bed. The resident appeared alert but responded to questions in short, simple words. During the interview a dark faded area was observed on the resident's left cheek area. On 6/10/25 at 1:50 P.M. review of the admission Record revealed R905 was admitted to the facility on [DATE], with pertinent diagnoses of chronic obstructive pulmonary disease, communication deficit, chronic kidney disease, vascular dementia, metabolic encephalopathy, cerebral infraction due to occlusion stenosis of cerebral artery and severe protein-calorie malnutrition. According to the Minimum Data Set (Significant change) dated 6/5/25, R905 had a Brief Interview for Mental Status (BIMS) of 6 of 15, indicating R905 was cognitively impaired (the ability to think), required substantial/maximal assistance to perform Activities of Daily Living (ADL's) and was always incontinent of urine and frequently incontinent of bowel. On 6/10/25 at 2:00 P.M., review of the care plan section of R905's clinical record stated: The resident has a behavior problem r/t (related to) dementia AEB accusatory behavior against staff and other residents. Resident has a skin tear on her face and accused staff of hitting her. (initiated 5/14/25). At 2:05 P.M. the Acting Director of Nursing (ADON) was asked about the incident and whether it was determined how the resident received the facial skin tear. A request was made to review the investigation related to the incident. On 6/10/25 at 2:30 P.M. Unit Manager (UM) D was interviewed concerning what happened to R905's face. UM D stated It was reported to me, I observed the area, it appeared to be a broken, open blister. When I observed the area, I reported it to the wound care team. No one knew how the resident got the dark area on her left cheek, and I did not want anybody to think we had done anything to her. The resident said we hit her. UM D was not able to provide any additional information as to how R905 sustained and injury on her left cheek. On 6/10/25 at 2:45 P.M., interview with Wound care nurse A confirmed UM D had requested the team to evaluate R905's skin tear to the face. Per nurse A the area in questioned was described as: Left cheek abrasion as reported given per UM D open area measures 1.0 x 1.1 cm, pale, pink base scanty serious drainage peri skin normal new treatment (TX): Apply Gentamicin ointment everyday x 14 days PO (Physician Order) Dr E. Record review of the Physician Order's dated 5/14/25, confirmed the same description and treatment indicated by nurse A. On 6/10/25 at 3:00 P.M., the ADON reported he couldn't confirm or locate an investigation for R905 related to the incident involving the skin tear but would ask the Administrator for assistance. On 6/10/25 at 3:15 P.M., the administrator confirmed there was no investigation related to the injury of unknown origin and based on the information reviewed the incident should have been investigated and reported to the state agency. Review of the facility's policy dated 11/28/2017, titled: Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property stated: It is the policy of this facility that reports of abuse, mistreatment, neglect, or abuse including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. (I). Investigation of injury of unknown origin or suspicious injuries must be investigated to rule out abuse. (I) injuries included but not limited to bruising, the inner thigh, chest, face and breast, bruises of an unusual size, multiple unexplained bruises and or bruising in an area not typically vulnerable to trauma. On 6/10/25 at 4:10 P.M., no additional information was provided upon exiting the facility.

Based on observation, interview and record review the facility failed to ensure enhanced barrier precautions (EBP) were implemented during wound care for two residents (R911 and R912) out of two residents reviewed for quality of care. Findings include: R912 Review of R912's electronic medical records (EMR) revealed resident was diagnosed with a stage 3 pressure ulcer (injury to skin from prolonged pressure) located on the sacrum (upper area of buttocks). On 6/9/25 at 12:00 PM, a wound care observation was conducted in R912's room. A sign was posted on the door indicating the requirement for enhanced barrier precautions. Additionally, a door - mounted storage unit containing gloves, gowns and masks were observed. The three staff members -Registered Nurse (RN) A, Licensed Practical Nurse (LPN) B, and LPN C entered the room and participated in this high contact wound care without donning (applying) gowns prior to initiating the procedure. Further review of R912's EMR revealed an admission date of 12/24/24, with a pertinent diagnosis of pressure ulcer of sacral (sacrum) area. Documentation also indicated the resident had moderate cognitive impairment and required substantial to maximal assistance with activities of daily living (ADLs). Review of R912's care plan dated 6/9/25 documented The resident requires enhanced barrier precautions r/t (related to) wounds. R912's Interventions documented Donn (apply) PPE (gown and Gloves) before entering the room when providing high contact res (residents) activities and doff (remove) PPE before exiting the room. Perform hand hygiene every time you enter and every time you exit the room, refer to door sign as needed. R911 Review of R911's EMR revealed resident was diagnosed with the following: right heel vascular (poor circulation) ulcer, right anterior (front) knee abrasion, right lateral (on side) hip/buttock stage four pressure ulcer, sacrum-stage four (full thickness skin loss) pressure ulcer, and left lateral hip-stage three pressure ulcer. Further review of R911's EMR revealed an admission date of 4/23/25, with a pertinent diagnosis of Fournier gangrene (a rare life-threatening infection that rapidly destroys soft tissues). Documentation also indicated the resident had intact cognition and required substantial to maximal assistance with bed mobility. On 6/9/25 at 12:37 PM, a wound care observation was conducted in R911's room. A sign was posted on the door indicating the requirement for enhanced barrier precautions. Additionally, a door - mounted storage unit containing gloves, gowns and masks were observed. The three staff members -Registered Nurse (RN) A, Licensed Practical Nurse (LPN) B, and LPN C entered the room and participated in this high contact wound care without donning gowns prior to initiating the procedure. Review of R911's care plan dated 4/23/25 documented The resident requires enhanced barrier precautions catheter (indwelling urinary), wounds requiring dressings. Further review of care plan documented, . Interventions-Staff will wear gloves and gowns for device care or use of central lines (tubing inserted into large veins; used to administer medications, fluids and blood), urinary catheters (tube inserted to remove urine), feeding tubes(tube inserted into stomach to provide nutrition, hydration and medication), tracheostomy (tube inserted into throat to maintain breathing), colostomy/ileostomy ( a surgical incision to allow removal of waste) or any wound care. Gown and glove one use only and for only one resident. An interview conducted on 6/9/25 at 1:05 PM with RN A, it was reported that a gown was not donned before providing treatment to residents R911 and R912. It was further reported that enhanced barrier precautions should be worn before providing wound care treatments. An interview conducted on 6/9/25 at 1:06 PM with LPN B, it was reported that a gown was not donned before providing treatment to residents R911 and R912. It was further reported that enhanced barrier precautions should be followed before providing wound care treatments. An interview conducted on 6/9/25 at 1:07 PM with LPN C, it was reported that a gown was not donned before providing treatment to residents R911 and R912. It was further reported that enhanced barrier precautions should be followed before providing wound care treatments. An interview conducted on 6/9/25 at 2:30 PM with Acting Director of Nursing (ADON). It was reported that staff are expected to follow the facility's policies and procedures for implementing enhanced barrier precautions when providing care to residents identified as requiring such measures. Review of facility's policy Personal Protective Equipment Guideline dated 4/12/24 documented the following: Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs (Multidrug-Resistant Organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the dignity for one resident (R110) of three residents reviewed for dignity, resulting in verbalized feelings of embarrassment and frustration. Findings included: On 9/25/24 at 11:47 a.m. R110 reported that the physician placed an order at least two months ago to be seen by a podiatrist to get the residents toenails cut and for the dry skin and it has not happened. R110 stated, I want my long thick toenails to be cut on both feet because I don't want anyone to see my toenails like that. Its embarrassing and that is why I got very angry. R110 pointed to their feet and the great toe and the second toe on the left foot were observed with dry scaly skin on top of the toes and between the toes with dark areas and long thick toenails with an unpleasant odor. The right foot also had long, thick, discolored toenails and dry skin between the toes. The fifth toenail on the right foot appeared to have been broken and exposed thick dried skin from the top of the toe to the top of the nail. According to the electronic health record (EHR), R110 was initially admitted into the facility on 8/26/22 and readmitted on [DATE] with diagnoses of Neuropathy, major depressive disorder, and functional quadriplegia. R110 's annual Minimum Data Set (MDS) with a reference date of 9/1/2024 indicated R110 was cognitively intact with a BIMS (brief interview for mental status) score of 14/15 and required one person-assistance for hygiene. Review of the Activity Daily Living (ADL) care plan-initiated date of 8/27/2022 documented, The resident has an ADL self-care performance deficit related to impaired mobility related to Neuromyelitis Optica, functional quadriplegia. Interventions: Check nail length and trim and clean on bath days and as necessary. Report any changes to the nurses. On 9/27/24 at 12:10 p.m. the Director of Nursing (DON) was interviewed regarding the lack of foot care for R110. The DON confirmed R110 was not seen by the podiatrist and could not explain why nursing staff did not provide basic hygiene to the resident's feet. The DON said that R110 had a reason to be frustrated and embarrassed about the long thick toenails and malodorous feet. According to the facility's 11/28/2017 Resident Rights policy: Our facility will treat each resident with respect and dignity and care for each resident in a manner an in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness/ Intellectual Disability/ Related Conditions Identification (DCH-3877) document was accurate, complete, and sent to the local state agency for an evaluation for a Level II determination for one (R57) of seven residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs. Findings include: R57: According to the Electronic Health Record (EHR), R57 admitted to the facility on [DATE] with diagnoses that included Adjustment Disorder, Bipolar Disorder, Anxiety, and Depression. R57 was prescribed two antipsychotic medications; Cymbalta (an anti-depressant) 30 milligrams (mg) twice a day and Olanzapine (an anti-psychotic) 2.5 mg twice a day (used to treat schizophrenia). On 8/24/24 a care plan was initiated for 'use of psychiatric medications'. A review of the only DCH-3877 form in the resident's EHR was dated 8/21/24 and indicated that R57 had no mental illness and was not being treated with antidepressants or antipsychotic medications. On 9/11/24, R57 was seen by Psychiatric services and the following was documented; Complaints of bipolar, depression, insomnia, and anxiety. Resident was tearful during interview and said they were emotionally and physically not well. Olazapine was added during resident's hospital stay. On 9/26/24 at 10:15 AM Social Worker (SW) D was asked to review if R57 had an updated PAS/ARR (DCH-3877 form). SW D reviewed the resident's EHR and acknowledged that it was inaccurate and had not been updated at this time. SW D said, Yes, we missed it (DCH-3877). It should have been done upon admission. It was on my list to do, I hadn't completed it yet. According to the facility's PASARR Guideline Effective dated 11/28/17 in part: Purpose: This facility promotes and supports a resident centered approach to care. The purpose of this guideline is to define and set expectations regarding the appropriate preadmission assessment of all individuals with a mental disorder and individuals with intellectual disability. It is the practice of the facility to coordinate the assessment process with the preadmission screening and annual resident review (PASARR) program under Medicaid in Subpart C to the extent practicable to avoid duplicative testing and effort. This includes incorporating the recommendations from the PASARR level II determination and evaluation in the residents' assessment, care plan, and transition of care: and referring all level II residents and all residents with new or evident conditions related to Level II review upon significant change in status assessment. The facility will not admit any new residents with: Mental Disorder- unless the State mental health authority has determined, prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by the facility and whether the individual requiresspecialized services: or Intellectual Disability - unless the State intellectual disability or developmental disability authority has determined, prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by the facility: and if the individual requires such level of services, whether the individual requires specialized services for intellectual disability. The PASARR process consists of the completion of a Level I screen per State and Federal requirements as well as the review and implementation of the Level II recommendations upon admission into the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure podiatry services and treatment were provided in a timely manner for one resident (R110) of one resident reviewed for foot care, resulting in the growth of long toenails, build-up of flaky skin on resident's feet, and delay in needed treatment. Findings include: On 9/25/24 at 11:47 a.m. R110 was observed resting in bed. During the resident interview, the resident complained of needing to be seen by the podiatrist due to long thick toenails. R110 pointed to both feet and said, The physician placed an order for a podiatrist appointment at least two months ago to get the toenails cut and for the dry skin and it has not happened. I don't know if they put my name on the list or not, but I have been mentioning it for about two months. R110's great toe and the second toe on the left foot had dry scaly skin on top of the toes and between the toes with dark areas and long thick toenails. The right foot also had long, thick, discolored toenails and dry skin between the toes. The fifth toenail on the right foot appeared to have been broken and exposed thick dried skin from the top of the toe to the top of the nail. R110 stated, I do not want my toes to get infected. I want the long thick toenails to be cut on both feet. On 9/25/24 at 12:12 p.m., the wound care nurse, Licensed Practical Nurse (LPN) E assessed R110's feet and said, The resident toes had dry skin, an odor, the left foot third toe had some discolorations, the toenails were long and the fifth toe on the right foot appeared to be detached. LPN E agreed R110's toenails needed to be cut and the resident should have been seen by a podiatrist for the dry skin and discoloration on the toes. According to the electronic health record (EHR), R110 was initially admitted into the facility on 8/26/22 and readmitted on [DATE] with diagnoses of Neuropathy, pressure ulcer of sacral region stage four, major depressive disorder, and functional quadriplegia. R110 's annual Minimum Data Set (MDS) with a reference date of 9/1/2024 indicated R110 was cognitively intact with a BIMS (brief interview for mental status) score of 14/15. A care plan initiated 9/3/2024 for Activity Daily Living (ADL)' had the following: The resident has an ADL self-care performance deficit related to impaired mobility related to neuromyelitis Optica and functional quadriplegia. Interventions as following: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Review of the physician orders documented the following: Podiatrist consult as needed dated 1/26/2024. Refer to podiatry for toenails fungus, and trim dated 8/27/2024. Further review of the R110's EHR did not revealed any podiatry consults or progress notes. On 9/27/24 at 12:10 p.m. the Director of Nursing (DON) was interviewed regarding the delay in foot care for R110. The DON confirmed R110's podiatrist consult order was missed, and the resident was not seen by the podiatrist. The DON could not explain why R110 was not seen by the Podiatrist during his monthly visit to the facility and was unable to provide any evidence of podiatry consult for R110 for 8/24/2024. According to the facility's 11/2023 Foot Care policy: 1. Residents will be provided with foot care and treatment in accordance with professional standards of practice . 3. Residents will be assisted in making transportation appointments to and from specialists (podiatrist) as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide medically related social services for one resident (R70) of two residents reviewed resulting in the delay of obtaining a legal guardian to initiate discharge planning in a timely manner and the resident expressing frustration. Findings include: On 9/27/24 at 10:00 AM, R70 was observed sitting on the side of the bed. R70 was queried about any concerns regarding the care by the facility, R70 responded, I want to be discharged , I don't want to be here. Review of R70's electronic health record (EHR) revealed admission into the facility on 3/12/20 with a pertinent diagnosis of vascular dementia (brain damage caused by multiple strokes). According to the Minimum Data Set (MDS) dated [DATE], R70 scored 8 out of 15 on Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Further review revealed resident did not have a guardian. Review of Report of Physician or Mental Health Professional dated and signed by the Psychiatrist on 4/18/23, documented, I believe the individual due to these described conditions, is not presently able to make informed decisions in the following areas: determining where to live, consenting for supportive services, handling financial affairs, authorizing or refusing medical treatment. Further review of R70's EHR revealed, on 9/28/23, SW (Social Worker) received a call from the receptionist reporting resident is attempting to leave facility AMA (Against Medical Advice). On 8/5/24, SW was asked to talk to resident because is adamantly seeking to D/C (discharge) back into the community with no real discharge plan in place because he is homeless. Interview on 9/27/24 at 10:48 AM with Social Worker (SW) D, acknowledged that R70 had made several requests to be discharged from the facility, but had no legal guardian to assist with discharge planning. SW D reported that a decision could not have been made to discharge to another location because a legal guardian had not been obtained. SW D stated, In all honesty, I should have been more consistent in monitoring why the resident did not get a legal guardian sooner and the (discharge) process initiated related to the courts. An interview on 9/27/24 at 12:52 PM the Nursing Home Administrator (NHA), said, When a resident is determined to be clinically unable to make decisions, a legal guardian should be obtained. The Social Worker did not try to obtain a legal guardian in a timely manner. If a guardian had been obtained, a decision could have been made to ensure the best discharge or placement for the best interest for the resident.

Based on observation, interview and record review the facility failed to post and plan alternate meals and All Time Available food choices, resulting in numerous complaints of dissatisfaction with meal choices and food. This deficient practice affected 159 of 170 residents who received meals from the kitchen. Findings include: On 9/25/24 at 9:38 A.M. during an observation in the kitchen, the menu posted identified the following meal choices: Crusted Chicken, Buttered pasta, Buttered Carrots, Apple Crumble, Beverage. There were no alternates written on the menu or posted. On 9/25/24 at 1:40 P.M. on the 2 south and 2 north Units during a lunch meal observation, no alternate meal selection was posted. The menu board had one meal (Today's Meal) posted and there was no other food items or choices for the residents. During the observation resident's H, J, K and L (who wanted to remain anonymous) were observed requesting nursing staff for alternates. Each of these residents were identified as being cognitively intact. On 9/26/24 at 12:35 P.M., during an observation on the tray line Dietary Manager G answered a call from the unit requesting an alternate food item for residentsH and J. Dietary Manager G asked the cook, what was the alternate for today's meal? The cook responded, I have chicken and rice. Dietary Manager G was asked why the residents were served the same food choices as the meal served the previous day for lunch? During the observation Dietary Manager G was asked how residents knew what alternate meal was served and where was it posted? Dietary manager G explained the facility had an ALL Time Available menu and it was posted in the dining rooms on each floor. Dietary Manager G was asked to show the location of the Alternate Menus for the residents. Escorted by Dietary managers G the 2 south, 2 north and 3 rd floor menu boards and dining areas were checked. There were no alternates, or All times Available menu posted on any of the floors. Dietary manager's G provided no explanation why the Alternates were not posted or planned. On 9/26/24 at 2:30 P.M. review of the Food Committee minutes from the Resident Council for May, June, and August 2024 indicated there had been identified concerns with alternate menus not being posted and not being followed. No minutes were provided for the month of July, 2024. On 9/27/24 at 12:30 P.M. review of the facility's policy under #2. stated in part . Menus will be periodically presented for resident review, including the resident council . The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items. #8. Menus will be posted in the Dining Services Department, dining rooms and resident/patient care areas. Upon exiting the facility 9/27/24 at 3:30 P.M.,no additional information was provided concerning why the resident's Alternates food choices and alternate meals were not planned and posted.

Based on observation, interview and record review the facility failed to maintain the physical plant and steam table wells used in the kitchen, affecting 159 of the 170 residents who consume food from the kitchen, resulting in the potential for cross contamination, bacterial harbage and staff injury. Findings include: On 9/25/24 at 9:38 A.M. during an observation of the kitchen the grease trap drain was observed overflowing with water from the three-compartment sink. Dietary Manager G indicated the grease drain had been cleaned out a couple of weeks ago but was now draining slow again. On 9/26/24 at 12:35 P.M., the grease trap drain overflowed during an observation of the lunch service. Employees on the tray line was observed standing,and sliding through standing water, attempting to complete the lunch service. During this observation two rubber tubs used to maintain food temperatures on the trayline leaked water between two tables running into the pathway under the tray line. During each of the above observations the wells on the steam table were observed with pieces of old food particles, ash, and burnt on residue. On 9/26/24 at 12:45 P.M. Dietary manager G was queried concerning the steam wells being cleaned. The manager indicated the wells had not been cleaned since starting the job, and acknowledged the wells needed cleaning. A request was made to review the master cleaning schedule, but was not presented as requested. Review of 2022 Food Code Titled Cleaning of Equipment and utensils Section 4-601.11 Equipment, Food-Contact Surfaces, Non-Food Contact Surfaces, and Utensils under (C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, food residue and other debris. On 9/27/24 at 1:40 P.M. interview with Corporate Maintenance Director N concerning the cleaning of the grease trap reported the drain had been cleaned 9/20/24, and the company was scheduled to return on 9/26/24 however did not return. At 2:40 P. M, towels and old rags were observed being used as a barrier for the spilling water from the grease drain. Upon exiting the facility on 9/27/24 at 3:30 P.M. no other additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #114 Review of Resident #114's (R114) medical record reflected they were admitted to the facility on [DATE] with diagnoses that included major depressive disorder, senile degeneration of brain, dementia, and nutritional deficiency. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/22/23, reflected R114 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R114 did not walk and required extensive to total assistance of one person for activities of daily living. In an interview on 8/16/23 at 1:02 PM, Family Member (FM) P reported a concern for missing clothing items. FM P stated clothing went missing on several occasions and FM P is having to bring in new clothing constantly to replenish the missing items. FM P reported that items such as house shoes, socks, pajama sets, shirts, and baseball hats have gone missing. Review of a Reimbursement Receipt dated 7/8/22 reflected R114 had the following items go missing; two packs of 10 packs of [NAME] T-shirts. Review of a Reimbursement Receipt dated 9/1/22 reflected R114 had the following items go missing; two jogging suits, one grey shirt and one white shirt, 4 shorts black, grey, blue, and white. In an interview on 8/17/23 at 11:16 AM, Nursing Home Administrator A reported that missing clothing items has been a problem in the past but with the implementation of a new labeling system, she is hopeful that the issue will be resolved. This citation pertains to intake #MI00133896. Based on observation, interview, and record review, the facility failed to ensure resident dignity for 2 residents (R#'s, 114 and 115) with a facility census of 154, resulting in the potential for embarrassment and decreased feelings of self worth. Findings include: During an observation on 8/16/23 at 12:50 PM, the first meal tray was delivered to the third floor dining room. During an observation on 8/16/23 at 12:55 PM, Certified Nurse Aid (CNA) GG told another staff member R115 was a, feeder, in front of 20 other residents in the dining room. All 20 residents in the dining room were served meals on trays and ate from trays the entire meal. During an observation on 8/16/23 at 1:08 PM, staff delivered last tray to a resident who was in the dining room at 12:45 p.m. after most all other residents in had finished eating including at the same table.

This citation pertains to intake: MI00133473 Based on record review and interview the facility failed to provide written or spoken notice of a room change for one resident (#359) of one resident reviewed for room change, resulting in the potential for resident anxiety, misinformation of the reason for the room move, and lack of opportunity for resident questions. Findings Included: Resident #359 (R359) Review of the medical record revealed R359 was admitted to the facility 11/10/2022 with diagnoses that included chronic embolism and thrombosis (blood clots), anxiety, depression, adjustment disorder, paraplegia (paralysis of the lower body) , mood disorder, protein calorie malnutrition, alcohol abuse, blindness in right eye, epilepsy (disorder with nerve cell activity is disrupted in brain causing seizures), cerebral infarction (stroke), traumatic brain injury, right sided hemiparesis and hemiplegia (one sided paralysis or weakness) , polyarthritis, and anemia (low red blood cells). Resident was discharged from the facility 03/23/2023. During review of R359's medical record demonstrated that he had moved rooms 01/09/2023 and 02/24/2023. Review of facility policy Notification of Change, effective date of 11/28/2017 and a revision date of 05/11/2018, demonstrated section Additional notification to the resident and/or resident representative number 3. Document the notification and the resident's response in the resident's medical record. Review of the medical record did not demonstrate any documentation of the notification of a room move of R359. In an interview on 08/17/2023 at 08:32 a.m. Nursing Home Administrator (NHA) A explained that it was facility policy to document notification of all room moves in the resident's medical record. NHA A explained that she could not demonstrate that R359 had been notified of his room change for the dates of 01/09/2023 and 02/24/2023. NHA A' could not explain why notification was completed.

Based on interview and record review the facility facility to ensure one out of two residents (Resident #5) had an accurate Advanced Directive form, resulting in the potential for resident wishes to not be followed. Findings Included: Review of the facility's Advanced Directive (AD) form titled, Code Status Elective Form revealed the form had options to check if a resident wished to be Full Resuscitation-(Full Code (life saving efforts to be given), or Do Not Resuscitate-(No Code) . (no life saving efforts to be given). A check mark was in the box next to Full Resuscitation-(Full Code), and also the word Full was circled which, per the form, indicated Resident #5 (R5) wished to have all medically appropriate care provided. On the signature line for Resident/Responsible Party the form revealed Verbal Consent dated 12/9/2022, but there was no name of the person who gave verbal consent. The form also revealed that two witness' were to sign the form, however there was only one witness' signature dated 12/9/2022. In an interview on 8/16/2023 at 3:37 PM, Social Worker (SW) E stated that R5 had given verbal consent because he could not write. SW E said the facility policy and standard was that if the resident was the one who gave the verbal consent, then the AD form only needed to state verbal consent, and the name of the individual who gave the verbal consent did not need to be documented on the form. SW E said if the resident's representative or guardian gave the verbal consent then the AD form needed to state who gave the verbal consent. In an interview on 8/17/2023 at 8:55 AM, Director of Nursing (DON) B said that if there was a verbal consent then the AD form must state who gave the verbal consent even if it was the resident. On 8/17/2023 at 10:01 AM, SW E stated that she updated the AD form dated 12/9/2022, and presented a copy which revealed R5's name was added to the AD form that was dated 12/9/2022. The AD directive form was not updated with the current date due to R5's name being added to an AD form that was over eight months old.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00138470 Based on interview and record review the facility failed to notify the family member/emergency contact of a change in condition and a required hospital transfer for one resident (#356) of two residents reviewed resulting in the family/emergency contact not being aware of a change in condition and the transfer to the hospital. Findings Included: Resident #356 (R356) Review of the medical record revealed R356 was admitted to the facility 02/10/2023 with diagnoses that included fracture of the left femur, type 2 diabetes, hypothyroidism (low thyroid hormone), hyperlipidemia (high fat in blood), cerebral infarction (stroke), muscle weakness, hearing loss, and dysphagia (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/17/2023, revealed R356 had Brief Interview of Mental Status (BIMS) of 12 (mildly impaired cognition) out of 15. R356 was discharged to the hospital 07/01/2023. In a telephone interview on 08/14/2023 at 02:54 p.m. R356's family member R explained that R356 had been taken to the hospital on [DATE] related to a change in her condition. R356's family member R' explained that she was listed as R356's number one emergency contact. She explained that she had not been notified of the R356's medical condition or that R356 had been transferred to the hospital. Review of R356 medical record demonstrated that R356's family member R was listed as emergency contact #1. Review the medical record demonstrated that R356 was transferred to hospital on [DATE] because she had become unresponsive. Review of R356 progress notes did not demonstrate that R356's family member had been notified of R356's change in medical condition or that she had been notified of the residents transfer to the hospital.

This citation pertains to Intakes: MI00137118 and MI00135021 Based on interview and record review the facility failed to protect two residents (#357, #358) right to be free from abuse of five residents reviewed resulting in the potential of physical harm to the residents. Findings Included: Resident #357 (R357) Review of the medical record revealed R357 was admitted to the facility 11/11/2021 with diagnoses that included right hip osteoarthritis, left sided hemiplegia (paralysis), hyperlipidemia (high fat in blood), dissociative and conversion disorder (mental health condition causes a person to become disconnected form important aspects of their lives and can mimic neurological conditions), nutritional deficiency, muscle weakness, psychomotor deficit (disturbance in psychological control of movement), and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2023, revealed R357 had Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. R357 was discharged from the facility 06/15/2023. Review R357 medical record revealed a progress entered 5/15/2023 at 03:00 pm, Incident Note Text: Resident had verbal altercation with staff member, resident redirected, resident denies being fearful, resumed normal activity without any ill effects. Review of R357 medical record revealed progress notes entered by Social Worker (SW) E on 05/15/2023 at 06:07 p.m. which stated: Social Service Note Text: Writer met with the resident regarding an alleged allegations of a verbal interaction between him and another staff member. The resident reports he was joking with another resident regarding him possibly having Covid. He reports the staff member said something to him like That's how people get shot, starting stuff. The resident states he didn't say anything at first, but she kept running off at the mouth and then he said something back to her . You need to shut the F . up. He reports she was allegedly going to her car to get her gun. Writer will f/u with resident for health, safety, and wellbeing. R357's medical record also revealed progress notes entered by Social Worker (SW) E on 05/16/2023 at 05:38 p.m. which stated, Social Service Note Late Entry: Note Text: Writer followed up with resident for his health, safety and well-being. Resident reports he is completely fine. R357's medical record revealed progress notes entered by SW E on 5/17/2023 5:39 p.m. which stated: Social Service Note Text: Writer followed up with resident for his health, safety, and well-being. Resident says he has not thought nothing else about it. In an interview on 08/15/2023 at 12:06 a.m. Human Resources Director Y explained that R357 was involved in an allegation of abuse. The facility immediately suspended CNA X and initiated an investigation. He explained that the abuse allegation was substantiated and CNA X was terminated from facility employment 05/19/2023 for abuse. Review of the facility investigation provided for this incident demonstrated that on Monday 05//15/2023 at 01:45 p.m. that it was reported to Director of Nursing (DON) B that Certified Nursing Aide (CNA) X told R357 that she was going to go to her car and get a gun. Review of the facility investigation demonstrated that incident was witnessed by other resident, while in the dining room, and witnessed by another staff member. Review of the facility 5-day investigation demonstrated that CNA X was terminated from employment 05/19/2023 for verbal abuse and threatening R357. In the 5-day facility investigation the allegation of abuse was substantiated by the facility. Resident #358 (R358) Review of the medical record revealed R358 was admitted to the facility 01/31/2023 with diagnoses that included malignant neoplasm (cancer) of the prostate, obstructive and reflux uropathy (disorder of the urinary tract), hyperlipemia (high fat in blood), protein calorie malnutrition, hypokalemia (low potassium) hypomagnesemia (low magnesium), altered mental status, dementia with behavioral disturbance, and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/03/2023, revealed R358 had Brief Interview of Mental Status (BIMS) of 6 (severely cognitively impaired) out of 15. R358 was discharged from the facility 03/02/2023. In a telephone interview on 08/14/2023 at 03:09 p.m. R358's family member Z explained that when she had visited R358 on 03/02/2023 he told her that he was assaulted by his roommate. Family member Z explained that she had voiced concerns about his roommate previously. Resident #360 (R360) Review of the medical record reveal R360 was admitted to the facility 10/13/2021 with diagnoses that included cerebral infarction (stroke), aphasia, right sided hemiplegia (paralysis), occlusion and stenosis of carotid artery, post traumatic stress disorder, schizophrenia, right foot deformities, anxiety, depression, adjustment disorder, cognitive communication deficit, cardiomegaly (enlarged heart), hypertension, and psychotic disorder with delusions. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2023, revealed R360 did not have a Brief Interview of Mental Status (BIMS) because the resident is not understood. R360 was discharge from the facility 03/01/2023. Review of R360 medical record demonstrate a progress note entered 03/01/2023 at 02:01 p.m. which stated, Resident had a physical encounter with his roommate on3/1/23. According to his CNA resident was observed punching his roommate in the jaw after he witness his roommate going in his closet bothering his belongings. Review of facility incident report regarding R360 and R358 incident demonstrated an interview with CNA AA taken 03/01/23 at 02:05 p.m. which stated, witnessed incidental contact as they were trying to separate roommate consistently make gestures with his hands all day as though he is hitting a speed bag and made contact with resident face. Further review of the incident report revealed that R360 was the resident that was hitting a speed bag and contacted R358's face. Further review of the R360's medical record demonstrated a progress note, dated 03/01/2023 at 02:40 p.m., Note Text: Resident sent out for aggressive behavior. In an interview on 08/16/2023 at 01:26 p.m. Assistant Director of Nursing (ADON) D explained that she had conducted the investigation regarding the incident between R360 and R358 on 03/01/2023. ADON D explained that the two residents had a disagreement regarding a shirt that was in the closet. She explained that R360 was a boxer, in his past, and would frequently box into the air. She explained that this allegation of abuse was not substantiated, because there was not intent on the part of R360 striking R358 in the face.

This citation pertains to intake: MI00135021 Based on interview and record review the facility failed to report allegations of abuse (physical abuse) for two residents (#358, #360) of five residents sampled resulting in allegations of abuse not being reported to the State Agency and the potential for further allegations of abuse to go unreported and not thoroughly investigated. Findings Included: Resident #358 (R358) Review of the medical record revealed R358 was admitted to the facility 01/31/2023 with diagnoses that included malignant neoplasm (cancer) of the prostate, obstructive and reflux uropathy (disorder of the urinary tract), hyperlipemia (high fat in blood), protein calorie malnutrition, hypokalemia (low potassium) hypomagnesemia (low magnesium), altered mental status, dementia with behavioral disturbance, and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/03/2023, revealed R358 had Brief Interview of Mental Status (BIMS) of 6 (severely cognitively impaired) out of 15. R358 was discharged from the facility 03/02/2023. In a telephone interview on 08/14/2023 at 03:09 p.m. R358's family member Z explained that when she had visited R358 on 03/02/2023 he told her that he was assaulted by his roommate. Family member Z explained that she had voiced concerns about his roommate previously. Resident #360 (R360) Review of the medical record reveal R360 was admitted to the facility 10/13/2021 with diagnoses that included cerebral infarction (stroke), aphasia, right sided hemiplegia (paralysis), occlusion and stenosis of carotid artery, post traumatic stress disorder, schizophrenia, right foot deformities, anxiety, depression, adjustment disorder, cognitive communication deficit, cardiomegaly (enlarged heart), hypertension, and psychotic disorder with delusions. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2023, revealed R360 did not have a Brief Interview of Mental Status (BIMS) because the resident is not understood. R360 was discharge from the facility 03/01/2023. Review of R360 medical record demonstrate a progress note entered 03/01/2023 at 02:01 p.m. which stated, Resident had a physical encounter with his roommate on3/1/23. According to his CNA resident was observed punching his roommate in the jaw after he witness his roommate going in his closet bothering his belongings. Review of facility incident report regarding R360 and R358 incident demonstrated an interview with CNA AA taken 03/01/23 at 02:05 p.m. which stated, witnessed incidental contact as they were trying to separate roommate consistently make gestures with his hands all day as though he is hitting a speed bag and made contact with resident face. Further review of the incident report revealed that R360 was the resident that was hitting a speed bag and contacted R358's face. Further review of the R360's medical record demonstrated a progress note, dated 03/01/2023 at 02:40 p.m., Note Text: Resident sent out for aggressive behavior. In an interview on 08/16/2023 at 01:26 p.m. Assistant Director of Nursing (ADON) D explained that she had conducted the investigation regarding the incident between R360 and R358 on 03/01/2023. ADON D explained that the two residents had a disagreement regarding a shirt that was in the closet. She explained that R360 was a boxer, in his past, and would frequently box into the air. She explained that this allegation of abuse was not substantiated, because there was not intent on the part of R360 striking R358 in the face. In an interview on 08/16/2023 at 01:30 p.m. Nursing Home Administrator (NHA) A could not explain why the allegation of abuse had not been reported to the appropriate State Agency. She explained that she was not the NHA at the time of the allegation. NHA A explained that should have been reported at the time of the allegation since it was an allegation of abuse. NHA A explained that she would now be reporting the allegation of abuse to the appropriate State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the resident and/or resident's representative a written reason of transfer to a hospital for one (Resident #125) of three residents reviewed for transfer/discharge, resulting in the potential of residents and/or family being un-informed of the reason for transfer. Findings include: Review of the medical record reflected that Resident #125 (R125) was readmitted to facility 8/7/23 with diagnoses including acute encephalitis, muscle weakness, and adult failure to thrive. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/23 reflected that R125 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact). Review of the Discharge MDS dated [DATE] reflected that R125 had an unplanned discharge to an acute care hospital and that his return to the facility was anticipated. In an observation and interview on 8/15/23 at 2:24 PM, R125 was observed lying in bed, on back, with head of bed at an approximate 45-degree angle. R125 stated that he had been sent out to the hospital a couple weeks ago, was diagnosed with pneumonia, remained in the hospital a week or so before returning to the facility, and did not think that he had received a written notice pertaining to the hospital transfer. R125's physician order dated 7/23/23 stated, Transfer to ER (Emergency Room) Resp (Respiratory) Distress. Review of the Health Status Note and SNF (Skilled Nursing Facility) to ED (Emergency Department) Handoff form dated 7/23/23, within R125's medical record, both indicated that R125 was transferred to the hospital for respiratory distress with no indication within either record that a written notice of hospital transfer was provided to R125 at the time of his 7/23/23 hospital transfer. In an interview on 8/16/23 at 3:13 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) G stated that upon a resident's hospital transfer a completed SNF to ED Handoff form, medication list, and face sheet would be sent to the hospital with the resident. LPN/UM G denied knowledge of the facility's written notice of transfer form or policy and upon review of R125's medical record surrounding the 7/23/23 hospital transfer, confirmed that there was no evidence that a written transfer notice was provided to R125 at the time of transfer. In an interview on 8/16/23 at 3:46 PM, Director of Nursing (DON) B stated that upon a resident's hospital transfer, a SNF to ED Handoff form would be completed and sent with the resident but denied knowledge of any other written transfer notice that was provided to the resident at the time of transfer. DON B stated that she would have to follow up with Nursing Home Administrator (NHA) A regarding that and would provide additional information, if able. No additional information was received prior to survey exit. Review of facility policy titled Transfer and Discharge Guideline with an effective date of 11/28/2017 stated, Purpose .It is the practice of this facility that each resident has the right to remain in the facility and not transfer or discharge a resident unless a transfer or discharge from the this facility is .Necessary for the resident's welfare and the resident's needs cannot be met in the facility .The resident and representative will receive timely notification, adequate preparation, orientation and information to make the transfer as orderly and safe as possible. The notice contains information about the transfer and information about the resident's appeal rights .Procedure .C. Contents of the Notice .Before the facility will transfer or discharge a resident, the facility will provide a written notice to the resident and resident representative in a manner and language in which is understood .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 (Resident #91) of 31 reviewed for MDS assessments, resulting in the potential for inaccurate care plans and unmet care needs. Findings include: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident # 91 (R91) was a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage due to a motor vehicle accident, diabetes, and bi-polar disorder. R91 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 08/15/23 at 2:40pm, R91 was observed resting in bed, upon approach R91 initiated a conversation using American Sign Language (ASL) this surveyor knowledgeable of alphabet and some basic ASL commonly used words. R91 reported he had no hearing ability, and did not use a hearing aid, when queried how he communicated with staff he reported by writing and pointed to his tablet and using gestures. Review of R91's MDS's with the assessment reference dates of 1/29/23, 05/01/23 and 08/01/23 section B question 0200 were consistently coded as 1 meaning R91 had minimal hearing loss. The 1/29/23 MDS further reflected R91 used a hearing aid. On 08/16/23 at 01:07 PM, during a phone interview with R91's family member F , he reported R91 was born profoundly deaf, and did not use a hearing aids. On 08/16/23 at 02:42 PM, during an interview with MDS Nurse C reported she was a regional MDS Nurse and had a heavy work load, MDS Nurse C further reported R91's MDS should have been coded as highly impaired-absence of useful hearing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #60 Review of the medical record revealed that Resident #60 (R60) was initially admitted to facility 6/3/2021 with diagnoses including schizoaffective disorder, bipolar disorder, vascular dementia, and major depressive disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/21/23 revealed that R60 had clear speech, was understood by others, and was able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 8 (moderately impaired cognition). Section N of the same MDS reflected that R60 received antipsychotic medication in the last 7 days. Review of the PAS/ARR dated 7/21/22 indicated an Annual Resident Review and reflected R60 had a diagnosis of Vascular Dementia and Bipolar Disorder and received antidepressant and mood stabilizing medications. Further review of the PAS/ARR was not noted to include the 3878. Review of the PAS/ARR dated 8/15/23 indicated an Annual Resident Review and reflected R60 had a diagnosis of Schizoaffective Disorder, Bipolar Disorder, and Vascular Dementia and received an antipsychotic medication. Further review of the PAS/ARR was not noted to include the 3878. In an interview on 8/17/23 at 8:45 AM, Social Services Director (SSD) J stated that the PAS/ARR was completed annually by the Social Services Department through the online portal and that the physician portion (3878) was also completed online through the same portal by the physician. Upon review of R60's PAS/ARR through the portal, SSD J confirmed that R60's completed 3877 for both the 7/21/22 and 8/17/23 review was in the portal but that R60's physician had not completed the 3878 for either annual review. SSD J further stated that based on R60's medical diagnoses and medications that the physician should have completed the 3878, did not have a definitive answer as to why the 3878 had not been completed, would be following up with the physician for completion, and that the facility currently did not have a process in place to audit the physician completion of the PAS/ARR. Review of the facility policy titled PASARR Guideline with an 11/28/2017 effective date stated, Purpose .It is the practice of the facility to coordinate the assessment process with the preadmission screening and annual resident review (PASARR) program .The PASARR process consists of the completion of a Level 1 screen per State and Federal requirements as well as review and implementation of the Level II recommendations upon admission into the facility . Based on interview and record review the facility failed to ensure a Preadmission/Annual Resident Review (PAS/ARR) was completed after the 30 day exemption period and failed to notify the State Agency Health Authority for 1 Residents ( #107) and failed complete the 3878 portion of the PAS/ARR for 1 Resident (60) of 4 residents reviewed for PAS/ARR from a total sample of 31, resulting in the potential for unmet mental health treatment and services. Findings include; Resident #107 According to the clinical record Resident 107 (R107) was admitted to the facility on [DATE] with diagnoses that included schizophrenia, bi-polar disorder and substance abuse. On 8/15/23 at approximately 10:00 am, R107 was observed resting in bed difficult to engage in conversation. Review of the PAS/ARR dated 9/20/22 reflected R107 had a diagnosis of schizophrenia and received anti depressant and antipsychotic medications, further review of the 3877 and 3878 reflected R107 was expected to be discharged back into the community within 30 days and was admitted with a 30 day hospital exemption. There was no updated PAS/ARR after the 30 day exemption and no coordination with OBRA reflected in the medical record. On 08/16/23 at 03:07 PM, during an interview with Social Worker (SW) E she reported she was responsible for updating residents PAS/ARR and coordination with OBRA for mental health needs. Review of R107's clinical record with SW E she offered no explanation for not updating the PAS/ARR Obviously it just got missed.

This citation pertains to intake: MI00136732 Based on interview and record review, the facility failed to provide bath/showers and continence care for one Resident (#208) of 5 Residents reviewed, resulting in missed showers and the potential for inadequate hygiene and feelings of embarrassment. Resident #208 (R208) Review of the medical record revealed R208 was admitted to the facility 05/03/2023 with diagnoses that included hyperlipidemia (high fat in blood), congestive heart failure (CHF), major depression, hypothyroidism (low thyroid hormone), hypertension, morbid obesity, fractur of right femur, atrial fibrillation, gastroesophageal reflux, anemia (low red blood cells), osteoarthritis, and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2023, revealed R208 had a Brief Interview of Mental Status (BIMS) of 9 (moderately impaired cognition) out of 15. R208's MDS-Section G (Functional Status), with the same ARD, revealed that she required extensive assistance with toileting and was totally dependent for showering/bathing. R208's MDS-Section H (Bladder and Bowel), with the same ARD) revealed that she was always incontinent of bowel and urine. R208 was discharged from the facility 6/16/2023. Review of the medical record demonstrated Point of Care (POC) task documentation (documentation of certified nursing aides (CNA) when care has been provided) that R208 was to receive a bath/shower on Mondays, on the day shift, and Wednesday, on the afternoon shift. Review of the POC, for bathing, demonstrated that R208 did not have a bath/shower on 05/10/2023 (Wednesday), 05/17/2023 (Wednesday), 05/22/2023 (Monday), 05/29/2023 (Monday), 05/21/2023 (Wednesday), 06/07/2023 (Wednesday), and 06/14/2023 (Wednesday). Review of the medical record demonstrated POC task documentation for Bladder Continence was not documented for 06/01/2023 (midnight shift), 06/02/2023 (midnight shift), 06/03/2023 (afternoon and midnight shift), 06/04/2023 (day shift, afternoon shift, and midnight shift), 06/05/2023 (afternoon shift and midnight shift), 06/08/2023 (midnight shift) and 06/012/2023 (midnight shift). In an interview 08/17/2023 at 10:19 a.m. Director of Nursing (DON) B explained that residents were to have baths/showers twice per week. She explained the CNA's would document completion in the residents bathing shower task, which is located in the residents POC. DON B confirmed that R208 had not received bathing or showers for the dates listed above. DON B could not provide an explanation why R208 had not received a bath/shower on those dates. DON B explained that it was the expectation that incontinent residents were to receive care every two hours and completion of that care would have been documented by the CNA's in the POC task for Bladder Continence. DON B confirmed that R208 had not received incontinent care for the dates listed above. DON B could not provide an explanation why R208 had not received incontinent care for those dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3 Review of the medical record revealed that Resident #3 (R3) was readmitted to facility 6/8/2020 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle wasting and atrophy, joint contracture, and rheumatoid arthritis. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/2023 revealed that R3 was understood by others and able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 13 (cognitively intact). Section G of the same MDS revealed that R3 required one-person extensive assist with bed mobility, dressing, eating, and toilet use and two-person extensive assist with transfers. In an observation and interview on 8/15/23 at 10:41 AM, R3 was observed lying in bed, on back, with head of bed at an approximate 90-degree angle. R3 stated that she was low in seeing, could not see her television very well, that her eyes were scratchy, and that she had asked to see the eye doctor a few months back but still had not seen one. Review of R3's medical record completed with the following findings noted: Physician order dated 6/27/23 stated, Ophthalmologist (a doctor that specializes in eye and vision care) consult for painful eye. Care Plan Focus with a 10/24/18 initiated date stated, The resident has impaired visual function r/t (related to): aging process and HX (history) of Stroke with an intervention to Arrange consultation with eye care practitioner as required. Review of all progress notes dated 6/27/23 through 8/15/23 included no indication that the 6/27/23 physician ordered ophthalmologist consult was reviewed with R3 or her guardian or that the appointment had been scheduled or completed. In an interview on 8/16/23 at 3:03 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) G confirmed familiarity with R3, stated that she had been the manager on the unit where R3 resided for the last year, and upon review of R3's medical record, denied prior knowledge of the 6/27/23 physician order for an ophthalmology consult. Per LPN/UM G, the appointment should have been arranged as the order was from June but upon further review of R3's medical record, LPN/UM G confirmed the absence of a progress note or scanned consult note to reflect that the appointment had been scheduled or completed. During the same interview, LPN/UM G stated that the facility's ancillary services, including vision, were coordinated by Social Services and that appointments outside of the facility were generally scheduled by Unit Secretary (US) S. LPN/UM G reported that after conferring with Unit Secretary S that an outside appointment had never been scheduled for R3 but that Social Services would have additional information if a vision appointment had been coordinated with the facility's ancillary services. In an interview on 8/16/23 at 3:53 PM, Social Services (SS) I confirmed familiarity with R3, stated that Social Services Director (SSD) J coordinated the facility's ancillary services, that the goal was for all residents to be seen at least annually for a routine vision exam and that if a more emergent exam was needed in between the ancillary service visits, an appointment would be coordinated with a community practitioner. Upon review of R3's 6/27/23 order for an ophthalmology consult, SS I stated that she had not previously seen or been informed of the order until 8/16/23 when LPN/UM G informed her that an appointment with a community ophthalmologist had just been arranged. Although SS I stated that R3 now had an ophthalmology appointment scheduled for 8/17/23, LPN/UM G, Unit Secretary S, and SS I all denied knowledge of the 6/27/23 order or efforts to facilitate the appointment prior to being made aware of the order on 8/16/23. Based on observation, interview and record review the facility failed to provide assistance to ensure ancillary services were arranged for 2 of 4 residents (Residents #141 and 3) reviewed for optical care, and audiology care, resulting in delayed care and treatment and frustration. Findings include: Resident #141 According to the clinical record including the Minimum Data Set (MDS) dated [DATE] , Resident # 141 (R141) was a [AGE] year old female admitted to the facility with diagnosis that included chronic kidney disease, hypertension and unspecified bilateral hearing loss. Further review of the MDS reflected R141 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), section B of the MDS reflected R141 had moderate hearing loss and no hearing aid. On 08/15/23 at 12:46 PM, R141 was interviewed in her room, R141 noticeably struggled to hear questions, and elaborated that she had a hearing test in June and thought she was getting hearing aids but had not been updated or informed on the situation. Further review of the clinical record did not reflect an audiology consult had occurred. On 08/16/23 at 03:32 PM, during an interview Social Worker (SW) E she reported R141 did have an audiology consult in June, and was waiting to hear from the audiologist. SW E was queried at what point would she call them on behalf of R141. SW E responded she would try to get more information. On 08/17/23 09:57, SW E provided R141's audiology consult dated 6/22/23, the consult revealed unspecified profound hearing loss in right ear, moderate to profound sensorineural hearing loss left ear, the consult further noted suspicion of a right ear infection and that after medical treatment for the infection audiology would like to reevaluate. The consult was reviewed with SW E whom agreed/acknowledged since the consult document was just sent over by audiology, R141 was not seen by the physician for the possible right ear infection and was not scheduled to be revaluated by audiology for hearing aids.

Based on observation, interview, and record review the facility failed to implement its policy and procedures to assure the accurate dispensing, administering, and documentation of controlled substances for two of five medication carts, resulting in the potential for controlled drug diversion. Findings Included: During observation of the 1 South medication cart on 08/17/2023 at 11:22 a.m. it was observed that the document entitled Controlled Substance Shift Inventory was not signed for 08/17/2023 at 07:00 a.m. by the oncoming nurse. The total number of medications at the end of the shift was also not completed. In an interview on 08/17/2023 at 11:25 a.m. Licensed Practical Nurse (LPN) T explained that she was the oncoming nursing for the 1 South medication cart. She explained that it was the expectation that the outgoing nurse and the oncoming nurse would count the controlled medication at 07:00 a.m. and record the total numbers and sign their signature in the appropriate box, which was located on the document entitled Controlled Substance Shift Inventory. LPN T explained that she had been busy this morning and must have forgotten to sign as the oncoming nurse at 07:00 a.m. for the date of 08/17/2023. During observation of 2 North back medication cart on 08/17/2023 at 11:48 a.m. it was observed that the document entitled Controlled Substance Shift Inventory was not signed for 08/17/2023 at 07:00 a.m. by the oncoming nurse. In an interview on 08/17/2023 at 11:49 a.m. Licensed Practical Nurse (LPN) W explained that she was the oncoming nursing for the 2 North back medication cart. LPN W explained that she was the oncoming nurse for the 2 North back medication cart. She explained that it's the expectation that the outgoing nurse and the oncoming nurse would count the controlled medication at 07:00 a.m. and record the total numbers and sign their signature in the appropriate box, which was located on the document entitled Controlled Substance Shift Inventory. In an interview on 08/17/2023 at 12:22 p.m. Director of Nursing (DON) B explained that controlled medication is to be counted between each shift or any time that a nurse is no longer responsible for the controlled medication. DON B explained that the controlled medication count would be recorded on the document Controlled Substance Shift Inventory and would be signed by both nurses in the appropriate signature box of the document. DON B observed copies of the 1 South and the 2 North Back Controlled Substance Shift Inventory documents and agreed that both oncoming nurses had not signed at 07:00 a.m. on 08/17/2023. She could not provide an explanation why signatures had not been present. DON B explained that she would personally recount the controlled medication of both medication carts with the current nurse responsible to ensure that the appropriate number of controlled medications was present. During review of policy entitled Medication Storage in the Facility, dated August 2019, revealed section ID2: Controlled Substance Storage E. This section stated, At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented. (See Documentation Examples, Form 9: Controlled substance Shift Inventory).

Based on observation, interview, and record review the facility failed to ensure a medication error rate less than five percent when 2 medication errors were observed from a total of 36 opportunities for one resident (R121) of four residents observed during medication administration, resulting in a medication error rate of 5.56 percent (%). Findings include: During an observation on 8/17/23 at 9:35 AM, Licensed Practical Nurse (LPN) N administered R121's medications scheduled for 9:00 AM; LPN N did not administer Januvia (used to treat diabetes) 50 milligrams (mg) or Nifedipine extended release (ER, used to treat high blood pressure) 90 mg. In review of R121's physician orders and August 2023's medication administration record (MAR), there were two active orders for Nifedipine: 120 mg daily and 90 mg daily scheduled to be administered at 9:00 AM. Januvia 50 mg was scheduled to be administered at 9:00 AM. R121's August 2023's MAR revealed LPN N documented Nifedipine 90 mg, Nifedipine 120 mg, and Januvia 50 mg, were administered on 8/17/23 at 9:00 AM. During an interview on 8/17/23 at 12:16 PM, regarding R121's omitted medications on 8/17/23 at 9:00 AM, LPN N stated she started late and was assigned 40 residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide dental services for one of three residents reviewed for dental services (Resident #139), resulting in continued mouth pain and unmet needs. Findings Include: Resident #139 (R139) R139 was observed sitting on her bed on 8/15/23 at 1:00 PM and stated during an interview that she had oral pain, had cavities, and needed a crown. In review of R139's Minimum Data Set (MDS) admission assessment dated [DATE], revealed she was admitted to the facility on [DATE]; had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 14 (13-15 Cognitively Intact); and required extensive assistance for personal hygiene (includes brushing teeth). The same MDS assessment indicated R139 had obvious or likely cavity or broken natural teeth. During an interview on 08/16/23 at 12:55 PM, Social Worker E stated she was not aware R139 needed to see the dentist. During an interview with Social Services Director J on 8/17/23 at 12:24 PM, she stated dental service needs were discussed in every quarterly care conference. Appointments Policy with revision date of 11/23/22, indicated the social work department would maintain an ancillary service log to track timeliness of dental, vision, audiology appointments and communicate with the nursing department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure two out of 31 one resident's (Resident #5 and 75) medical records were complete and accurate resulting in the potential for unmet care needs. Findings Included: Resident #5 (R5): Review of the facility's Advanced Directive (AD) form titled, Code Status Elective Form revealed the form had options to check if a resident wished to be Full Resuscitation-(Full Code (life saving efforts to be given), or Do Not Resuscitate-(No Code) . (no life saving efforts to be given). A check mark was in the box next to Full Resuscitation-(Full Code), and also the word Full was circled which, per the form, indicated Resident #5 (R5) wished to have all medically appropriate care provided. On the signature line for Resident/Responsible Party the form revealed Verbal Consent dated 12/9/2022, but there was no name of the person who gave verbal consent. The form also revealed that two witness' were to sign the form, however there was only one witness' signature dated 12/9/2022. In an interview on 8/16/2023 at 3:37 PM, Social Worker (SW) E stated that R5 had given verbal consent because he could not write. SW E said the facility policy and standard was that if the resident was the one who gave the verbal consent, then the AD form only needed to state verbal consent, and the name of the individual who gave the verbal consent did not need to be documented on the form. SW E said if the resident's representative or guardian gave the verbal consent then the AD form needed to state who gave the verbal consent. In an interview on 8/17/2023 at 8:55 AM, Director of Nursing (DON) B said that if there was a verbal consent then the AD form must state who gave the verbal consent even if it was the resident. On 8/17/2023 at 10:01 AM, SW E stated that she updated the AD form dated 12/9/2022, and presented a copy which revealed R5's name was added to the AD form that was dated 12/9/2022. The AD directive form was not updated with the current date due to R5's name being added to an AD form that was over eight months old. Resident #75 (R75): Per R75's electronic medical record (EMR) R5 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease (kidney failure) and dependency on renal dialysis (treatment for kidney failure). Review of the facility's policy and procedure for, Post Dialysis Protocol: revealed .Communication between outpatient dialysis provider and facility should include: .Written communication form with review of daily weights, any changes in condition or mood. Review of R75's EMR revealed the last dialysis communication form was dated 7/29/2023. No other communication form was found in R75's EMR. Review of R75's Physician's orders revealed an active order for R75 to receive dialysis on Tuesdays, Wednesdays, and Saturdays. In an interview on 8/17/2023 at 9:06 AM, Director of Nursing (DON) B stated that the communication documents always would come back with the R75 upon return from dialysis. DON B said nursing filled out the form before the R75 left the facility for dialysis. DON B said R75 would bring the form back upon return to the facility. In another interview on 8/17/2023 at 11:05 AM, DON B stated that the dialysis communication forms were to be uploaded into R75's EMR was with in 24 hours. On 8/17/2023 at 11:01 AM, the facility provided dialysis communication forms dated 8/1/2023 through 8/15/2023 that were not upload into R75's EMR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00133207 Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, and homelike environment for 34 residents (including Resident #40 and 115) on the third floor, reviewed for physical environment. The facility also failed to maintain a clean comfortable home like environment in the dining room on the third floor that had the likelihood to impact all residents who were using the dining room for their meals and other activities. Findings include: During an observation on 8/15/23 at 10:53 AM, room [ROOM NUMBER] had no window curtains, two beds with matching comforters, rough unfinished dry wall by bathroom, soiled(dark mater splashed) wall behind toilet, discolored broken grout around toilet, toilet paper holder very loose with broken dry wall. During an observation on 8/15/23 at 11:04 AM, room [ROOM NUMBER] had two beds and the bed located closest to the door did not have the privacy curtain in place and the track was broken and hanging from the ceiling. During an observation and interview on 8/15/23 at 11:11 AM, room [ROOM NUMBER] had rough un-finished dry wall located by the bathroom door, loose television wires over bathroom door that would not allow door to close. The bathroom wall appeared soiled with dark splash stains behind the toilet. The room did not have window accents in place or pictures on the wall or personal items and had one closet for two residents. Resident in room reported had informed staff about wires over door with no follow up. Continued tour of the third floor reflected 15 total room with no window accents or homelike decor throughout the unit including the dining room. During an observation on 8/15/23 at 2:41 PM, the room temperature appeared very hot in the third floor dining room with five residents sleeping in chairs and nine others sitting around tables with no activities at the time. Large running fans observed in doorway and four wall air conditioner(AC) units not running. Outside temperatures was 75 degrees. The west(left) wall of the third floor dining room AC units was not on and appeared heavily soiled with dark substance that appeared to food spillage and the window sill had residue glass rings of stick substance noted. Equipment appeared stored in north west corner of dining room including scale, several geri chairs, and activity supplies. During an observation on 8/16/23 at 12:50 PM, 20 residents were noted in the third floor dining room. Two resident geri chairs were noted as very soiled. R115 was sitting in a very soiled geri chair that had dark colored, dried mater that dripped from seated surface down side of chair. R40 was seated in soiled reclined geri chair that with unidentified dried on material under chair seat. During an interview and observation on 8/16/23 at 3:35 pm, CNA GG entered the third floor shower room and verified there was no anti-slip strips in place and the front two wheels brakes of shower chair were not functional. CNA GG verified equipment lifts in shower rooms (2 hoyer lifts) were soiled and night shift was responsible for cleaning. CNA GG verified R115 was sitting in very soiled geri chair with dried dark matter that appeared to drip form seat cushion in dining room and reported was soiled prior to that day and night shift should have cleaned chair. During an observation on 8/17/23 at 8:56 AM, the second floor shower room had broken seal around toilet base. During an observation on 8/17/23 at 9:03 AM, third floor dining room with three geri chairs parked against west wall along with wheelchair scale. During an interview on 8/17/23 at 9:13 AM, Interim Maintenance Director(MD) HH reported was filling in for prior director that quit with no notice (8/15/23) and was from another facility. MD HH reported three other maintenance staff that are familiar with facility and would coordinate facility tour with them. During an observation and interview on 8/17/23 at 9:15 AM, Certified Nurse Aid(CNA) GG verified room [ROOM NUMBER] only had one closet for two residents and one resident had to use drawers (for a closet). CNA GG reported other rooms one the floor had portable closets but was unsure why room [ROOM NUMBER] did not and verified resident in bed by window(without closet) had been in the room for several months. During an interview and observation on 8/17/23 at 9:36 AM, MD HH and facility maintenance staff(MS) II conducted a tour of the facility. MS II reported they were familiar with the facility and had worked there for 17 years. MS II used the thermal temperature device to obtain temperature in dining room of 79 degrees and reported it was often warm in the area. (Outside temperature was 78 degrees). MS II verified west wall AC unit was off and reported was unsure why and turned on. MS II reported the other AC unit on the same wall did not function at the same time related to, technical issues. MD HH verified west wall AC unit soiled and reported Housekeeping was responsible to clean unit. MD HH reported large unit near south wall of dining room was off and was air purifier and reported was unsure why it was off and turned on. MS II verified no anti-slip strips were present in the third floor shower room and reported no knowledge of resident fall that resulted in fractures in June with interventions that included anti-slip strips on floor in shower room. MD HH reported each resident's bed should have functioning privacy curtain in place and reported Housekeeping staff were responsible for replacing curtains and maintenance staff repair the track if needed. MD HH verified room [ROOM NUMBER] had a broken privacy curtain track and no curtain. MS II verified room [ROOM NUMBER] bed 2 did not have closet and stated they broke last week and had not yet replaced them. MS II verified room [ROOM NUMBER] had wires from the television over the bathroom door were not secured properly and reported the television was ready to fall off the wall and secured television and wires to allow bathroom door to close without risk of television falling from wall. MS II verified rough dry wall located by bathroom door. MS II and MD HH verified room [ROOM NUMBER] did not have a bathroom door knob and should have one in place to function properly. MS II and MD HH verified the 2nd floor shower room did not have anti-slip tape in place. MS II reported the third floor was locked unit and had not yet been renovated and did not have window accents or decor like the 2nd and 1st floor of the facility. MS II reported the 1st and 2nd floors were renovated about 10 years ago and they had not yet renovated the 3rd floor and was unable to answer why. During an interview on 8/17/23 at 10:46 AM, the Assistant Director of Nursing(ADON) D reported they had worked at the facility for over ten years and reported the 1st and 2nd floor were renovated about 10 years ago and the 3rd floor had not yet been renovated and verified was not a homelike environment including no window accents or pictures on walls. ADON D reported equipment should be cleaned by night shift and as needed. Review of the facility Work Order report, dated 5/1/23 to 8/17/23, reflected work orders dated 6/12/23 related to Air Conditioning (AC) not functioning on third floor with updated status of canceled 6/30/23 that indicated AC needed professional repair or replacement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the bed hold policy was provided to three (Resident #27, #125, and #207) of three residents reviewed for hospital transfer, resulting in the potential for resident's and/or representatives to be uninformed of the facility's bed hold policy. Findings include: Resident #125 Review of the medical record reflected that Resident #125 (R125) was readmitted to facility 8/7/23 with diagnoses including acute encephalitis, muscle weakness, and adult failure to thrive. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/23 reflected that R125 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact). Review of the Discharge MDS dated [DATE] reflected that R125 had an unplanned discharge to an acute care hospital and that his return to the facility was anticipated. In an observation and interview on 8/15/23 at 2:24 PM, R125 was observed lying in bed, on back, with head of bed at an approximate 45-degree angle. R125 stated that he had been sent out to the hospital a couple weeks ago, was diagnosed with pneumonia, remained in the hospital a week or so before returning to the facility, and denied that the facility's bed hold policy had been reviewed with or provided to him prior to the hospital transfer. R125's physician order dated 7/23/23 stated, Transfer to ER (Emergency Room) Resp (Respiratory) Distress. Review of the Health Status Note and SNF (Skilled Nursing Facility) to ED (Emergency Department) Handoff form dated 7/23/23, within R125's medical record, both indicated that R125 was transferred to the hospital for respiratory distress with no indication within either record that the facility's bed hold policy was reviewed with or provided to R125 at the time of his 7/23/23 hospital transfer. In an interview on 8/16/23 at 3:13 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) G stated that upon a resident's hospital transfer a completed SNF to ED Handoff form, medication list, and face sheet would be sent to the hospital with the resident. LPN/UM G stated that the assigned nurse did not review or provide a resident with the facility's bed hold policy at the time of a hospital transfer but stated that Admissions Director H might follow-up with the resident/responsible party after the transfer regarding a bed hold. In an interview on 8/16/23 at 3:31 PM, Admissions Director (AD) H stated that the facility's bed hold policy was part of the admissions contract, was reviewed with the resident/responsible party at admission and would not be presented at the time of hospital transfer unless the facility census was at or above 98% (percent). AD H confirmed R125's 7/23/23 hospital transfer and 8/7/23 facility readmission but stated that the facility bed hold policy was not reviewed or provided to R125, at the time of that transfer, as the facility census was not at or above 98%. In an interview on 8/16/23 at 3:46 PM, Director of Nursing (DON) B stated that the facility's bed hold policy was part of the admissions packet and therefore was reviewed with the resident/responsible party at admission. DON B further stated that the facility's bed hold policy should also be reviewed with and provided to the resident/responsible party at the time of a hospital transfer but acknowledged that the facility was not currently doing that. Review of the facility policy titled Bed Hold and Return Guideline with a 4/25/2019 effective date stated, Purpose .It is the practice of that residents who were transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer .Residents and their representative will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave . Resident #207 (R207) Review of the medical record revealed R207 was admitted to the facility 05/12/2023 with diagnoses that included hyperlipidemia (high fat in blood), Alzheimer's disease, fracture of left humerus (bone in arm), dementia with behavioral disturbances, obesity, muscle weakness, delirium, repeated falls, hypertension, malignant neoplasm (cancer) of large intestine, adult failure to thrive, and muscle wasting. R207 was discharged on 05/13/2023 to the hospital. Review of R207's medical record did not demonstrate that R207 had been provided the facility bed hold policy. In an interview on 08/17/2023 at 10:10 a.m. Nursing Home Administrator (NHA) A explained that R207 did not receive the facility bed hold policy. NHA A explained that it was her expectation that discharged residents are to be provided the facility bed hold policy. NHA A could not explain why R207 did not receive the facility bed hold policy when she was discharged to the hospital on [DATE]. Resident #27 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], Resident 27 (R27) was admitted to the facility with multiple medical diagnoses that included end stage renal disease, and had a legal guardian in place. further review of the clinical record reflected R27 transferred to the hospital from the dialysis center on 06/01/23 and again on 07/10/23. There was no documentation in 27's medical record that reflected R27's guardian had been provided a copy or had been made aware of the facility's bed hold policy. On 08/16/23 at 02:04 PM, during an interview with Director of Nursing (DON) B and Assistant Director of Nursing (ADON) D both reported that the bed hold policy was provided upon admission, not upon or after being transferred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3 Review of the medical record revealed that Resident #3 (R3) was readmitted to facility 6/8/2020 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle wasting and atrophy, joint contracture, and rheumatoid arthritis. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/2023 revealed that R3 was understood by others and able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 13 (cognitively intact). Section G of the same MDS revealed that R3 required one-person extensive assist with bed mobility, dressing, eating, and toilet use; two-person extensive assist with transfers; and had an upper and lower extremity functional limitation in range of motion on one side. In an observation and interview on 8/15/23 at 10:41 AM, R3 was observed lying in bed, on back, dressed in facility gown with bilateral arms positioned at sides, bent at an approximate 90-degree angle at elbows, forearms and hands resting on chest, with fingers on bilateral hands flexed inward with fingertips touching palms of hands. R3 stated that she had a history of a stroke, was unable to straighten arms or extend fingers, was unable to walk, and required staff assistance with eating, bathing, and dressing. R3 stated that she had arm splints that staff applied and removed, reported that they had not been applied in quite some time, but was unable to provide additional details regarding splint usage. On 8/16/23 at 2:48 PM, R3 was observed lying in bed, on back, with bilateral arms positioned at sides and bent at elbows, forearms and hands resting on chest, and fingers flexed inward with fingertips touching palms of hands. Review of R3's Care Plan Focus with a date initiated of 9/9/21 stated, Splint/Brace: Resident requires use of splint for positioning; Care Plan Goal with a 9/7/23 target date stated, Resident will wear Elbow Ext (extender) on BUE (bilateral upper extremities) & hand 4 times/week to tolerance to minimize potential increase in muscle tightness and allow max participation in ADLs (activities of daily living), by next review date; Care Plan Intervention with a 9/15/22 initiated date stated, Resident Splint: Unless medically contraindicated: Provide gentle PROM (passive range of motion) to bil (bilateral) elbow prior to applications of bil elbow extenders 1.5 hrs (hours) at a time .3x/wk (times per week) or as tolerated. Review of R3's progress notes from 6/2023 to current included no documentation regarding R3's bilateral elbow splints. In an interview on 8/16/23 at 2:52 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) G confirmed familiarity with R3 as had been the manager on the unit where R3 resided for the last year; stated that R3 required extensive to total assist with bathing, dressing, and eating; had limited range of motion and contractures of both arms; and was uncertain as to whether R3 had splints or braces for positioning of upper extremities. Upon review of R3's medical record, LPN/UM G stated that R3 did not have an order for upper extremity splints/braces, acknowledged that care plan reflected upper extremity splint/brace application, but reiterated that she had never assisted with or noted R3 to have them in place. During the same interview, LPN/UM G confirmed that after conferring with the therapy manager that R3's care plan was still current and active as R3 still needed bilateral upper extremity splints, that she would write an order for the splints, and that the therapy manager would order new splints if prior splints could not be located. LPN/UM G stated that she had been unaware that R3 had a care plan for splint usage, would obtain and reimplement them per the order and care plan, and agreed that R3 would benefit from them to decrease risk of further upper extremity contractures. Review of R3's medical record immediately following the interview included an order dated 8/16/23 at 3:02 PM written by LPN/UM G which stated, Splints to B/L (bilateral) upper extremities r/t (related to) contractures. Resident #71 Review of the medical record revealed that Resident #71 (R71) was admitted to facility 1/20/2022 with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, need for assistance with personal care, and muscle weakness. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/29/2023 revealed that R71 was understood by others and able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). Section G of the same MDS revealed that R71 required one-person extensive assist with bed mobility and toilet use, one-person limited assist with dressing and eating, two-person extensive assist with transfers, and had an upper and lower extremity functional limitation in range of motion on one side. In an observation and interview on 08/15/23 at 12:03 PM, R71 was observed lying in bed, on back, with head of bed at an approximate 45-degree angle. R71's left upper arm was observed to be positioned at her side with her forearm and hand elevated on a pillow and her fingers flexed inward. R71 stated that she had hemiplegia (one-sided muscle paralysis or weakness) due to history of a stroke that affected her entire left side, could not move her left side, but stated that she could and was observed to use her right arm to pick up and move her left arm. R71 stated that she had a splint for her left hand, was able to apply the splint herself but only used a couple times a week as frequently forgot about it and denied that staff reminded her or assisted her to apply. Splint observed on top of dresser to right of bed, against the wall, and out of R71's reach. In an observation and interview on 8/16/23 at 1:54 PM, R71 was observed lying in bed, on back, dressed in facility gown with left upper extremity bent at elbow with forearm and hand resting on abdomen. Left upper extremity splint was observed to remain on top of dresser to right of bed, against wall, and out of R71's reach. R71 denied wearing splint on 8/15/23 and thus far 8/16/23 and that staff had not offered/encouraged or assisted with splint application on either date. Review of R71's medical record completed with the following findings noted: Order dated 2/7/23 stated, Provide gentle PROM (passive range of motion) to left hand prior to application of splint 2hrs (hours) at a time, checking skin integrity, wearing no longer than 4hrs/day (hours per day) or up to tolerance. Medication Administration Record (MAR) dated 8/1/2023 - 8/31/2023 reflected order for left hand range of motion and splint application and was noted to be signed as completed by assigned nurse daily. Care Plan Focus dated 3/6/23 stated, Splint/brace: Resident requires use of splint for (Left hand with sling) positioning or contracture management; Care Plan Goal stated, Resident will wear splint on their Left Hand 1x/day (time per day) for 120 minutes/4 hours or to tolerance with a 3/6/23 date of initiation and 10/21/23 target date; and Care Plan Intervention stated, Resident Splint: Unless medically contraindicated: Provide PROM/AROM (passive range of motion/active range of motion) to affected limb prior to application of splint . In an interview on 8/16/23 at 2:06 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) K confirmed familiarity with R71, stated that R71 had limited range of motion affecting left side with history of therapy and restorative services. Per LPN/UM K R71's assigned Certified Nurse Aide (CNA) currently completed range of motion exercises with cares and applied left hand splint and arm sling and that assigned nurse removed both the splint and sling, per order. In an interview on 8/16/23 at 2:15 PM, Certified Nurse Aide (CNA) L confirmed familiarity with R71, stated that she had been R71's assigned CNA over the prior 2-week period, and that R71 required assist with bathing, dressing, and incontinence care. When questioned, CNA L stated that during the prior 2-week period, she had looked for but was unable to find R71's left hand splint and had never assisted R71 with splint application or removal as they did knot know where the splint was. On 8/16/23 at 2:19 PM, LPN/UM K was observed to enter R71's room and exit room holding left hand splint. In a follow-up interview, LPN/UM K stated that the hand splint was on R71's bedside dresser, agreed that it was out of R71's reach, was unaware that the splint was not being utilized until that time, and agreed that it was a concern that staff was not reminding, encouraging, or assisting with placement of R71's splint. In an interview on 8/16/23 at 2:25 PM, Licensed Practical Nurse (LPN) M confirmed familiarity with R71 as stated that she was the assigned day shift nurse on the unit where R71 resided over the last several months. LPN M stated that although R71 had a stroke and had limitations in left sided range of motion, was unaware of any splints that R71 used and denied that she had ever observed a splint in place. Upon review of R71's medical record, LPN M confirmed that R71 did have an order for range of motion and splint application to left hand but reiterated that, to her knowledge, R71 had never had a splint for her left upper extremity, had never seen her with one in place, and had never assisted R71 to apply or remove a splint. LPN M further stated that although R71 did not have a splint, she signed the order that reflected ROM and splint application as completed as assisted R71 with the ordered PROM daily. Review of the August 2023 MAR reflected that LPN M had signed the order as completed on 10 of the last 16 days although LPN M confirmed that the ordered splint was not applied on any of the 10 days. Review of the facility policy titled Careplan Standard Guideline with an 11/28/17 effective date stated, Guideline .The resident care plan will incorporate risk factors identified in preadmission assessment, hospital records and admission evaluations, with changes in condition, reviewed and updated quarterly .Comprehensive Careplan .The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights . Review of the Face Sheet and Annual Minimum Data Set (MDS) dated [DATE], reflected R40 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), dementia without behavior disturbances, and depression. The MDS reflected R40 had a BIM (Brief Interview for Mental Status) score of 4 which indicated her ability to make daily decisions was severely impaired, and she required one-person physical assist with bed mobility, transfers, walk in room and corridor, locomotion on unit, toileting, hygiene, and bathing and had no mention on behaviors. Continued review of R40 MDS reflected a significant change MDS, dated [DATE], with re-admission date of 7/1/23 post hospital admission for fall at facility resulting in left shoulder and hip fractures. The MDS reflected R40 had changes in need for increased assistance including required two-person assist with bed mobility, transfers, and one person physical assist with eating and dressing. During an observation on 8/15/23 at 11:51 AM, R40 was observed in bed with eyes closed, dressed in a hospital gown, a small spot of blood noted on covers with the mat on floor next to left side of bed. Review of the facility Matrix on 8/15/23 at 12:43 PM, reflected R40 had a fall with major injury. Review of R40's Nursing Progress Notes, dated 6/21/2023 at 10:12 PM, reflected, Writer called to the shower room by staff writer observed resident on the floor writer ask what happen staff stated 'I was washing her and she tried to get up and walk and slipped' writer did head to toe assessment skin indicated no injury noted writer attempted to to ROM resident was yelling and guarding her left arm, hip and leg writer and staff assisted resident back to bed called MD whom order to send her to ER (emergency room) to r/o (rule out) FX (fracture) writer give PRN (as needed) Acetaminophen .Writer notified guardian [named] also ADON (assistant director of nursing). Review of R40 Nursing Progress Note, dated 6/30/2023 at 5:20 PM, reflected, Patient is [AGE] year old readmission, admitted via ems from [named hospital]. Patient primary language is Japanese, but is able to respond well to commands and is pleasant. patient diagnosis multiple fracture including left arm fracture, from fall. Patient is a regular diet. no complaints of pain or discomfort, vital signs: blood pressure 170/87 pulse 72 spo2 (oxygen saturation) 98% on room air respirations 18. patient has scattered bruising throughout left side of body. 14 staples to the left hip intake no drainage present. orders placed for removal date .Call light in reach, bed in low position and patient encouraged to use call light when in need. Review of the Fall Care Plan, dated 3/25/21, reflected, The resident is at risk for falls r/t (related to) Dementia, Non Compliance, Bipolar Disorder, Poor Safety Awareness, and Mental Disorder aeb:-with mildly impaired standing balance -ambulates at will -requires supervision to occasional limited assist with transfers and ambulation . The resident will be free of minor injury through the review date.Date Initiated: 09/25/2019 Target Date: 10/05/2023 .Interventions .Bed in low position when in bed Date Initiated: 12/13/2019 . Anticipate and meet the resident's needs. Date Initiated: 02/23/2023 . Follow facility fall protocol. Date Initiated: 12/13/2019 . The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach .The resident has had an actual fall with injury r/t Poor Balance -resident sustained a witnessed fall while in the shower due to loss of balance, resident transferred to the hospital to r/o FX Fx of left hip and shoulder Date Initiated: 06/21/2023 . Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 06/21/2023 .Continue interventions on the at-risk plan. Date Initiated: 06/21/2023 .For no apparent acute injury, determine and address causative factors of the fall. Date Initiated: 06/21/2023 . During an interview and record review on 8/16/23 at 2:38 PM, Assistant Director of Nursing (ADON) D reported they had worked at the facility for about 10 years and provided a, Soft file, for R40's fall in the shower room with fracture to left arm and hip on 6/21/23. Review of R40 Incident/Accident Report, dated 6/21/23, reflected R40 had a witnessed fall in the shower. The report reflected R40 as oriented to person and unable to give description of what happened and had pain of 8 out of 10 on pain scale. The report appeared incomplete as evidenced by no named witness, predisposing environmental factors indicated, none, and wet floor was not marked, and injuries reported post incident reflected none. Continued review of the report reflected legal guardian was notified 6/21/23 at 10:07 p.m., ADON D was notified at 10:03 p.m., and Physician was notified at 11:01 p.m. During an interview on 8/16/23 at 3:08 PM, Certified Nurse Aid(CNA) JJ reported received education after R40 fall in shower on 6/21/23 related to not leaving residents alone in shower and adding anti-skid tape to floor in shower room floor. During an interview and observation on 8/16/23 at 3:10 PM, CNA GG reported they had worked at the facility for over five years. CNA GG reported they often worked with R40 and was caring for R40 on 6/21/23 when R40 fell and fractured their left arm and hip in shower. CNA GG reported around 7:00 p.m. they were giving R40 a shower in third floor shower room and R40 was in the shower chair. CNA GG reported R40 had soap in hair and turned back to R40 to adjust water temperature and R40 stood up and fell to floor. CNA GG reported R40 landed on left side of body and CNA GG reported yelled from shower room for help. CNA GG reported nurse arrived and assessed R40 and reported R40 did not communicate well in English but stated, Ouch, when left shoulder and leg moved. CNA GG reported three staff physically picked R40 from the floor to the geri chair and R40 repeated, ouch during transfer. CNA GG reported three staff dried off R40, dressed her in a gown and physically picked up R40 and transferred from the geri chair to the bed and Emergency Medical Services(EMS) arrived to transfer R40 to hospital not long after. CNA GG reported received education from management after R40 fall that included proper management, adding anti-slip strips to the shower room floor, not to turn back to residents during shower, and stated, like I did, not to leave residents in shower room alone, prepare all supplies in advance, and use emergency call light in shower room. During the interview CNA GG entered R40's room at 3:30 PM and verified R40 was laying in bed and verified R40's bed was elevated too high and observed a about hip level, with call light located under the bed, out of reach. CNA GG lowered the resident bed and placed a call light within reach and reported staff should have had R40 bed in low position and call light in reach for R40 safety. CNA GG entered the third floor shower room and verified the shower chairs front two brakes were not functional and there was no anti-slip tape on the shower room floor. During an observation on 8/17/23 at 9:09 AM, no anti-slip tape on the floor of the third floor shower room. Based on observation, interview, and record review the facility failed to develop for five out of 31 residents (Resident #'s 3, 5, 40, 71, and 91) person-centered comprehensive care plans, resulting in the potential for resident's needs not being met. Findings Included: Resident #5: Review of the facility's Advanced Directive (AD) form titled, Code Status Elective Form revealed the form had options to check if a resident wished to be Full Resuscitation-(Full Code life saving efforts to be given), or Do Not Resuscitate-(No Code) . (no life saving efforts to be given). A check mark was in the box next to Full Resuscitation-(Full Code), and also the word Full was circled which, per the form, indicated Resident #5 (R5) wished to have all medically appropriate care provided. Review of all active care plans that were in place for R5 revealed no plan of care was in place for R5's AD wishes. In an interview on 8/17/2023 at 8:55 AM, Director of Nursing (DON) B stated that R5's AD were to be on R5's care plans as part of his plan of care. According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident # 91 (R91) was a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage due to a motor vehicle accident, diabetes, and bi-polar disorder. R91 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 08/15/23 at 2:40pm, R91 was observed resting in bed, upon approach R91 initiated a conversation using American Sign Language (ASL) this surveyor is knowledgeable of alphabet and some basic ASL commonly used words. R91 reported he had no hearing ability, and did not use a hearing aid, when queried how he communicated with staff he reported by writing and pointed to his tablet and using gestures. Review of R91's Minimum Data Set (MDS)'s with the assessment reference dates of 1/29/23, 05/01/23 and 08/01/23 section B question 0200 were consistently coded as 1 meaning R91 had minimal hearing loss. The 1/29/23 MDS further reflected R91 used a hearing aid. Review of R91's care plan dated 1/23/23 reflected a communication problem related to traumatic brain injury, the care plan did not identify that R91 was deaf and used sign language. On 08/16/23 at 01:07 PM, during a phone interview with R91's family member F , he reported R91 was born profoundly deaf, and did not use a hearing aids. On 08/16/23 at 02:42 PM, during an interview with MDS Nurse C, she reported she was a regional MDS Nurse and had a heavy work load, MDS Nurse C further reported R91's MDS should have been coded as highly impaired-absence of useful hearing. When queried, MDS Nurse C reported she was not aware that R91 was born deaf, and she had assumed R91's communication problems were a result of traumatic brain injury.

During observation of the 1 South medication care on 08/17/2023 at 11:22 a.m. it was observed that the following medications did not have a date when the medication was open placed on the container of th medication: Fluticasone Propionate/Salmeterol discus 500 micrograms (mcg)/50 mcg and Lansoprazole 3 milligrams (mg)/milliliter (ml). In an interview on 08/17/2023 at 11;22 a.m. during 1 South medication care observation, Licensed Practical Nurse (LPN) T explained that all medication is to be dated when opened. She explained that she would discard the medication that was not dated, as listed above, and order new medication. During observation of the 2 South back medication cart on 08/17/2023 at 11:48 a.m. it was observed that the following medications did not have a date when the medication was open placed on the container of the medication: Fluticasone Furoate 100mcg-vilaterol 25mcg/dose inhaler. Based on observation, interview, and record review the facility failed to ensure medication stored in three of five medication carts were dated after opening and discarded at the time of the expiration date or per manufacture's recommendations, resulting in the potential for the medications to cause complications and/or not be affective. Findings Included: During an observation of a medication cart located on 1 North, on 8/17/23 at 7:53 AM, with Licensed Practical Nurse (LPN) O, an opened bottle of Neomycin, Polymyxin B Sulfates and Hydrocortisone eye drops (used to treat eye infections) was observed without an opened date; LPN O stated she was going to throw the eye drops away. Ipratropium Bromide and Albuterol Sulfate vials (inhalation solution that relax airways) were observed stored in an opened foil pouch with an opened date of 6/30/23; LPN O stated the vials in an opened pouch could be used for 30 days. According to Prescribers Drug Reference at https://PDR.net /drug-summary/Combivent-Respimat-albuterol-ipratropium-bromide-2591, Ipratropium Bromide and Albuterol Sulfate, storage instructions included when vials were removed from the foil pouch, to use within one week. In review of the Medication Storage in the Facility policy dated April 2018, medications were to be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 1) adhere to infection control practices during medication administration observation; and 2) maintain clean and sanitized environment including resident equipment and common areas, resulting in the potential for cross-contamination, spread of bacteria, and increased risk of infection. Findings include: During an observation on 8/15/23 at 10:53 AM, room [ROOM NUMBER] had no window curtains, two beds with matching comforters, rough unfinished dry wall by bathroom, soiled(dark mater splashed) wall behind toilet, discolored broken grout around toilet, toilet paper holder very loose with broken dry wall. During an observation and interview on 8/15/23 at 11:11 AM, room [ROOM NUMBER] had bathroom wall appeared soiled with dark splash stains behind the toilet. During an observation on 8/15/23 at 2:41 PM, the west(left) wall of the third floor dining room Air Conditioning (AC) units were not on and appeared heavily soiled with dark substance that appeared to food spillage and the window sill had residue glass rings of stick substance noted. During an observation on 8/16/23 at 12:50 PM, 20 residents were noted in the third floor dining room. Two resident geri chairs were noted as very soiled. During an observation on 8/17/23 at 9:03 AM, third floor dining room with three geri chairs parked against west wall along with wheelchair scale. Continued same very soiled wall AC unit with cup rings on ledge of west wall. During an interview on 8/17/23 at 9:13 AM, Interim Maintenance Director(MD) HH reported they were filling in for the prior director that quit with no notice (8/15/23) and was from another facility. MD HH reported three other maintenance staff that are familiar with facility and would coordinate facility tour with them. During an interview and observation on 8/17/23 at 9:36 AM, MD HH and facility maintenance staff(MS) II conducted a tour of the facility. MS II reported was familiar with the facility and had worked there for 17 years. MD HH verified west wall AC unit was soiled and reported Housekeeping was responsible to clean unit. MD HH reported large unit near south wall of dining room was off and was air purifier and reported was unsure why it was off and turned on. During an interview on 8/17/23 at 10:46 AM Assistant Director of Nursing(ADON) D reported had worked at the facility for over ten years. ADON D reported equipment should be cleaned by night shift and as needed. ADON D reported managers completed month surveillance check list and this surveyor requested to review. ADON D reported would obtain and provided to surveyor. Did not receive evidence of monthly surveillance prior to survey exit on 8/17/23. During a medication pass observation on 8/17/23 at 7:53 AM, Licensed Practical Nurse (LPN) O placed an insulin pen in a Styrofoam cup, and then placed the cup on a resident's over-the-bed table; the cup tipped over and the pen came in contact with the resident's over-the-bed table. The insulin pen in the cup was not used due to a low blood sugar. LPN O removed her gloves and did not perform hand hygiene. LPN O went back to the medication cart and set the used blood glucose meter and insulin pen on top of the cart and then back into the cart without cleaning; LPN O did not clean the top of the medication cart after contamination. Following the same observation, LPN O stated the same blood glucose meter was used for all residents. A 3-ringed binder titled narcotic book was observed on top of a medication cart on 1 North on 8/17/23 at 8:17 AM. The binder's plastic covering was ripped and taped with paper tape. The paper tape and binder were visibly soiled. During a medication pass observation on 8/17/23 at 8:17 AM LPN Q placed medication cup on one of three foam trays; LPN Q touched her hair, leaned forward to obtain gloves and then placed the gloves on one of the foam trays. On 8/17/23 at 8:52 AM an inhaler was carried from the resident's room back to the medication cart and the bottom of the tray made contact with the inhaler. The inhaler was not cleaned. LPN Q removed her cell phone from her pocket and placed her phone on top of the narcotic book. During a medication pass observation with LPN N on 8/17/23 at 8:35 AM, she placed the blood glucose monitor on a residents over-the-bed table without a barrier. Following checking the residents blood sugar, LPN N placed the blood glucose monitor in her pocket.

In a confidential resident group interview on 8/16/23 at 11:29 AM, 10 of 10 residents reported the lunch and dinner meals was not palatable. Several residents stated that they feel that have to order out to get a decent meal. 10 of 10 residents reported that the portion sized of the meal is small, comparing the portion to kid sized meals. 9 of 10 residents reported that the pork is too tough to cut or chew. 10 of 10 residents reported that the food is not warm and have observed the staff leaving the meal cart doors open and conversating instead of passing trays. In an interview on 08/17/23 at 10:24 AM, Dietary Manager (DM) reported that the residents have had some food committee meetings to discuss food concerns but has cancelled the past few monthly meetings. DM reported that he is aware of food concerns and had been speaking to a few select residents monthly regarding food concerns and possible resolutions. Based on observation and interview, the facility failed to ensure palatable food temperatures and food texture, resulting in poor satisfactory of meals by residents, affecting all resident who consume food from the kitchen. Findings include: On 8/16/23 at 12:16 PM, a food cart was observed to be delivered to the second level. At 12:21 PM, staff were observed to begin passing trays. At 12:27 PM, a test tray was pulled from the cart, before staff were done passing all of the trays. The following food temperatures were recorded using a digital probe thermometer: Salisbury steak - 117 degrees F, mashed potatoes - 108 degrees F, and cooked cabbage - 115 degrees F. At this time, Regional Dietary Manager FF was queried on what temperature the facility expects the meals to be delivered at, and stated as close to 135 degrees F as possible. The tray that was pulled was observed to have the insulated base used as the lid. When queried regarding the irregular tray set-up, Regional Dietary Manager FF stated that the staff might have thought that the base was the lid, and reassured that they have an adequate supply of insulating dome lids.

Based on observation, interview, and record review, the facility failed to maintain the physical facility, maintain plumbing in good repair, and maintain equipment, resulting in the potential for contamination of the physical facility and food product, affecting all residents who consume food from the kitchen. Finding include: On 8/16/23 at 11:04 AM, the floor underneath the dish machine drain board was observed to have dissolved floor tile grout. Two tiles were observed to be loose at this time. Additionally, the waste disposal flex cuff, in the dish washing area, was observed to be leaking slightly. According to the 2017 FDA Food Code Section 6-201.11 Floors, Walls, and Ceilings. Except as specified under § 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE. On 8/16/23 at 11:15 AM, the two-compartment sink drain line was observed to be leaking on to the floor. Additionally in the back corner, beyond the two compartment sink, a black liquid was observed to be surrounding a PVC drain line. According to the 2017 FDA Food Code Section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; P and (B) Maintained in good repair. On 8/16/23 at 11:19 AM, the can opener blade was observed to have a groove in the blade, and metal shaving were observed around the gear. Additionally, the hand sink drain line was observed to be excessively leaking, with a catch pan collecting the water under the sink. At this time, Director of Kitchen EE stated that is was reported to Maintenance around two to three weeks prior. On 8/16/23 at 11:21 AM, the reach-in cooler, across from the cookline, was observed to not be provided with an internal ambient thermometer. On 8/16/23 at 11:30 AM, a window, in the dry storage room, was observed to be cracked open with no screen to prevent insects from entering the premises. According to the 2017 FDA Food Code Section 6-202.15 Outer Openings, Protected. (A) Except as specified in (B), (C), and (E) and under (D) of this section, outer openings of a FOOD ESTABLISHMENT shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings; (2) Closed, tight-fitting windows; and (3) Solid, self-closing, tight-fitting doors .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain resident rooms in good repair, maintain clean ventilation, and maintain backflow protection, resulting in a non-homelike facility and potential for contamination of the domestic water supply, affecting all residents in the facility. Findings include: During an environmental inspection on 8/16/23 between 12:16 PM and 2:03 PM, the following observations were made: -Two ceiling tiles, in the hall near room [ROOM NUMBER], were observed to be stained with water damage. -The shower room, near room [ROOM NUMBER], was observed to have gum or [NAME] adhesive on the floor; the ceiling in the shower enclosure was observed to have bubbling paint. -The ventilation screen, in boiler room [ROOM NUMBER], was observed to have fallen out of the vent frame, allowing for potential pests to enter the premise. -The PTAC (packaged terminal air unit) filter, located in room [ROOM NUMBER], was observed to be caked with dust. -The walls, located in room [ROOM NUMBER], were observed to have etching in the wall paper and miscolored pain behind Bed 1. -The lighting in the 2-North shower room was observed to be dim, specifically around the toilet enclosure, reducing visibility to the extent that observation of sanitation were difficult. At this time, Maintenance Staff II stated that they had put one light on the opposite end of the shower room, but they need to add another one. Additionally, the shower hose was observed to be long enough to touch the floor. The shower fixture was not provided with a backflow protection device to preclude the backflow of liquid or gas contaminants. -A large scrape/etch was observed along the back wall of room [ROOM NUMBER]. -The PTAC, located in room [ROOM NUMBER], was observed to have a custom fit, blue foam filter. The filter was observed to be caked with dust. -The small linen and supply cart, located on the 2nd floor, was observed to have a tear, approximately 3 inches long, on the protective cover. -The call light cord provided for the toilet enclosure, located in the 3rd Floor shower room, was observed to be missing. -The bottom drawer of the built-in wardrobe/dresser was observed to be pulled out of the track and sitting on the dresser surface. At this time, Maintenance Staff II stated that no one had told him about the dresser and that the track appears to be broken. -The ceiling tiles, located in resident room [ROOM NUMBER], was observed to have two water stains. A third stain was observed to be freshly wet. At this time, Maintenance Staff II stated they will investigate the issue. According to the 2018 Michigan Plumbing Code Section 608.2 Plumbing Fixtures. The supply lines and fitting for plumbing fixtures shall be installed so as to prevent backflow. Plumbing fixtures fittings shall provide backflow protection in accordance with ASME A112.18.1/CSA B125.1. During an observation on 8/15/23 at 10:53 AM, room [ROOM NUMBER] had no window curtains, two beds with matching comforters, rough unfinished dry wall by bathroom, soiled(dark mater splashed) wall behind toilet, discolored broken grout around toilet, toilet paper holder very loose with broken dry wall. During an observation on 8/15/23 at 11:04 AM, room [ROOM NUMBER] had two beds and the bed located closest to the door did not have privacy curtain in place and track was broken and hanging from the ceiling. During an observation and interview on 8/15/23 at 11:11 AM, room [ROOM NUMBER] had rough un-finished dry wall located by bathroom door, loose television wires over bathroom door that would not allow the door to close. The bathroom wall appeared soiled with dark splash stains behind the toilet. The room did not have window accents in place or pictures on the wall or personal items and had one closet for two residents. Residents in the room reported they had informed staff about wires over door with no follow up. Continued tour of the third floor reflected 15 total room with no window accents or homelike decor throughout the unit including the dining room. During an observation on 8/15/23 at 2:41 PM, the room temperature appeared very hot in the third floor dining room with five residents sleeping in chairs and nine others sitting around tables with no activities at the time. Large running fans observed in doorway and four wall air conditioner(AC) units not running. Outside temperatures was 75 degrees. The west(left) wall of the third floor dining room AC units was not on and appeared heavily soiled with dark substance that appeared to food spillage and the window sill had residue glass rings of stick substance noted. Equipment appeared stored in north west corner of dining room including scale, several geri chairs, and activity supplies. During an observation on 8/16/23 at 12:50 PM, 20 residents were noted in the third floor dining room. Continued very soiled west wall AC unit along with two resident geri chairs were noted as very soiled. During an observation on 8/17/23 at 8:56 AM, the second floor shower room had broken seal around toilet base. During an observation on 8/17/23 at 9:03 AM, third floor dining room with three geri chairs parked against west wall along with wheelchair scale. Continued same very soiled wall AC unit with cup rings on ledge of west wall. During an interview on 8/17/23 at 9:13 AM, Interim Maintenance Director(MD) HH reported he was filling in for the prior director that quit with no notice on 8/15/23 and was from another facility. MD HH reported three other maintenance staff that are familiar with facility and would coordinate facility tour with them. During an observation and interview on 8/17/23 at 9:15 AM, Certified Nurse Aid(CNA) GG verified room [ROOM NUMBER] only had one closet for two residents and one resident had to use drawers. CNA GG reported other rooms one the floor had portable closets but was unsure why room [ROOM NUMBER] did not and verified resident in bed by window(without closet) had been in room for several months. During an interview and observation on 8/17/23 at 9:36 AM, MD HH and facility maintenance staff(MS) II conducted a tour of the facility. MS II reported was familiar with the facility and had worked there for 17 years. MS II used the thermal temperature device to obtain temperature in dining room of 79 degrees and reported was often warm in the area. (Outside temperature was 78 degrees). MS II verified west wall AC unit was off and reported was unsure why and turned on. MS II reported the other AC unit on the same wall did not function at the same time related to, technical issues. MD HH verified west wall AC unit soiled and reported Housekeeping was responsible to clean unit. MD HH reported large unit near south wall of dining room was off and was air purifier and reported was unsure why it was off and turned on. MS II verified no anti-slip strips were present in the third floor shower room and reported no knowledge of resident fall that resulted in fractures in June with interventions that included anti-slip strips on floor in shower room. MD HH reported each resident bed should have functioning privacy curtain in place and reported Housekeeping staff responsible for replacing curtains and maintenance staff repair track if needed. MD HH verified room [ROOM NUMBER] had broken privacy curtain track and no curtain. MS II verified room [ROOM NUMBER] bed 2 did not have closet and stated broke last week and had not yet replace. MS II verified room [ROOM NUMBER] had wires from television over bathroom door were not secured properly and reported television was ready to fall off the wall and secured television and wires to allow bathroom door to close without risk of television falling from wall. MS II verified rough dry wall located by bathroom door. MS II and MD HH verified room [ROOM NUMBER] did not have a bathroom door knob and should have one in place to function properly. MS II and MD HH verified 2nd floor shower room did not have anti-slip tape in place. MS II reported third floor was locked unit and had not yet been renovated and did not have window accents or decor like the 2nd and 1st floor of the facility. MS II reported the 1st and 2nd floors were renovated about 10 years ago and they had not yet renovated the 3rd floor and was unable to answer why. During an interview on 8/17/23 at 10:46 AM Assistant Director of Nursing(ADON) D reported had worked at the facility for over ten years and reported the 1st and 2nd floor were renovated about 10 years ago and the 3rd floor had not yet been renovated and verified was not a homelike environment including no window accents or pictures on walls. ADON D reported equipment should be cleaned by night shift and as needed. Review of the facility Work Order report, dated 5/1/23 to 8/17/23, reflected work orders dated 6/12/23 related to AC not functioning on third floor with updated status of canceled 6/30/23 that indicated AC needed professional repair or replacement.

Based on observation, interview, and record review the facility failed to implement a 'communication' care plan for one (R23) of 12 residents reviewed for ADLs ( activities of daily living) when he did not have a 'communication board' (sheet of pictures/symbols used to communicate) available to him resulting in the potential for R23 being unable to express his needs. Findings include: During observation and interview with R23 on 6/22/22 at 11:18 AM and 6/23/22 at 11:19 AM, the resident could only communicate his needs by nodding/shaking his head and hand gestures, in the form of 'fist bumps' or 'thumbs up'. There was no communication board in the resident's room. According to R23's Electronic Medical Record he had multiple diagnoses that included history of a stroke with aphasia (inability to express speech). A 'communication' care plan initiated on 12/8/2020 indicated that R23 had a communication problem related to 'global aphasia' and used nonverbal 'nods' and 'hand gestures' when communicating. Interventions included, resident can't speak, uses a communication board. On 6/23/22 at 11:57 AM LPN G confirmed that R23 had a communication board in the past, but did not have one ('communication board) in his room currently. LPN G said she would obtain one (communication board) and place on resident's table. According to the facility's 'ADL - Activity of Daily Living' policy last revised on 5/7/2020; Guideline In accordance with the comprehensive assessment, together with respect for individual resident needs and choices our facility provides care and services for the following activities: * Speech, * Language, * Other functional communication systems Our collaborative professional team, together with the resident and / or resident representative: 2. Develop and implement interventions in accordance with the resident ' s evaluated need, goals for care, preferences and will address the identified limitation in an ability to perform ADLs; 3. Monitor and evaluate the resident ' s response to care plan interventions and treatment; 4. Revise the approaches as appropriate

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #139 On 6/22/22 at 10:42 a.m., during the initial pool process, R#139 was observed resting in bed, wearing a hospital gown. R#139 did not engage much during the interview or verbalize any wants or needs. The resident had a look of confusion when spoken to. The resident was also observed with overgrown grey facial hair in beard area and hair looked greasy and unkept. There was also a urine smell in room that was stronger near the resident. On 6/22/22 at 11:13 a.m., review of R#139's clinical record documented the resident was admitted into the facility on 2/16/22 with diagnoses that included dementia, schizophrenia, and muscle weakness. According to the quarterly MDS assessment dated [DATE], R#139 was severely cognitively impaired (BIMS= 3) and required extensive one-person assistance with ADLs, particularly with bathing and hygiene. Review of the ADL care plan dated 3/17/22 documented: The resident has ADL self-care performance deficit regarding to impaired cognition secondary to dementia as evidence by -requires assistance with hygiene, grooming, and toileting, ambulation, and transfers. -requires daily cues, reminders, and supervision of daily activities. o Bathing: Physical Assist. o Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated. Review of the electronic care guide ([NAME]) documented the following showers/bed baths rendered: 6/6/2022 04:22 N/A 6/7/2022 05:34 N/A 6/15/2022 11:51 Bed Bath 6/17/2022 00:23 N/A In addition, the nurse aide schedule documented on 5/25/22 on the 3p-11p (afternoon shift), R#139 was to get a shower, however documentation of the ADL performed was not present or available. On 6/8/22 on the same shift (afternoon) documented the resident was to receive a shower, however documentation of the ADL was not available or present. Review of the nurse aide scheduled for 6/22/22 revealed the resident was not scheduled for a shower or bed bath however received a shower immediately after the surveyor conducted the initial interview and observation. On 6/28/22 at 12:08 p.m. the Director of Nursing, Unit Manager F, and the Assistant Director of Nursing were interviewed and stated documentation in the [NAME] has been a problem, so showers are to be documented on the shower sheets on the unit. This citation pertains to intakes: MI00125777 and MI00127534. Based on observation, interview, and record review, the facility failed to ensure 'activity of daily living' (ADL) care for showers, grooming, and personal hygiene were provided for three residents (R23, R139, and R151) of 12 residents reviewed for ADLs, resulting in verbalized complaints of not receiving scheduled showers including foot care, and shaves, with the potential for skin irritation and embarrassment from poor personal hygiene. Findings include: R151: The State Agency received a complaint that R151's feet were 'black' and 'moldy' from not being washed. On 6/22/22 at 10:03 AM, R151 was observed laying in her bed watching TV with 'non-skid' socks on her feet. All of R151's fingernails were ragged (not filed smooth) with brown/grayish debris around and underneath the nails. During interview R151 could not recall when she last had nail care or her feet washed. R151's socks were removed after permission was given. Both feet had significant amounts of dark gray-blackened flakes on the top of the feet and in between all the toes. R151's toenails were thickened, yellow, and trimmed short. During removal of the resident's socks, moderate amounts of dried yellow gray flakes of skin fell off both feet and onto bed sheets. R151 could not say when she last had her feet washed or nail care. At this time nurse manager, LPN G came into the room and observed R151's feet. During interview LPN G said that R151's family member had recently complained about the condition of the resident's feet. LPN G confirmed a podiatrist had recently been in to provide toenail care, and acknowledged the resident's feet still needed to be cleaned. LPN G said she would have a CNA (certified nursing assistant) come in and wash them. According to the Electronic Medical Record (EMR), R151 admitted to the facility in 2017 with diagnoses that included a stroke and cancer of the esophagus. The Minimum Data Set (MDS) dated [DATE] indicated R151 had 'intact cognition' with a Brief Interview for Mental Status (BIMS) score of 13/15. R151 was identified to require extensive assistance from one staff person for all activities of daily living which included personal hygiene and bathing. According to ADL care plan initiated on 11/30/2018; resident is to have her nails checked, and cleaned on bath day and as needed, resident is to received sponge bath when a full bath /shower can't be tolerated, and resident requires extensive assistance by 1 staff for all personal hygiene and oral care. According to the 'task' section in R151's EMR the resident's bath days are Thursday AM and Monday PM. In last 30 days R151 had two documented 'bed baths' on 6/16 and 6/23. On 6/22/22 at 1:38 PM R151 was observed in bed watching TV with 'non-skid' socks on her feet. R151's fingernails were ragged with brown/grayish debris around and underneath the nails. R151 said, they just cleaned my feet and gave permission to remove socks. Both feet had some dark gray-blackened flakes around and in between the toes. At this time LPN G came into the room. LPN G confirmed a CNA had just washed R151's feet, but the resident's bath day is tomorrow and will get a more thorough cleaning with fingernail care. On 6/23/22 11:04 AM and again at 3:42 PM R151 was observed in bed with non-skid socks on. During both observations R151's fingernails were ragged with brown/black debris underneath the nails and small/moderate amounts of dried flaky dark brown skin was observed on the top of the resident's feet and in between the toes. R23: On 6/22/22 at 11:18 AM R23 was observed in his bed with a long full beard and moustache. R23 was unable to verbalize but used hand gestures and nodded his head to make his needs known. During interview R23 indicated he wanted his beard and moustache shaved by nodding his head 'yes' and placing his left hand on beard. R23's feet were observed to have a significant amount of crusty dark yellow skin sloughing off his feet and between his toes. It was unclear when the resident had last had a shave or bath. According to the EMR, R23 admitted to the facility with multiple diagnoses that included a stroke resulting in aphasia (loss of ability to express/understand speech). The MDS dated [DATE] indicated R23 had a BIMS of 00/15 and that the resident was rarely understood. R23 required extensive assistance from 2 persons for personal hygiene which included shaving. A care plan for ADLs initiated on 12/12/2018 included the following intervention; Resident is totally dependent on one staff member to provide shower/bath and as necessary 2 time a week. According to the 'task' section in R23's EMR the resident's bath days are Wednesday AM and Friday PM. In last 30 days R23 had two documented 'bed baths' on 6/1/22 and 6/19/22. On 6/23/22 (Thursday) at 11:19 AM R23 was observed in his bed with a long full beard and moustache. At this time LPN G came into the room and confirmed that R23 had expressed he wanted a shave yesterday and did not get one. LPN G said she gave CNA M clippers and razors to shave R23 yesterday. On 6/23/22 at approximately 11:25 AM CNA M was interviewed via phone. CNA M said that R23 declined to be shaved yesterday and she did not do it. CNA M said she did not notify LPN G that R23 had declined to be shaved yesterday. On 6/23/22 at 11:35 AM LPN G asked R23 if he wanted to be shaved. R23 clearly indicated 'yes' by nodding his head and placing his left hand on his beard. LPN G said she would shave R23. During this time R23 allowed removal of his socks. Both of his feet had significant amounts of crusty dark yellow skin sloughing off his feet and between his toes. The resident confirmed he had a bed bath yesterday but did not get his feet washed. 06/24/22 at 11:14 AM R23 was laying in his bed cleanly shaved. R23 expressed happiness when asked about about getting shaved by nodding his head and giving a 'fist bump'. According to the facility's 'ADL- Activity of Daily Living' policy, last revised on 5/7/2020 Guidelines: In accordance with the comprehensive assessment, together with respect for individual resident needs and choices our facility provides care and services for the following activities: · Hygiene: Bathing, dressing, grooming and oral care · Our collaborative professional team, together with the resident and / or resident representative: 1. Will recognize and evaluate an inability to perform ADLs or a risk for decline in any ability to perform ADLs; 2. Develop and implement interventions in accordance with the resident ' s evaluated need, goals for care, preferences and will address the identified limitation in an ability to perform ADLs; 3. Monitor and evaluate the resident ' s response to care plan interventions and treatment; 4. Revise the approaches as appropriate

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision while activities of daily living (shower) was being rendered for one resident (R#139) of 4 residents reviewed for accidents/hazards/supervision, potentially resulting in a fall with injury. Findings include: On 6/22/22 at 11:45 a.m. R#139 was observed walking out of the shower room alone, wet, and naked. The resident was left in the shower room after receiving a shower by CNA S. R#139 was visibly upset as evidence by when asked if he was ok, he cried, No. The resident also looked afraid and confused. The resident proceeded to walk down the hall with unsteady balance when CNA T saw the resident and stated, Where's the aide. CNA T rushed towards the resident to assist him back into the shower room. CNA S suddenly appeared from down the hall with clothes in hand and stated, I was only gone for a minute to get him some clothes. CNA S also rushed to assist CNA T with getting the resident back into the shower room. On 6/22/22 at 11:13 a.m., review of R#139's clinical record documented the resident was admitted into the facility on 2/16/22 with diagnoses that included dementia, schizophrenia, and muscle weakness. According to the quarterly MDS assessment dated [DATE], R#139 was severely cognitively impaired (BIMS= 3) and required extensive one-person assistance with ADLs, particularly with bathing and hygiene. R#139 was also assessed for falls and had one fall (no injury) since admission. Review of the fall care plan dated 3/17/22 documented: The resident is at risk for falls related to impaired balance and gait, attempts of unassisted transfers and ambulation, wanders, poor safety awareness, and episodes of confusion. Interventions: Do not leave resident unattended in the bathroom. On 6/28/22 at 12:08 p.m. the Director of Nursing was interviewed and stated, He should not have been left by himself in there.

Based on observation, interview, and record review the facility failed to follow the standards of infection control (hand washing, glove use), during urinary catheter care for one resident (R7) of total sample of 39 residents, reviewed for infection control, resulting in the potential for cross contamination and the spread of disease to a vulnerable population. Findings include: Resident #7 During cathter care observation for R7 on 6/23/22 at 9:01 AM, Certfied Nurse Aide (CNA) D was observed washing her hands, donning gloves and wiped around urinary catheter with a wash cloth. CNA D then changed her gloves 2 additional times without washing hands between glove changes. CNA D then turned R7 toward her and wiped R7's buttocks. With the same contaminated gloves the CNA applied a barrier ointment and clean brief to R7. After applying the clean brief, CNA D then, with the same contaminated gloves, put a blanket and sheet on R7. At 9:55 AM, when asked, CNA D reported she was not aware she was suposed to perform hand hygeine between glove use. Review of an admission Record revealed, R7 was admitted into the facility on 6/18/20 with pertinent diagnosis which included neurogenic bladder, Supra Pubic Catheter, and history of urinary tract infections. Review of a Minimum Data Set (MDS) assessment, with a reference date of 12/19/21 revealed R7 had moderate cognitive impairment with a Brief interview for Mental Status (BIMS) score of 10, out of a total possible score of 15. Review of a physician order dated 3/28/2022 documented R7 was treated with an antibiotic for 7 days for a urinary tract infection. In an interview on 6/23/22 at 2:26 p.m., Director of Nursing (DON) B reported staff should perform hand hygeine between glove use and after resident care. DON B then reported hand hygiene inservices are provided to staff monthly. Review of an Infection Prevention and Control Guideline policy dated 11/28/17 revealed, Standard and transmission-based precautions to be followed to prevent the spread of infections .Hand Hygiene to be followed by staff with direct care, handling resident care equiment and the environment.

Based on observation, interview and record review the facility failed to ensure food was stored properly and meals served in a uniformed manner to residents, affecting all residents that received meals from the kitchen, resulting in the potential for food borne illnesses and unsatisfactory dining experience. Findings include: During observation of kitchen on 6/22/22 at 8:30 AM, in the storage room refrigerator the following items were observed. 1. One- block of mild cheddar cheese with open date of 5/11/22 and dispose date of 5/19/22 with green mold on sides. 2. 3- sandwich bags with orange American cheese not dated. 3. 3- sandwich bags with white American cheese not dated. During interview on 6/22/22 at 1:10 PM with Food Director E, it was confirmed that all food stored should be dated and thrown out on dispose date. Record review of policy provided by facility Food and Nutrition Services Sanitation and Food Safety (revised 2017, documented the following: .Labeling and Dating Foods. To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded.