**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly maintain residents' wheelchairs for two residents (R34 and R86), out of six residents reviewed for a safe and comfortable environment, resulting in resident discomfort and potential for the spread of harmful pathogens. Findings include: On 5/27/25 at 10:19 AM, R34 was observed asleep in bed. Both armrests of the wheelchair observed in R34's room were in disrepair. The covering on one armrest was severely frayed and only partially covered the foam underneath. There was no padding or covering on the other armrest which would result in the resident's arm positioned on bare metal. The covering on the back section of R34's wheelchair was partially missing exposing the foam underneath. On 5/27/25 at 12:51 PM, R86 was observed awake in her room sitting in a wheelchair. The covering on both armrests on R86's wheelchair were split and frayed, and the padding underneath was exposed. R86 said sometimes the armrests hurt her arms. On 5/30/25 at 10:41 AM, Therapy Manager (TM) F said managers do rounds on the residents and were to contact maintenance if a resident's wheelchair required repair. TM F stated, We have (wheelchair arm) replacement pads available. TM F added damaged wheelchair armrest pads should be replaced because it's more comfortable for the patient and the look is more appropriate. After observing R34 sitting in his wheelchair, TM F said one armrest was missing a cushion, the other armrest was worn out and needed to be replaced, and the back support was torn and needed to be replaced. After observing R86's wheelchair, TM F said both armrests were torn and did not have a smooth, solid surface. A review of the clinical record for R34 documented an initial admission date of 7/29/19 and readmission date of 5/23/24. R34's diagnoses included osteoarthritis, muscle wasting, difficulty in walking, and dementia. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment and the use of a wheelchair for mobility. A review of the clinical record for R86 documented an initial admission date of 4/23/21 and readmission date of 1/3/24. R86's diagnoses included atrial fibrillation, hemiplegia and hemiparesis affecting right dominant side, and difficulty in walking. A MDS assessment dated [DATE] documented intact cognition and the use of a wheelchair for mobility. On 5/30/25 at 1:31 PM, the Director of Nursing (DON) said the condition of R34's and R86's wheelchairs should have been seen by nursing and reported to maintenance for replacement. The cracked surface of the wheelchair armrest could cause bruising of the resident's skin. The DON added that it was an infection control issue because the cracked surface of the armrest could not be truly cleaned if exposed to bodily fluid. On 5/30/25 at 3:00 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information pertaining to this citation when asked.

Based on observation, interview, and record review, the facility failed to ensure that medications were administered in accordance to professional standards of practice for two (R12 and R17) of five residents reviewed for medication administration resulting in the potential for medication errors to occur. Findings include: On 5/28/25 at 8:28 AM Licensed Practical Nurse (LPN) C was observed to have two medications cups with pills inside stacked on top of each other on the medication cart. During inquiry LPN C said the medications were for two different residents, R12 and R17. R12's medication cup was on the top and R12's medication cup was underneath. LPN C said they were going to administer the medications to the residents and then sign them out because, It saves time to pull two resident's medications at the same time. Upon inspection of the medication cups it was determined that neither R12 or R17 had their entire 9:00 AM prescribed medications in the medication cups. LPN C said, I only put the packaged medications in the cups. Not the floor stock medications. LPN C acknowledged that this was not the standards of practice for medication administration and did not align with the facility's medications administration policy. At this time nurse manager, LPN B was present and asked about medication administration. LPN B replied, We should only pull one resident's medications at a time, administer the medication to that resident, and then sign the medications out. I don't know what is going on here. Observation of the medication cup identified to be for R12 revealed the following 8 pills in the cup: 1- folic acid 5 milligrams (mg) 5 tablets of 1 mg each 2- carbamazepine 200 mg 2 tablets 3- norco 5-325 mg 1 tablet According to the physician's orders and Medication Administration Record (MAR) the following medications were also prescribed for the 9:00 AM and not in R12's medication cup or prepared for administration: - aspirin 81 mg - calcium carbonate 600 mg - lactulose 30 milliliters (ml) - magnesium hydroxide 30 ml - artificial tears 1- 0.3% 1 drop each eye Observation of the medication cup identified to be for R17 revealed the following 7 pills in the cup: 1- tamsulosin 0.4 milligrams (mg) 1 capsule 2- chlorthalidone 25 mg 1 tablet 3- farxiga 5 mg 1 tab 4- hydralazine 50 mg 2 tabs 5- metformin 1000 mg 1 caplet 6- xanax .5 mg 1 tablet According to the physician's orders and Medication Administration Record (MAR) the following medication was also prescribed for the 9:00 AM and not in R17's medication cup; - aspirin chewable 81 mg 1 tablet On 5/27/25 at approximately 11:00 AM during an interview the Director of Nursing (DON) said, The nurse should prepare one resident's medication at a time. After administering those medications to that resident then sign them out. I don't know why someone would pull multiple resident's medications at the same time. It's not safe and doesn't follow the standards of practice. According to the facility's Medication Administration policy last revised on 10/17/2023 in part read: Residents medications are administered in an accurate, safe, timely, and sanitary manner. 4. Follow safe preparation practices. a- prepare medications immediately prior to administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that nail care was provided for one dependent resident (R107) of three reviewed for activities of daily living care (ADLs). Findings include: On 5/27/25 at 10:51 AM, 5/28/25 at 1:40 PM, and 5/29/25 at 12:14 PM, observations were made of R107's nails being one forth to one third of an inch above the tip of their thumb and multiple fingers. R107's nails were observed to be discolored with a light brownish appearance. R107 was interviewed multiple times about the length and appearance of their nails and did not respond to the surveyor's questions. On 5/29/25 at 12:16 PM, certified nurse assistant (CNA) A was interviewd and shown R107's nails. CNA A indicated that they needed to be trimmed and cleaned. On 5/29/25 at 12:31 PM, unit nurse manager/licensed practical nurse (UNM/LPN) B was interviewed about their expectations regarding nail care involving R107. UNM B indicated that they had noticed the condition of R107's nails yesterday and that the nurse working yesterday should have taken care of them. A review of R107's electronic medical record (EMR) under the Task section for the past thirty days of R107's ADL care revealed documentation which indicated that routine care was provided for the resident on a daily basis, including .Nail care. A review of R107's behavior for the past thirty days involving, Behavior Monitoring: resistant to care combative, grabbing revealed, twenty six out of thirty days which were documented as, None of the above observed and three days documented as, Not applicable. A further review of R107's EMR revealed that R107 was most recently admitted to the facility on [DATE] with diagnoses that included Dementia and Protein-calorie malnutrition. R107's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R107 had a severely impaired cognition and required maximum assistance to being totally dependent for their ADLs. On 5/29/25 at 1:29 PM, the Administrator (NHA) was interviewed regarding their expectations for nail care involving dependent residents. The NHA indicated that residents' nails should be cleaned and trimmed as needed. Refusals and/or resistance to care should be documented. A facility policy titled, Activities of Daily Living (ADL) Program Last Revised: 4/5/2024 stated the following, Purpose: ADL[s] may include, but are not limited to .grooming .Procedure: .A resident may benefit from [an] .ADL Program if .g. Residents who require extensive assistance with grooming .3. Determine specific tasks and areas of ADLs .Grooming may include x. Trimming nails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a physician ordered lab draw (Keppra level) was completed for one resident (R84) reviewed for lab results, resulting in R84's physician being unaware that the ordered Keppra level was not completed along with the potential for an abnormal Keppra blood level go undetected and untreated. Findings include: Review of R84's Electronic Health Record (EHR) revealed the resident re-admitted to the facility on [DATE] with multiple diagnoses that included Chronic Kidney disease and Epilepsy (seizures). According to the physician's orders on 4/11/25, R84 was prescribed Keppra 750 milligrams (mg) twice a day. On 4/24/25, R84 was ordered to have a Keppra blood level drawn. As of 5/27/25 there was no Keppra level results available and no progress notes to indicate a Keppra level had been drawn. Further review of R84's EHR revealed the resident had no seizure activity in the facility. On 5/27/25 at approximately 1:00 PM the Director of Nursing (DON) reviewed R84's EHR and said, It looks like the Keppra level was not drawn. I will reach out to the lab to determine where the Keppra level is. On 5/29/25 at 10:27 AM the DON said the Keppra level was not drawn by lab because the nurse did not put the order in correctly. The DON added the Medical Director will be notified and the Keppra level would be drawn immediately. The DON was asked for a policy for labs and said, We don't have a policy for labs or blood draws, but we do have one for following physician's orders. The Keppra level should have been done and followed up with by now. According to Drugs.com; Keppra (levetiracetam) is an anticonvulsant/antiseizure drug. Optimal response (therapeutic range) for levetiracetam is achieved with blood serum levels of 10.0 - 40.0 micrograms/milliliter (mcg/ml). According to Labtestsonline.org; Keppra (levetiracetam) does not require routine periodic monitoring, but levetiracetam test may be requested and reviewed to adjust the dosage as necessary. Review of the facility's Physician's Order policy last revised on 10/20/2023 in part reads; Physician orders are obtained to provide clear direction in the care of the resident. Treatment rendered to a resident must be in accordance with the specific standing, written, verbal, or telephone order of the a physician .

Based on interview and record review the facility failed to accurately document one resident's (R93) code status in the electronic medical record (EMR) out of six residents reviewed for advanced medical directives (AMD), resulting in the potential for R93's choices not being followed. Findings include: Record review of R93's information page in the EMR documented in the code status area that resident was a Full Code (resuscitation would be performed in the event resident had no heartbeat or breathing had stopped). Record review of R93's Do-Not-Resuscitate Order revealed, I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. Further review of form revealed resident had signed the document on 7/8/24, as well as R93's attending physician. An interview was conducted on 5/27/25 at 11:10 PM with R93, it was confirmed that the resident was a DNR (Do not resuscitate). Review of R93's EMR revealed admission into the facility on 7/8/24 with a pertinent diagnosis of a history of myocardial infarction (heart attack). Review of R93's Brief Interview for Mental Status (BIMS) dated 4/11/25, R93 scored 15 out of 15 (intact cognition). Review of Physician Orders dated 2/19/25 documented resident was a full code. Review of Physician Progress Notes dated 5/20/25, 4/22/25, 2/4/25, 12/24/24 documented CODE STATUS-DNR. An interview was conducted on 5/29/25 at 10:04 AM with Licensed Practical Nurse (LPN) K, it was reported in the event a resident had no heartbeat and breathing had stopped, LPN K would refer to the resident's information page under code status to confirm if resuscitation should be performed before proceeding forward with care. An interview was conducted on 5/29/25 at 10:20 AM with LPN C, it was reported in the event a resident had no heartbeat and breathing had stopped, LPN C would refer to the resident's information page under code status to confirm if resuscitation should be performed before proceeding forward with care. An interview was conducted on 5/29/25 at 10:22 AM with Unit Manager (UM) L, It was reported in the event a resident had no heartbeat and breathing had stopped the nursing staff should refer to the resident's information page and under code status before proceeding with care. It was further reported that R93's code status was changed when the resident had returned from a hospital stay on 2/19/25 in error, and the resident should have not been changed to a full code and remained a DNR per the resident's wishes. An interview was conducted on 5/29/25 at 12:12 PM with the Director of Nursing (DON), it was reported that nursing should consult the special instructions (information page) before proceeding with care. It was further reported that R93's EMR was marked inaccurately and R93 should have remained a DNR after returning to the facility on 2/19/25. The facility's policy Advance Directive-Michigan dated 7/6/23 documented, . A. Recognition of Resident Self-Determination. The Facility is committed to the promotion of the well-being of all our Residents. We recognize each Resident's right to refuse treatment, to live a dignified life, and to self-determination, which includes the right to refuse care and to formulate advance directives regarding future care.

Based on observation, interview, and record review, the facility failed to ensure an adequate supply of emergency food was available. Findings include: On 5/29/25 at 11:16 AM, an observation and interview regarding the facility's emergency food supply was conducted with Dietary Manager (DM) H. DM H provided a document titled, Emergency Planning Recommendations for your Facility which indicated in part the following: We suggest storing a minimum of a 3-day supply of non-perishable food on site. DM H agreed that non-perishable foods were shelf-stable (food stored at room temperature and able to last long periods without spoiling). This document included a disaster menu for Day 1, Day 2, and Day 3. The disaster menus for Day 1, Day 2, and Day 3 were compared to the shelf-stable food on hand. The following items were not available and not substitutable with other foods on hand: assorted 100% juices, high protein breakfast bars, shelf-stable milk, and canned potatoes. The following shelf-stable food items listed on the disaster menus were also not available but may, in an emergency, be substituted with other items that were on hand: green beans, chicken and dumplings, carrots, apricots, ham, green peas, pulled chicken, mixed vegetables, assorted sodas, and stewed tomatoes. On 5/30/25 at 1:56 PM, the Nursing Home Administrator (NHA) stated, We should have the correct amount of food for three days. In the future we will make sure we have what is exactly on the menu. On 5/30/25 at 3:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information pertaining to this citation when asked.

Based on observation, interview, and record review, the facility failed to: 1. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, meatballs, corned beef, baked beans, and diced potatoes; 2. Ensure the caulking of the hand washing sink was in good repair; 3. Store an ice scoop in a clean and sanitary manner; and 4. Properly date-label food stored in a resident refrigerator. These deficient practices resulted in the potential for food-borne illness for the residents that eat from the kitchen and residents that reside on the first-floor unit. Findings include: On 5/27/25 at 8:36 AM, the initial tour of the kitchen began with Dietary Manager (DM) H. The following was observed inside of the walk-in cooler: a pan of previously cooked meatballs dated 5/24, a pan of previously cooked corned beef dated 5/26, a pan of previously cooked baked beans dated 5/26, and a pan of previously cook diced potatoes dated 5/26. DM H said staff did not complete a cooling log for these previously cooked food items. On 5/28/25 at 12:39 PM, Certified Nurse Aide (CNA) J was observed passing ice water to residents on the first floor. CNA J was observed reaching into a portable ice chest, pulling out a scoop full of ice, putting the ice in a cup, and placing the ice scoop back in the chest with the ice. CNA J was not wearing gloves. When queried if the ice scoop should be stored inside the ice chest, CNA J said, I should have stuck it in the bin (located outside of the ice chest) to avoid contamination (of the ice). On 5/29/25 at 11:16 AM during a return visit to the kitchen, DM H said the cooks were responsible for storing previously cooked food in the cooler and were unaware of the correct procedures to cool cooked food. The caulking around the handwashing sink was observed to be missing. DM H stated, If water gets behind (the sink) bacteria could grow. When asked about the proper storage of an ice scoop, DM H said cross contamination could occur when you place the ice scoop handle on the ice. On 5/29/25 at 11:30 AM, the contents of the 1st floor resident's refrigerator were observed with DM H. The following items stored in the refrigerator were not identified with a resident's name: a disposable container of partially eaten stir fry, a 16.9 oz. bottle of carbonated beverage, an opened loaf of bread, an opened pack of sliced salami, an opened pack of sliced American cheese, and a disposable container of salad. A review of the policy titled, Food from Outside Sources, dated 11/12/21, documented in part the following: All food brought in is to be checked by the Nurse, Dietary Manager, or Dietitian. It must be placed in a sealed container and labeled for the content, the guest's/resident's name and date the food was received, and an expiration date of 3 days after food was brought in. It is recommended that only enough food be brought in for that visit. According to the 2013 FDA Food Code: Section 3-101.11, Safe, Unadulterated, and Honestly Presented, was reviewed and revealed, Food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented. Section 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: (E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not time/temperature control for safety food. Section 3-501.14, Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135ºF to 70°F; and (2) Within a total of 6 hours from 135ºF to 41°F or less. Section 4-501.11, Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. On 5/30/25 at 3:00 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information pertaining to this citation when asked.

Based on observation, interview, and record review, the facility failed to ensure consistent proper working order of the facility's walk-in freezer which had the potential to affect all residents that eat from the kitchen. Findings include: During the initial tour of the kitchen on 5/27/25 at 8:36 AM with Dietary Manager (DM) H, the internal temperature of the walk-in freezer was observed to be 9 ºF (Fahrenheit). A four-ounce cup of ice cream stored in the freezer was observed soft, not frozen solid. During a return visit to the kitchen on 5/29/25 at 11:16 AM with DM H present, the internal temperature of the walk-in freezer was 9 ºF. A four-ounce cup of ice cream stored in the freezer was soft, not frozen solid. The walk-in freezer door did not seal properly when closed. A noticeable gap was visible when the freezer door was closed which allowed cold air to escape. DM H stated, I never considered it (the freezer door not closing properly) being a concern because the meat was always frozen. We need to shop for a new freezer. On 5/30/25 at 1:56 PM during an interview, the Nursing Home Administrator (NHA) said they knew the freezer door needed to be replaced but had not started the process prior to this survey. A review of the 2013 FDA Food Code revealed the following: - Section 3-501.11. Stored frozen foods shall be maintained frozen. - Section 4-501.11. Food repair and proper adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. On 5/30/25 at 3:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information pertaining to this citation when asked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00149633. Based on interview and record review, the facility failed to notify the Resident Representative (RR) of a diagnosis of pneumonia and physician's order for an antibiotic for one resident (R101) out of three residents reviewed for change in condition Findings include: It was reported to the State Agency that the facility did not notify the RR about the resident's medical condition. A review of the clinical record revealed R101 was initially admitted to the facility on [DATE] and discharged from the facility on 1/16/25. R101's diagnoses included Alzheimer's disease, dysphagia, and adult failure to thrive. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. Additional review of R101's clinical record documented in part the following: 1. Change in Condition Evaluation of 1/15/25 at 12:21 PM: Resident feels hot to touch, resident temperature documented. Physician recommended chest x-ray. R101's RR notified on 1/15/25 at 12:33 PM. 2. Nursing progress note of 1/15/25 at 9:55 PM: Patient received resting in bed. No signs/symptoms of shortness of breath or any distress noted. No complaints of pain. Patient's chest x-ray and abdominal x-ray completed. Results reviewed with on-call medical doctor. Order for Doxycyline 100 mg (an antibiotic) twice a day for seven days. Diagnosis: pneumonia, related to chest x-ray results. 3. Physician order on 1/15/25 for Doxycyline hyclate, give one tablet by mouth two times a day for pneumonia During an interview on 2/3/25 at 12:37 PM, the Director of Nursing (DON) said she was aware that R101 had been diagnosed with pneumonia and had been prescribed an antibiotic. The DON explained R101's RR should have been notified about the new diagnosis and antibiotic order but had not been. A facility policy titled, Notification of Change, dated 2/14/24, was reviewed and revealed in part the following: -The facility must inform the resident, consult with the resident's practitioner; and notify consistent with his or her authority, the resident representative(s) when there is a change in status. Even when a resident is competent, his or her designated resident representative or family, as appropriate, should be notified of significant changes in the resident's health status unless the resident does not want the notification. - A change in status would include the following: -- A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). --A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). - The licensed nurse will document in the resident electronic medical record the notification and information that was provided, including any additional orders from the practitioner. On 2/3/25 at 2:05 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

Based on observation, interview, and record review, the facility failed to immediately notify the family of a change in condition and subsequent transfer to the hospital for one (R55) of three residents reviewed for notification of change. Findings include: On 04/04/24 at 10:00 AM an observation of R55's room revealed an empty bed and recliner chair. Upon inquiry, Licensed Practical Nurse (LPN) J reported that R55 was sent out to the hospital prior to the start of her shift. On 04/04/24 at approximately 11:29 AM R55's Family Member (FM) #1 was observed at the nurse's station asking where R55 was. LPN I told FM #1 the resident (R55) was transferred to the hospital and another family member (FM#2) was aware. At this time FM#1 said, No, you never told us. This has happened 2 or 3 times now. They do not tell us. FM #1 then called FM #2 on his cell phone to verify if FM#2 had been notified of R55's change in condition and subsequent transfer to the hospital. FM #2 over the phone said, No, they didn't tell us. We found out because we went up there to visit and she (R55) wasn't there. Then they told us she went to the hospital. On 04/04/24 at 11:30 AM, R55's Electronic Health Record (EHR) was reviewed. There were no progress notes for 04/04/24. There was no documentation to support R55's family members had been notified of the resident's change in condition or transfer to the hospital. On 04/04/24 at 11:42 AM, during an interview with Nurse Practitioner (NP) K said she ordered R55 to be transferred to the hospital for abnormal labs that required treatment in a hospital. NP K reviewed R55's EHR and confirmed there were no progress notes at this time. NP K could not say if R55's family member had been notified of the change in condition or transfer. During an interview with the Director of Nursing (DON) at 12:07 PM she said the facility's staff should have notified the family member immediately of the resident's transfer to the hospital. The DON reviewed R55's EHR and confirmed there was no documentation to support when R55 had been transferred to the hospital or that R55's family had been contacted. According to the facility's 'Transfer and Discharge' policy last revised 3/26/24, in part: Procedure: Emergency Transfer to Acute Care 1. When a resident is transferred on an emergency basis to an acute care facility, notice of the transfer is provided to the resident and the resident representative as soon as practicable.

Based on interview and record review, the facility failed to respond to concerns from residents about staff call light response times, resulting in dissatisfaction and unmet needs among 13 residents of 20 residents with the quality of care. Findings Include: On 4/4/24 at 1:55 PM a meeting was held with the members of the council. Residents presented concerns and dissatisfaction with call light response times. An anonymous resident commented about being told by staff to put a call light on before shift change because staff is busy. An anonymous resident gave an example of call light wait time explaining one day it took three and a half hours before a call light was answered. During the meeting of 20 residents, 13 residents raised their hands in response to the question of problems with call light response times. On 4/4/24 at 4:30 PM, record review of the Council Meeting Notes revealed on 3/19/24 a note was made stating in part, . (residents) discussed answering call lights not being answered in a timely manner. On 4/5/24 at 9:30 AM the Activities Director L was interviewed and the concerns about call light response time were discussed. Activities Director L indicated the process for resident council concerns voiced by council is for a pink form titled Resident, Family, Employee, and Visitor Assistance Form to be filled out by the Activities Director L after a meeting and then a follow-up is done with a department manager about the specific concern. Once the problem is resolved the person who made the complaint is informed of the outcome and asked to sign indicating if they are or are not satisfied with the response. Activities Director L showed five pink forms kept in a binder that had been completed within the last few months. None of the concerns listed on the forms addressed call light response times and the Activities Director L said the concerns mentioned in the 4/4/24 Resident Council Meeting had not been made known. Activities Director L said We address concerns immediately. On 4/5/24 at 3:23 pm, during quality assurance review, the Administrator reported being unaware or resident concerns with all light response times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00141524. Based on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin and unexpected death for one (R162) of two resident reviewed for abuse. Findings include: The State agency received a complaint that R162 was found expired in her room on the floor with an injury of unknown origin to the back of her head. A review of R162's closed Electronic Health Record (EHR) revealed that on [DATE] at approximately 7:45 AM the resident was observed laying on her left side on the floor in front of her bed and determined to be expired. There was no additional progress note or total body assessment that documented the condition of the resident's head or body. R162 was receiving palliative care (medical care focusing on pain relief) and had a 'Do Not Resuscitate' order. There was no Accident and Incident (A&I) report for [DATE] in the resident's EHR. On [DATE] at 11:22 AM the facility's 'Safety Coordinator' Licensed Practical Nurse (LPN) H was asked about R162's incident on [DATE]. LPN H said there was no A&I report or further documentation because the resident had expired. LPN H acknowledged that R162 was found on the floor and said, There was no A&I report to indicate that a fall occurred. So we don't know what happened. LPN H could not say with certainty if R162 had an injury to the back of her head. On [DATE] at 11:33 AM the Director of Nursing (DON) was asked about R162 being found deceased on the floor on [DATE]. The DON acknowledged that no investigation or A&I report had been documented. The DON said she had interviewed both the nurse and the CNA (certified nursing assistant) that day and started an investigation regarding R162' death, but there was no documentation to support that. The DON said, An investigation should have been completed for the resident (R162). It is in the facility policy. The DON could not say with certainty if R162 had an injury to the back of her head. At 2:15 PM the DON said she conducted a late investigation and made a late entry in R162's closed EHR. According to the facility's Abuse Prohibition Policy last revised on [DATE], in part: Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative. Definition: Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Injuries of unknown source - An injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person; and the source of the injury could not be explained by the guest/resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the extent of the injury, or the injury is located in an area not generally vulnerable to trauma), or the number of injuries observed at one particular point in time or the incidence of injuries over time.

Based on interview and record review the facility failed to ensure accurate information for transfer was communicated to the receiving hospital for one (R55) of two residents reviewed for discharges and transfers. Findings include: On 04/04/24 at approximately 10:00 AM Licensed Practical Nurse (LPN) J reported that R55 was sent out to the hospital prior to the start of her shift and was unaware of the circumstances that required R55 to be transferred to the hospital. On 04/04/24 at 11:30 AM, R55's Electronic Health Record (EHR) was reviewed. An order dated 4/4/24 at 7:27 AM indicated R55 was to be sent to the hospital for abnormal labs. A 'Transfer Form' dated 4/4/24 at 7:37 AM documented 'transfer details' that were dated 3/12/24 and indicated that R55 was sent out to the hospital for 'shortness of breath'. There was no corresponding progress note for 04/04/24 to indicate any additional medical information was provided to the receiving hospital. On 04/04/24 at 11:42 AM upon inquiry, Nurse Practitioner (NP) K said she ordered R55 to be transferred to the hospital for abnormal labs that required treatment in a hospital. NP K said the resident did not have shortness of breath. NP K reviewed R55's EHR and confirmed the 'Transfer Form' was inaccurate and there was no corresponding progress note to indicate the receiving hospital had the accurate reason for R55's transfer. NP K said she was in the process of documenting a progress note for R55 at this time. During an interview with the Director of Nursing (DON) at 2:43 PM she reviewed R55's EHR and confirmed the 'Transfer Form' dated 4/4/24 was inaccurate. The DON said the nurse who completed the transfer form dated 4/4/24 had just copied the information from a previous transfer form and could not explain why. The DON said, one-to-one education has been given to the nurse. According to the facility's 'Transfer and Discharge' policy last revised 3/26/24, in part: Procedure: Emergency Transfer to Acute Care: 4. A transfer form is completed, a list of medications and a copy of the care plan goals is sent to the receiving hospital. 5. Nursing documents the hospital transfer in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to apply splinting devices for two (R23 and R62) of eight residents reviewed for limited range of motion, resulting in the potential for increased joint contracture, loss of range of motion and increased pain. R23 On 4/03/24 at 10:39 AM R23's was observed in bed with left hand clenched into a fist. On 4/04/24 at 11:34 AM R23 was observed in bed with left hand clenched into a fist no carrot, or towel roll in hand. On 4/04/24 at 3:15 PM R23 was observed in bed with left hand clenched into a fist with no carrot or towel roll in left hand. Review of R23's Electronic Health Record (EHR) revealed the most recent admission to facility on 4/19/2022 with diagnosis that included Alzheimer's disease, diffuse traumatic brain injury, and hemiplegia and hemiparesis left side. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment and dependent for activities of daily living (ADLs). Review of R23's April Medication Administration Record (MAR) revealed hand roll to left hand in the day and off at night was applied on dates 4/1/2024 through 4/4/2024 by Licensed Practical Nurse (LPN) F. R62 On 04/03/24 at 10:15 AM R62 was observed in bed with both elbows bent, elbow braces on side table not worn by resident. On 4/04/24 at 10:25 AM R62 was observed in bed elbows bent, elbow braces not worn lying on side table in room. On 4/04/24 at 11:22 AM R62 was observed in bed elbows bent not wearing elbow splints. Review of R62's Electronic Health Record (EHR) revealed admitted to facility on 5/5/2023 with diagnosis that included chronic respiratory failure, contractures to right and left elbows, and traumatic brain injury. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment and dependent for activities of daily living (ADL). Review of R62's April MAR revealed elbow braces bilateral on 4 to 6 hrs daily on at 10 AM one time a day on at 10 AM off between 2 PM and 4 PM daily were applied on dates 4/1/2024 through 4/4/2024 by LPN F. On 4/4/2024 at 3:17 PM LPN F was interviewed regarding the application and removal of R62's elbow splints and R23's hand splint. LPN F said she did not apply R62's elbow splints or R23's hand splint this week but documented that she did apply them on the MAR for April 2024. LPN F agreed that R23 and R62's April MAR for splint application were not correct and that R23 and R62 did not have restorative splinting services this week. On 4/5/2024 at 1:52 PM the Director of Nursing (DON) was interviewed and said that there is not a restorative nurse or aide and that the floor staff apply splints to the residents. The DON agreed that R23 and R62 should have the restorative splinting program as ordered by the physician in order to prevent worsening of contractures. Review of the facility policy titled Restorative Nursing effective date 4/26/2022 revealed in part . The facility strives to enable the resident to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being. Nursing Restorative is available up to 6-7 times per week and is provided for residents meeting restorative program criteria.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to date a respiratory water bag for one (R62) of two residents reviewed for oxygen use. Findings include: On 4/03/24 at 9:57 AM, R62's water bag for tracheostomy oxygen humidification was observed in use with no date labeled on bag. On 4/04/24 at 8:15 AM, R62's water bag for tracheostomy oxygen humidification was observed in use with no date labeled on bag. On 4/4/24 at 1:14 PM, R62's water bag for tracheostomy oxygen humidification was observed in use with no date labeled on bag. On 4/04/24 at 1:47 PM Licensed Practical Nurse (LPN) H was interviewed and said the water bag is used to humidify the supplemental oxygen to R62's tracheostomy and should be dated so that staff are aware when it was last changed. On 4/05/24 at 1:51 PM the Director of Nursing (DON) was interviewed and agreed R62's water bag should be dated to ensure when the bag was initially used and changed. Review of R62's Electronic Health Record (EHR) revealed admitted to facility on 5/5/2023 with diagnosis that included chronic respiratory failure, tracheostomy, contractures to right and left elbows, and traumatic brain injury. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. Review of the facility supplied water bag manufacturer's guidelines revealed in part . Replace the water bag every 60 days or earlier if it becomes discolored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure complete and accurate documentation was maintained in an Electronic Health Record (EHR) for three residents (R23, R62, and R55) of 30 residents reviewed for accurate medical records resulting in inaccurate and incomplete medical records with inadequate care delivery. Findings include: R62 Review of R62's EHR revealed admitted to facility on 5/5/2023 with diagnosis that included chronic respiratory failure, contractures to right and left elbows, and traumatic brain injury. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment. Review of R62's April Medication Administration Record (MAR) revealed that elbow braces bilateral on 4 to 6hrs daily on at 10 AM one time a day on at 10 AM off between 2 PM and 4 PM daily were applied on dates 4/1/2024 through 4/4/2024 by Licensed Practical Nurse (LPN) F. R23 Review of R23's EHR revealed most recent admission to facility on 4/19/2022 with diagnosis that included alzheimer's disease, diffuse traumatic brain injury, and hemiplegia and hemiparesis left side. A MDS assessmnet dated 3/19/2024 documented severe cognitive impairement. Review of R23's April MAR revealed hand roll to left hand in the day and off at night was applied on dates 4/1/2024 through 4/4/2024 by LPN F. On 4/4/2024 at 3:17 PM LPN F was interviewed regarding the application and removal of R62's elbow splints and R23's hand splint. LPN F said she did not apply R62's elbow splints or R23's hand splint this week but documented that she did apply them on the MAR for April 2024. LPN F agreed that R23 and R62's April MAR for splint application were not correct. On 4/5/2024 at 1:52 PM the Director of Nursing (DON) was interviewed and agreed documentation should be accurate and complete to ensure that residents are getting proper care and treatments. R55 On 04/04/24 at approximately 10:00 AM Licensed Practical Nurse (LPN) J reported that R55 was sent out to the hospital prior to the start of her shift and was unaware of the circumstances that required R55 to be transferred to the hospital. On 04/04/24 at 11:30 AM, R55's Electronic Health Record (EHR) was reviewed. An order dated 4/4/24 at 7:27 AM indicated R55 was to be sent to the hospital for abnormal labs. A 'Transfer Form' dated 4/4/24 at 7:37 AM documented 'transfer details' that were dated 3/12/24 and indicated that R55 was sent out to the hospital for 'shortness of breath'. There was no corresponding progress note for 04/04/24 to indicate any additional medical information was provided to the receiving hospital. On 04/04/24 at 11:42 AM upon inquiry, Nurse Practitioner (NP) K said she ordered R55 to be transferred to the hospital for abnormal labs that required treatment in a hospital. NP K said the resident did not have shortness of breath. NP K reviewed R55's EHR and confirmed the 'Transfer Form' was inaccurate and there was no corresponding progress note to indicate the receiving hospital had the accurate reason for R55's transfer. During an interview with the Director of Nursing (DON) at 2:43 PM she reviewed R55's EHR and confirmed the 'Transfer Form' dated 4/4/24 was inaccurate. The DON said the nurse who completed the transfer form dated 4/4/24 had just copied the information from a previous transfer form and could not explain why. The DON said, one-to-one education has been given to the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two residents (R126 and R87) out of five residents reviewed for immunizations, were provided influenza vaccination and education resulting in the potential for the development and spread of influenza among vulnerable residents in the facility. Findings include: On 4/5/2024 at 11:00AM the Infection Preventionist (IP) A was interviewed and reported the following residents did not have documentation of a current influenza immunization or refusal: -Review of the Electronic Health Record (EHR) for R126 admitted on [DATE] with diagnosis of respiratory failure, heart failure. R126 did not have documentation to indicate that the influenza vaccine was offered or was contraindicated. -Review of the EHR for R87 revealed admitted on [DATE] with diagnosis of urinary tract infection and dementia. R87 did not have documentation to indicate that the influenza vaccine was offered or was contraindicated. On 4/5/2024 at 1:12 PM the Director of Nursing (DON) was interviewed and agreed both R126 and R87 should have been educated and offered the influenza vaccine. Review of the facility policy titled Immunization :Influenza (FLU) Vaccination of Guest/Residents revised 1/11/22 revealed in part . It is the policy of this facility that annually resident will be offered immunization against influenza, The vaccine program runs from early October through March 31st, every admission is screened using the criteria contained within the standing protocol and given the vaccine if indicated, after receiving education regarding the vaccine.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 142 residents who receive meal services (oral foods) out of the facility's total census of 153 residents. Findings include: In an observation on 4/3/24 at 11:23 a.m., Dietary [NAME] B touched a piece of cooked pork loin with bare hands while getting a temperature. Dietary [NAME] B picked up part of the pork loin and put it back in the pan without wearing gloves. CDM (Certified Dietary Manager) D instructed Dietary [NAME] B to put on gloves. In an observation on 4/3/24 at 11:24 a.m., Assistant [NAME] C removed gloves and did not perform hand hygiene before writing down temps in a book. In an observation on 4/3/24 11:50 a.m., Dietary [NAME] B removed gloves then walked to a drawer, opened it, and touched serving utensils. Dietary [NAME] B did not perform hand hygiene after glove removal. In an observation on 4/3/24 11:54 a.m., Dietary [NAME] B had gloved hands. Dietary [NAME] B removed gloves and walked to front of the kitchen and reported she was looking for buns. Dietary B did not immediately perform hand hygiene after removal of the gloves. In an observation on 4/3/24 at 11:56 a.m., Dietary Aide E removed gloves, walked in the walk-in cooler, and exited the walk-in cooler with ranch in hand. CDM D instructed Dietary Aide E to wash her hands. In an interview on 4/3/24 at 11:58 a.m., CDM D reported staff should wash their hands after removing gloves and gloves should be changed between tasks. CDM D reported staff should wear gloves when handling food. Review of the U.S. Public Health Service 2017 Food Code, Chapter 2-301.14 When to Wash directs that: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLEUSE ARTICLES and: and contamination and to prevent cross contamination when changing tasks; (H) Before donning gloves for working with FOOD; and (I) After engaging in other activities that contaminate the hands. Review of a Food Handling and Production policy revised 11/12/21 documented, It is the policy of this facility to comply with strict time and temperature requirements and use proper food handling techniques to prevent foodborne illness. Procedure . wash hands regularly . 9. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable utensils to avoid manual contact with prepared foods . Review of a Hand Hygiene policy revised 10/11/23 documented, hand washing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections. Hand hygiene should be performed after removing personal protective equipment (e.g. gloves, gown, facemask).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI139413 & MI140760. Based on interview and record review, the facility failed to (1) obtain authorization to manage personal funds (social security check), (2) properly manage a trust account, and (3) follow the guidelines to become the appropriate representative payee for one resident (R701) of three residents reviewed for resident rights, resulting in the resident and the family expressing anger and frustration of not having control over personal funds. Findings include: On 12/5/23 at 11:44 a.m. the complainant was contacted via telephone regarding the allegation of the facility taking R701's personal funds without permission. The complainant said R701 no longer resides in the facility and transferred to another facility due to owing the facility a large bill. The complainant also said the facility fraudulently became the resident's representative payee through social security to have all R701's money to come to the facility. The complainant became very angry and stated, How are they able to just take someone's money without their authorization. (R701) has other obligations to pay. Because they took all of the money, (R701) does not have a home to return to. The complainant also said the resident was overwhelmed by the situation and did not want to transfer to another facility to still have no home to return to. Review of the electronic clinical record documented R701 was initially admitted into the facility on [DATE] and readmitted on [DATE] from the hospital with diagnoses that included peripheral vascular disease and intraductal carcinoma in site of left breast (breast cancer). R701 was discharged to another facility on 11/10/23. According to the discharge Minimum Data Set assessment dated [DATE], R701 was cognitively intact (BIMS score of 15) and required total two-person assistance with most activities of daily living. Review of the face sheet revealed, R701 did not have a legal guardian and was their own responsible party for finances. On 12/5/23 at 1:27 p.m. the Business Office Manager (BOM) A was interviewed and said the facility became the resident's representative payee in June. The facility became the resident's representative payee due to not paying bills to the facility independently. The resident received social security benefits and a pension. The resident had a monthly patient amount set by Medicaid that was owed to the facility for the resident's care. The BOM A said the resident did not give written or verbal authorization to the facility to become the representative payee or to have any remaining money sent to a trust account, but discussions were had about both. BOM A stated, I thought once we became the rep payee that authorized us to open a trust account for the resident. Review of the form titled SSA787 Representative Payee revealed BOM A submitted the form to the government agency for reasons of: (R701) does not pay the monthly PPA (patient pay amount) owed to the facility . Review of the form titled Resident Trust Authorization documented: I BEEN INFORMED OF THE FACILITY RESIDENT TRUST FUND POLICY. I WISH TO PARTICIPATE IN THE RESIDENT TRUST FUND AND AGREE TO ALLOW THE FACILITY TO HOLD, DEPOSIT, DISBURSE, AND ACCOUNT FOR MY PERSONAL FUNDS AND TO PAY AMOUNTS OWED TO THE FACILITY OR MAKE OTHER PAYMENTS AS DIRECTED. This option was marked with an X, however R701 did not sign the document. The facility signed the form as Facility is Rep Payee dated 6/15/23 under the section that read LEGAL GUARDIAN, DPOA, RESPONSIBLE PARTY. Review of the same form that was signed and dated on 12/19/22 by R701 documented: I DO NOT WISH TO PARTICIPATE IN THE RESIDENT TRUST FUND. On 12/5/23 at 2:26 p.m. R701 was contacted via telephone. R701 stated, I did not give them permission to take my money. I didn't sign anything because I told them I had an apartment I had to pay for too when I get out of here. Now I don't have my apartment and have to stay in another nursing home. What they did was not legal. The facility did not submit any policies regarding personal funds. BOM 'A' said the corporation has a collection policy but did not submit it by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI139413 & MI140760. Based on interview and record review, the facility failed to obtain authorization to use resident funds (social security) for one resident (R701) of one reviewed for misappropriation of funds resulting in the facility use of resident funds for a five month period of time without the resident's consent. Findings include: On 12/5/23 at 11:44 a.m. the complainant was contacted via telephone regarding the allegation of the facility taking R701's personal funds without permission. The complainant said R701 no longer resides in the facility and transferred to another facility due to owing the facility a large bill. The complainant also said the facility fraudulently became the resident's representative payee through social security to have all R701's money to come to the facility. The complainant became very angry and stated, How are they able to just take someone's money without their authorization. (R701) has other obligations to pay. Because they took all of the money, (R701) does not have a home to return to. The complainant also said the resident was overwhelmed by the situation and did not want to transfer to another facility to still have no home to return to. Review of the electronic clinical record documented R701 was initially admitted into the facility on [DATE] and readmitted on [DATE] from the hospital with diagnoses that included peripheral vascular disease and intraductal carcinoma in site of left breast (breast cancer). R701 was discharged to another facility on 11/10/23. According to the discharge Minimum Data Set assessment dated [DATE], R701 was cognitively intact (BIMS score of 15) and required total two-person assistance with most activities of daily living. Review of the face sheet revealed, R701 did not have a legal guardian and was their own responsible party for finances. On 12/5/23 at 1:27 p.m. the Business Office Manager (BOM) A was interviewed and said the facility became the resident's representative payee in June. The facility became the resident's representative payee due to not paying bills to the facility independently. The resident received social security benefits and a pension. The resident had a monthly patient amount set by Medicaid that was owed to the facility for the resident's care. The BOM A said the resident did not give written or verbal authorization to the facility to become the representative payee or to have any remaining money sent to a trust account, but discussions were had about both. BOM A stated, I thought once we became the rep payee that authorized us to open a trust account for the resident. When the resident was discharged to the hospital, the remaining money in the account went the back balance. BOM 'A' said the facility did not obtain consent from R701 to enter a payment arrangement to pay a back balance. Review of the form titled SSA787 Representative Payee revealed BOM A submitted the form to the government agency for reasons of: (R701) does not pay the monthly PPA (patient pay amount) owed to the facility . Review of the form titled Resident Trust Authorization documented: I BEEN INFORMED OF THE FACILITY RESIDENT TRUST FUND POLICY. I WISH TO PARTICIPATE IN THE RESIDENT TRUST FUND AND AGREE TO ALLOW THE FACILITY TO HOLD, DEPOSIT, DISBURSE, AND ACCOUNT FOR MY PERSONAL FUNDS AND TO PAY AMOUNTS OWED TO THE FACILITY OR MAKE OTHER PAYMENTS AS DIRECTED. This option was marked with an X, however R701 did not sign the document. The facility signed the form as Facility is Rep Payee dated 6/15/23 under the section that read LEGAL GUARDIAN, DPOA, RESPONSIBLE PARTY. Review of the same form that was signed and dated on 12/19/22 by R701 documented: I DO NOT WISH TO PARTICIPATE IN THE RESIDENT TRUST FUND. Review of a letter dated 6/28/23 presented by BOM 'A' revealed the following: On behalf of the Nursing Facility, I would like to set up a payment agreement for the remaining balance owed to the Nursing Home. Please allow $40.00 to be paid each month toward your back balance each month. This will ensure the intentions of paying off your balance owed. Please sign and return the Business Office . This letter was not signed by R701. Review of a printed documented titled Trust- Transaction History, start date 5/1/23, end date 12/31/23 revealed the following: Resident Trust Account: 6/13/23 $1,635 was deposited, $1,620 was debited (Patient Payment to the Facility), leaving a balance of $15 left in the resident's trust account. On 6/30/23 there was an Interest balance of $15. On 7/11/23 $1,635 was deposited leaving a balance of $1,650. On 7/14/23 $1,640 (Patient Payment to the Facility) was debited from the account. A balance of $10 was left. On 7/26/23 the facility debited $10 from the account, leaving a balance of $0. On 8/8/23 there was a deposit of $1,635. On 8/17/23 the facility debited $1,605 (Patient Payment to the Facility) from the account, leaving a balance of $30. On 8/31/23 the facility debited $30 (Patient Payment to the Facility) from the account, leaving a balance of $0. On 12/5/23 at 2:26 p.m. R701 was contacted via telephone. R701 stated, I did not give them permission to take my money. I didn't sign anything because I told them I had an apartment I had to pay for too when I get out of here. Now I don't have my apartment and have to stay in another nursing home. What they did was not legal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the legal representative formulated an Advance Directive to grant and/or withhold life sustaining treatment (Cardiopulmonary Resuscitation/CPR, Artificial Nutrition/Peg Tube, Artificial Hydration/ IV, and Diagnostic Testing) according to their wishes upon admissions, quarterly review, and/ or significant change for 1 resident (R62) of 4 sampled residents reviewed for advance directives, resulting in the potenital for denial of the resident's right to have life sustaining or withheld decisions honored. Findings include: On [DATE] at 10:44 a.m. R62 was observed resting in bed. R62 was also observed to be nonverbal and unable to make needs known. On [DATE] at 10:07 a.m. review of the clinical record documented R62 was admitted into the facility on [DATE] with diagnoses that included encephalopathy and dementia. According to admission Minimum Data Set assessment dated [DATE] R62 was severely cognitive impaired, had no speech, and rarely was able to be understood and understand. R62 also required total care with two-person assistance with activities of daily living. Review of the clinical record also documented R62 had a court appointed legal guardian that went into effect on [DATE]. Review of the resident's advance directive that indicated a Full Code status dated [DATE] was signed by someone other than the legal guardian. On [DATE] at 10:11 a.m. Social Worker (SW) P was asked to identify the signature on the advance directive. SW (P) initially said she was unable to identify the signature then stated the resident signed the document. SW (P) was shown the current and active Letter of Guardianship. SW (P) agreed the legal guardian should have signed the advance directive. On [DATE] at 10:31 a.m. SW (P) presented an advance directive with the current legal guardian's signature dated for [DATE]. Review of the facility's policy titled Advance Directives Policy dated 11/2017 documented: .If the resident does not have the proper capacity to complete this form, a healthcare legal decision maker will be asked to complete the Code Status Form to the extent of their authority (as determined by the Advance Directive Policy). The Facility will assist the Healthcare Legal Decision Maker in understanding the extent of such person's authority to withdraw or withhold treatment of the resident and preferences consistent with such authority will be indicated on the form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive care plan for a prosthetic shrinker sleeve (an elastic sock made to control swelling, promote healing, and assist in shaping an amputated leg to fit an artificial leg) for one resident (R467) out of two residents reviewed for rehab services, resulting in no established goals and interventions related to shrinker sleeve use and the potential for a delay in rehabilitation. Findings include: During an observation and interview on 2/13/2023 at 4:19 PM, Resident #467 (R467) was awake and sitting in his bed. R467 verbalized a concern regarding the lack of progress and follow up he was experiencing regarding the use of his prosthetic leg. A prosthetic shrinker sleeve was observed on R467's bedside table. A review of the admission Record for R467 documented an admission date of 1/20/2020 and readmission date of 1/30/2023. R467's diagnoses included orthopedic aftercare following surgical amputation, type 2 diabetes mellitus, acquired absence of left leg above knee, and peripheral vascular disease. A Minimum Data Set assessment dated [DATE] documented intact cognition and lower extremity impairment on one side. During an interview on 2/14/2023 at 1:35 PM Physical Therapist and Therapy Manager (PT/TM) M said they are waiting for R467's staples to be removed before he can begin using a prosthetic leg. The prosthetist spoke with R467 last week and told him about the process and is coming back to obtain measurements. When queried about R467's shrinker sleeve, PT/TM M stated, (R467) should be using the shrinker sleeve now. I will check with his primary therapist to see what the schedule is for wearing it. PT/TM M said the Therapy Department lets nursing know what to put in the orders for wearing the shrinker sleeve. During an interview on 2/14/2023 at 1:49 PM, PT N said R467 received his shrinker sleeve last week Wednesday or Thursday and the resident puts it on every day. PT N stated, I saw him put it on. He's wearing it a few hours in the morning and afternoon. PT N said he did not document his observation of R467 wearing the shrinker sleeve. During an interview on 2/14/2023 at 1:53 PM, PT/TM M said a care plan should have been developed related to R467's use of the shrinker sleeve. PT/TM M indicated he will let nursing know that R467 should have a care plan developed for wearing the shrinker sleeve. During an interview on 2/15/2023 at 12:06 PM, the Director of Nursing (DON) said R467 should have a care plan for wearing the shrinker sleeve. The DON stated, There should be a care plan because resident care goes into the [NAME] so that my staff knows what to do to provide care. Nursing should have been informed. The facility policy titled, Care Planning, dated 6/24/2021, was reviewed and revealed in part the following: - In addition to care plans based on admission orders, goals for admission and desired outcomes, IDT assessments, physician orders, dietary needs, therapy services, social services, PASSAR recommendations, and discharge plans the baseline care plans are triggered in PCC from the Nursing Comprehensive assessment. - The care plan must be specific, resident centered, individualized and unique to each resident and may include: Involve and communicate the needs of the resident with the direct care staff (i.e. CNA [NAME]). Include treatments and interventions that are realistic and appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform nail care for one resident (R64) and provide timely incontinence care for one resident (R151) out of 31 residents reviewed for dependent activities of daily Living (ADLS), resulting in unkempt nails, body odor, and in the potential for skin breakdown and poor self esteem of the resident. Findings include: Resident #64 Record review of R64's face sheet revealed admission into the facility on [DATE] with a pertinent diagnosis of dementia. According to the Minimum Data Set (MDS) dated [DATE], R64 had impaired cognition and was provided extensive assist with most Activities of Daily Living (ADLS). During an observation and interview on 02/13/23 at 02:41 PM, R64 was observed in bed with long jagged fingernails with a buildup of dark brown debris on the underside of nails. Resident was asked if it was a preference to have long nails, R64 nodded yes. When asked if it was a preference to have nails clean, R64 said Yes. During an observation on 02/14/23 at 09:34 AM and on 2/15/23 at 9:35 AM R64 was observed with long jagged fingernails with a buildup of dark brown debris on the underside of nails. During an interview on 02/15/23 09:39 AM with LPN A, after and observation was made of the condition of R64's nails, it was confirmed that they were not clean. When asked if residents nails should be kept clean and free of debris, LPN A stated, Yes. During an observation and interview on 02/15/23 11:01 AM, Unit Manager (UM) B was asked should R64 receive nail care to remove the buildup of brown debris, UM B replied, Yes and further explained, It should be provided on shower days and whenever needed. UM B then asked R64 if it would be ok to clean her fingernails, R64 replied, Ok. During an interview on 02/15/23 11:15 AM with Director of Nursing (DON) when asked if all residents fingernails should be free of debris and kept groomed, DON, stated Yes. The DON was asked for a policy related to resident's nail care. However, the facility policy titled Personal Hygiene did not address facility residents. Resident #151 During the initial tour of the facility on 2/13/2023 at 10:43 AM, Resident #151 (R151) was observed asleep in her bed. R151's body was not covered with a sheet or blanket. A medium brown colored stain, which encircled R151's body underneath her brief, was observed on her sheet and a strong, lingering smell of urine was present. During an observation on 2/13/2023 at 11:24 AM, a return visit was made to R151's room. The medium brown colored stain remained on the sheet beneath her body and the strong, lingering smell of urine was still present. R151 remained asleep, however her torso had been covered with a hospital gown. During an interview on 2/14/2023 at 3:13 PM, R151 said she sleeps a lot and has to fight to stay awake to watch TV. A review of the admission Record for R151 documented an admission date of 10/14/2022 with diagnoses that included congestive heart disease, peripheral vascular disease, and contracture of muscle of right and left lower legs. An MDS assessment dated [DATE] documented intact cognition, total dependence upon staff for toileting, and extensive two or more persons assistance for bed mobility. A review of Certified Nurse Aide (CNA) task completion for 2/13/2023 revealed toilet use support was documented at 1:02 AM and 2:35 PM. During an interview on 2/15/2023 at 12:10 PM, the DON stated that the reference brown ring and urine smell would indicate that the resident had been soiled and been lying in urine longer than they should have been. The resident urinated and had been lying there for an extended period. On 2/16/2023 at 3:20 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement skin care treatments for 3 residents (R58, R74, and R135) of 3 reviewed for non-pressure related skin conditions resulting in discomfort, untimely wound care, and the potential for further harm to skin integrity and wound degradation. Findings include: Resident #58 On 2/13/23 at 11:38 a.m. R58 was observed resting in bed with heel protectors on both feet. Further observation revealed a white bandage dressing on the left foot covering the heal and ankle with a date of 2/10/23. On 2/13/23 at 3:22 p.m. review of the clinical record documented R58 was initially admitted into the facility on 2/21/22 and readmitted 10/2022 with diagnoses that included unspecified soft tissue disorder of pressure multiple sites and dementia. According to the quarter Minimum Data Set assessment (MDS) dated [DATE], R58 required total two-person assistance with activities of daily living. The assessment also documented R58 had a diabetic foot ulcer with application of dressings to feet as skin/ ulcer treatment. Review of the skin care plan dated 12/10/21 documented: At risk for further impaired skin integrity/pressure injury R/T: actual wounds; Intervention: Follow facility policies/protocols for the prevention/treatment of impaired skin. Review of the physician's orders documented: Wound care cleanse left heel with ns, apply calcium alginate with silver cover with Abd pad and Keflex every Tuesday, Wednesday, Friday, Sunday. Wound care orders 10/25/22. Review of February 2023 Treatment Administration Record (TAR) documented on 2/12/23 (Sunday) wound care treatment had not been administered. On 2/15/23 at 11:40 a.m. the Director of Nursing (DON) was and stated, I recognize there is a problem with treatment not being done on the weekends as instructed. The Wound Care Nurse is responsible for giving wound care. If my treatment nurse is not in, then the floor nurses are assigned to give wound care. Resident #74 On 2/13/23 at 10:35 a.m. R74 was observed in the room resting in bed. During the interview, the resident was observed repeatedly scratching chest, left hip, left leg, left side back area, and buttocks. R74 said the itching has been happening for about a month. The resident also stated, I itch all over. R74 said she was not getting anything to help with the itching The resident appeared irritated as she continued to scratch multiple areas during the interview. On 2/15/23 at 1:04 p.m. review of the clinical record documented R74 was admitted into the facility 8/7/17 with diagnoses that included chronic idiopathic urticaria (chronic hives (rash)). According to the quarterly MDS assessment dated [DATE], R74 had moderate impaired cognition and required limited assistance with activities of daily living. Review of physician's orders dated 9/25/22 documented: Eucerin lotion apply to skin topically one time a day related to idiopathic urticaria. Please give tube to patient for her to apply herself. Review of the physician's progress notes dated 2/9/23 and 1/23/23 documented the following: . positive itching, negative rash . medications: Eucerin lotion apply to skin topically one time a day related to idiopathic urticaria. The Medication Administration Record for February 2023 revealed: Eucerin Lotion (Emollient). Apply to skin topically one time a day related to IDIOPATHIC URTICARIA. Pls give tube to patient for her to apply herself was administered for the dates February 1st- 14th by nursing at 9:00 am daily. On 2/15/23 at 1:50 p.m., R74 gave permission for the bedside table drawer to be checked for the Eucerin lotion. There was no lotion in the drawers. The resident said she never received lotion for the itching to put on herself. On 2/15/23 at 1:54 p.m. The treatment cart was observed not to have Eucerin lotion. Nurse (A) also looked through the cart and stated, It looks like we are out of it. Nurse (A) was asked to identify the residents that used the lotion. Nurse (A) identified a resident different from R74. Nurse (A) was asked did she administer the lotion to R74. Nurse (A) stated, I don't think that resident has an order for that. On 2/15/23 at 5:15 p.m. the DON was interviewed and stated, The lotion is not a medication so it should be in house stock, and I will follow up with central supply. I will educate the nurses on following physician's orders again. On 2/15/23 at 5:27 p.m. the DON confirmed the lotion had not been ordered by the facility and had not been delivered by pharmacy. The DON stated, The resident indeed had not received it. Resident #135 During an observation and interview on 2/13/2023 at 1:30 PM, Resident #135 (R135) said he had sores on both legs and the dressing gets changed every other day. R135 stated staff did not change his dressing yesterday because it was the Super Bowl. The dressing on R135's right leg was dated 2/8/2023. The dressing on R135's left leg was undated. On 2/13/2023 at 1:43 PM, observations of R135's dressings and skin were conducted with Licensed Practical Nurse (LPN) C. LPN C noted the dressing on R135's right leg was dated 2/8/23 and the dressing on R135's left leg was undated. LPN C said R135's feet have very, very dry skin and there are dead skin particles on the bath blanket under his lower extremities. LPN C said there was yellow drainage on the bath blanket from the wound. LPN C said the skin on the bottom of R135's foot was dry and scaly. LPN C stated, I saw part of his dry skin that had pulled away but not fallen off. Physician orders for R135 were reviewed with LPN C and revealed there was an order for Ammonium Lactate Lotion 12%. Apply to bilateral feet topically two times a day for dry skin. LPN C said it did not look like the lotion had been applied to his feet. LPN C inspected the contents of the unit's medication cart and treatment cart and did not locate the prescribed lotion for R135. A review of the admission Record for R135 revealed an admission date of 1/9/2023 with diagnoses that included venous insufficiency and type 2 diabetes mellitus. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of R135's Treatment Administration Record for February 2023 documented the following: 1. Wound care cleanse right lateral calf with NS, apply medihoney to slough and betadine to granulated tissue, cover with abd pad + kerlix every day shift. Start date of 2/10/2023. The TAR reflected this dressing change was not performed on 2/10/2023, 2/11/2023, and 2/12/2023. 2. Wound care cleanse right shin with NS, apply betadine, cover with abd pad, kerlix every day shift. The TAR reflected this dressing change was not performed on 2/6/2023, 2/10/2023, 2/11/2023, and 2/12/2023. 3. Wound care cleanse left calf with NS, apply betadine, cover with abd pad + kerlix every day shift. Start date on 1/13/2023. The TAR reflected this dressing change was not performed on 2/6/2023, 2/10/2023, 2/11/2023, and 2/12/2023. During an interview on 2/16/2023 at 12:09 PM, the Director of Nursing (DON) said she was aware that over the weekend some dressings were not completed. The DON stated The wound coordinator communicated to the weekend nurses that they needed to do their own wound care. Some did and some did not. Review of the facility's policy titled Skin Management dated 7/14/21 documented the following: Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. On 2/16/2023 at 3:20 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was not.

Based on observation, interview, and record review, the facility failed to ensure the second floor ice machine was maintained in a safe and sanitary operating condition, resulting in the ice machine not being protected against contamination from sewage or other sources of contamination, potentially effecting all residents consuming ice from this machine. Findings include: During an observation and interview on 2/16/2023 at 12:43 PM with Maintenance Director D, the drain line from the second floor ice machine was observed to not have the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain). On 2/16/2023 at 3:20 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was not. 5-202.13: An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch.

Based on observation, interview, and record review, the facility failed to: 1. Remove expired, undated, unlabeled food from the kitchen walk-in cooler and resident refrigerators; 2. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, baked beans and BBQ ribs; 3. Properly seal frozen food items; 4. Ensure pans were clean and allowed to air dry before stacking and storage; 5. Ensure the use of beard guards of staff working in the kitchen; 6. Accurately document the walk-in freezer temperatures; 7. Ensure ladles were stored properly to prevent contamination; 8. Adequately clean kitchen surfaces; 9. Remove expired liquid nutrition supplements from active stock; 10. Properly store ice scoops in a sanitary manner; and 11. Properly clean in and around an ice machine. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On 2/13/2023 beginning at 9:48 AM, the initial tour of the kitchen was conducted with Dietary Manager (DM) E. During the tour, the following items were observed in the walk-in cooler: - a container of ham salad. Labeled with use by date of 2/11/2023 - an open pack of sliced ham - undated - The following previously cooked and cooled food items were observed in the walk-in cooler: a 1/2 pan of baked beans cooked on 1/25/2023 - which had been frozen, and a full pan of ribs cooked on 2/12/2023. When asked if there were cooling logs for the previously cooked food, DM E stated, We haven't started using those yet. We should have those. The following items were observed in the walk-in freezer not sealed and opened to the freezer air: a box containing approximately eight breaded cod patties, a box 1/3 full of catfish nuggets, and a box 3/4 full of fried egg patties. The following was observed in the clean pot and pan area: - one perforated full-size pan contained food debris and was nestled with clean pans - two pans, full size and 1/2 size, were wet and nestled with clean pans Dietary Aide (DA) F was observed moving about the kitchen wearing a face mask that did not fully and adequately cover his full beard. The temperature of the walk-in freezer was 0°F. A review of staff documentation of freezer temperatures from 2/1/2023 to 2/13/2023 ranged from 39 - 41°F. This document indicated the freezer temperature should be 0°F, and staff were to report abnormal temperatures to the dietary manager or dietitian immediately. DM E said staff were not completing this document correctly. On a return visit to the kitchen on 2/15/2023 at 3:00 PM, the following was observed: - Four ladles of varying sizes were observed hanging from a metal bar, bowl side up. DM E stated, Anything could fall and land right into it. - The handles to the double oven were soiled with grease and food debris - The vents above the double oven and grill contained visible grease. DM E stated, It (the cleaning) was half done. They didn't do a good job. On 2/15/2023 at 3:19 PM, afternoon [NAME] G was observed preparing sandwiches for dinner. [NAME] G was wearing a face mask that did not fully and adequately cover his full beard. During an observation and interview on 2/15/2023 at 11:03 AM with Licensed Practical Nurse (LPN) Unit Manager (UM) H, the following was noted in the resident refrigerator on the first floor: - the inside base of the refrigerator and the top shelving of the crisper drawers were soiled with food debris. - a deli meat and cheese sandwich, not labeled with a resident's name and date. - five disposable carry out food containers. UM H said these containers held staff food. - the refrigerator freezer contained a frozen apple pie not labeled with a resident's name. UM H stated it was probably staff. During an observation and interview on 2/15/2023 at 11:09 AM with LPN, UM I, the following was noted in the resident refrigerator on the second floor: - a bag with an opened date of 2/13/2023, but no discard date, contained an opened loaf of bread, opened pack of salami, and opened pack of sliced American cheese. - frost had built up in the refrigerator freezer to the point that the freezer door was unable to be closed. The refrigerator in the second-floor medication storage room contained three 8 ounce containers of liquid nutritional supplements dated January 1, 2023. UM I agreed the expired supplements were stored with the active stock. During an observation and interview on 2/15/2023 at 11:40 AM with LPN, UM B, the following was noted in the resident refrigerator on the third floor: - a 30 ounce opened tub of creamy tomato basil soup not labeled with a resident name or use-by-date. - a bag of food dated 2/13/2023 and labeled with two initials. UM B was unable to identify who the two initials referenced. The bag of food contained a bag of granola, bottle of orange juice, and two 8 ounce containers of yogurt. - a bag of food dated 2/15/23 contained chili and crackers. UM B said this bag belonged to a staff member. The refrigerator freezer contained a microwaveable meat and cheese turnover. UM B said this belonged to a staff member. During an observation and interview on 2/15/2023 at approximately 12:45 PM with LPN, UM J, the following was noted in the resident refrigerator on the North Wing unit: - two 8 ounce containers of a liquid supplement. One dated November 2022 and the other one dated October 2022. These items were stored with the active stock. - two resident bag lunches with use-by-date of 2/14/2023. Each bag contained a deli meat sandwich, juice, and graham crackers. An ice machine was located next to the North Wing refrigerator. The ice scoop was observed lying directly on the ice in the ice machine. During an observation and interview on 2/16/2023 at 12:43 PM with Maintenance Director D, the following was noted regarding the second-floor ice machine and the surrounding area: - at least six disposable cup lids were on the floor behind the ice machine - the flooring surface underneath and behind the ice machine was soiled with accumulated and encrusted dust and dirt debris - the outer covering of the second-floor ice machine was noted to be scratched, missing, and peeling off. - A metal plate inside of the ice machine, identified by Maintenance Director D as a stainless steel deflector, was stained with a substance that was burnt orange/rust in color. When a damp paper towel was used to wipe off the burnt orange/rust substance, Maintenance Director D stated it was a concern and added, I didn't think it would wipe off that easily with a little bit of water. Maintenance Director D said the cup lids need to be thrown away, the floor needs to be swept and mopped, and germs can get underneath the peeling ice machine covering. During an interview on 2/16/2023 at 12:23 PM, the Director of Nursing (DON) stated, We have a breakroom in the basement for staff food. Staff are aware that their food should not be in the (resident's) refrigerator. Regarding the expired liquid nutrition supplement, the DON stated, It was expired and needed to be discarded. During an interview on 2/16/2023 at 1:51 PM, DM E stated, Everything should be labeled and dated. DM E said food should have the following: arrival date, opened date, and use by date. DM E indicated cleaning and maintaining resident refrigerators was a function of dietary staff. The unlabeled food and expired food should have been thrown out. Regarding bearded staff, DM E stated, They should wear a beard cover. A review of the facility policy titled, Food Purchasing and Storage, dated April 2015, revealed the following: - The temperature of all refrigerators and freezers will be checked and recorded daily on the temperature logs (Refrigerator Log DOP 507.02 and Freezer Log DPO 507.03). Elevated temperatures will be brought to the attention of the Dietary Manager or Dietitian immediately. - Leftover foods should be put in the Refrigerator in shallow pans (2-4 inches deep) so the interior temperature of the food chills quickly to 41°F. - All food items in refrigerators will be properly dated, labeled, and placed in containers with lids, will be wrapped, or stored in sealed food storage bags. - All frozen food will be dated, labeled and wrapped or sealed. Moisture-proof, tight-fitting materials will be used to prevent freezer burn. A review of the facility policy titled, Refrigerator and Freezer Maintenance, dated April 2015, revealed the following: - The Dietary Manager or Dietitian is responsible to schedule routine cleaning and defrosting of refrigerators and freezers. According to the 2013 FDA Food Code: Section 2-402: Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. 3-304.12 In-Use Utensils, Between-Use Storage. (E)In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not time/temperature control for safety food. 7-204.12 (43) In-use utensils properly stored: .Ice scoops may be stored handles up in an ice bin except for an ice machine. 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135ºF to 70°F; and (2) Within a total of 6 hours from 135ºF to 41°F or less. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 4-602.13, Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation includes two deficient practice statements. Deficient Practice #1. Based on observation, interview, and record review, the facility failed to maintain three resident rooms (101, 116, and 120) reviewed for the environment, resulting in an unsafe and an unclean environment. Findings include: During environmental observations, the following was noted: On 2/13/23 at 10:02 am, in room [ROOM NUMBER] a telephone jack wires were observed to be exposed out side of the wall socket and a flap of wallpaper was lifted exposing dry wall on the bottom left corner of the PTAC (portable terminal air conditioning unit). On 2/13/23 at 11:08 am, a 3x3 crack in the vinyl flooring exposing a cement slab was observed on the left side R71's bed in room [ROOM NUMBER]. Further investigation of the crack on the floor reveaked it to have rough, ragged edges. On 2/13/23 at 11:50 am, in room [ROOM NUMBER] the bathroom sink was observed to have rust in the sink bowl and rust running in a downward direction from the overflow drain hole. On 2/13/23 at 11:52 am, R35 was interviewed and stated, I wash myself up in this sink everyday. On 2/16/23 at 10:04 am Maintenance Director (MD) D was queried and said he did not know that there was crack in R71's room, exposed wires and peeled wallpaper in room R65's room, and rust in the sink in R35's room. MD D stated, We are supposed to do rounds periodically in the building to check for maintainence issue. On 2/16/23 at 11:41am the Nuring Home Administrator (NHA) explained that maintainence does rounds and the environmental issues should have been fixed. The NHA said that the environmental concerns that were identified during the survey were safety concerns. A review of a policy titled Maintainence Department dated 8/17/21 revealed, The department will do on-going monitoring of the facility for areas needing repair and, if needed, will report to the supervisor for approval of repairs needed. Deficient Practice #2 Based on observation, interview, and record review, the facility failed ensure the kitchen walk-in milk cooler maintained the temperature of fluid milk at or below 41°F, resulting in the increased potential for food borne illness for all residents that consume milk from the kitchen. During an observation on 2/13/2023 at 11:30 AM, the temperature of an eight-ounce carton of milk on the kitchen serving tray line was 47°F. The temperature of a carton of milk still inside the walk-in milk cooler was obtained and determined to be 45°F. During a test tray observation with Administrative Assistant (AA) O on 2/14/2023 at 9:32 AM, the temperature of the milk on the lunch tray registered at 56°F During an interview on 2/15/2023 at 3:10 PM, Dietary Manager (DM) E said a repair technician came out and looked at the walk-in milk cooler. DM E stated, The cooling man said there was a leak somewhere. DM E said they removed the food out of the walk-in milk cooler and stored it in the other walk-in cooler. On 2/16/2023 at 3:20 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not. A review of the facility policy titled, Refrigerator and Freezer Maintenance, dated April 2015, revealed the following: - It is the policy of this facility to maintain refrigerators and freezers at the proper temperatures and functionality. According to the 2013 FDA Food Code: 3-501.16 , Potentially Hazardous Food, Hot and Cold Holding, revealed, Except during preparation, cooking, or cooling, potentially hazardous food shall be maintained at 135 degrees F or above or at 41 degrees F or less. Section 4-501.11, Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00130414. Based on observation, interview, and record review the facility failed to provide adequate supervision during toileting while in bed for one (R526) of three residents reviewed for falls, resulting in R526 falling out of the bed during the removal of a bedpan. Findings include: On 12/2/22 at 11:00 AM R526 was observed in her bariatric-sized bed (larger bed used to support weight challenged residents) watching TV. During interview, R526 said, They dropped me when they took me off the bedpan and I've had back pain since then. R526 could not recall when she was dropped out of bed. According to R526's Electronic Medical Record (EMR) she admitted to the facility on [DATE] with multiple diagnoses that included morbid obesity, osteoarthritis, and schizophrenia with mild cognitive impairment. A progress note dated 7/1/22 at 5:38 PM documented, Resident was on the bedpan and when turned too far, rolled off the bed falling to her knees on the floor. On 7/3/22, R526 had a MRI (magnetic resonance imaging) of the spine that reported there was no fracture. According to the Minimum Data Set (MDS) assessment dated [DATE], R526 required extensive assistance with two persons for bed mobility and transfers. Review of the 'Incident and Accident report' dated 7/1/22 revealed the following, Assigned Certified Nursing Assistant (CNA) G was assisting resident off the bedpan and resident turned too far and rolled off the bed onto her knees on the floor. The bed is too small for the resident. It was noted that R526 only had one staff person assisting her with bed mobility and transferring off the bedpan. On 12/2/22 at 1:30 PM the Administrator confirmed that R526 was assessed to require two staff persons for bed mobility and transfers from surface-to-surface and there was only one staff person during this transfer that resulted in the resident rolling off the bed and onto the floor. The Administrator said the facility did change R526's bed to a larger, bariatric sized bed and updated her care plan accordingly.