**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00150156. Based on interview and record review, the facility failed to ensure appropriate information was communicated to the receiving hospital for one resident (R105) out of five residents reviewed for transfer. Findings include: It was reported to the State Agency that the facility failed to transfer a resident to the hospital with pertinent medical information. An anonymous complainant reported that the EMTs (Emergency Medical Technicians) that transported R105 to the hospital were only provided a piece of copy paper with the resident's name, date of birth , physician's name, and facility's medical record number for the resident written on it. A review of the clinical record for R105 documented an initial admission date of 8/15/24 and readmission on [DATE]. R105's diagnoses included dementia, unspecified psychosis, and delusional disorders. A Minimum Data Set assessment dated [DATE] documented the resident had severe cognitive impairment. A review of progress notes documented in part the following: - 2/9/25 at 9:09 PM. Transfer to hospital summary: Patient was transported to hospital per doctor order for abscess on left upper back. Patient was transported by ambulance on stretcher with two ems staff. Patient family member were notified. - 2/9/25 at 11:02 PM. Patient returned from hospital after upper back abscess drainage and packed with gauze. Patient was assessed .Patient is prescribed Bactrim DS (double strength) 800mg-160mg bid (twice daily) for 7 days. Patient Doctor and family member were notified. call light within patient reach and bed in low position. Staff monitor patient. On 2/20/25 at 12:16 PM, Unit Manager, Licensed Practical Nurse (LPN) D said when a resident is transferred to the hospital a transfer (eINTERACT) form should be completed. This form is given to the receiving institution because it includes proper information to ensure there is no lapse in service. On 2/20/25 at 12:55 PM, Unit Manager, LPN E said prior to transferring a resident to the hospital, if it's not an emergency, the nurse should gather information. The nurse is to use the eINTERACT form to document the resident's information. This form is printed and sent with the resident along with the face sheet and medication list. On 2/20/25 at 2:02 PM, the Acting Director of Nursing (ADON) said the procedure for transferring a resident to the hospital, in a non-emergency situation, included the completion of the eINTERACT form and sending it to the hospital with the resident along with the resident's face sheet and copy of the resident's medication list. The ADON reviewed R105's clinical record and confirmed there was no transfer form (eINTERACT) completed regarding R105's transfer to the hospital on 2/9/25. The ADON could not provide documentation to support the receiving hospital had received any information about the resident's transfer. On 2/20/25 at 3:25 PM, the Nursing Home Administrator (NHA) said the facility should send resident information to the hospital. A review of the policy titled, Transfer and Discharge, dated 2025, documented in part the following: For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: - Contact information of the practitioner who was responsible for the care of the resident; - Resident representative information, including contact information; - Advance directive information; - All other information necessary to meet the resident's needs, which includes, but may not be limited to: -- Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; Diagnoses and allergies; Medications (including when last received); and Most recent relevant labs, other diagnostic tests, and recent immunizations. - All special instructions and/or precautions for ongoing care, as appropriate such as: Transmission-based precautions such as contact, droplet, or airborne; - All other information necessary to meet the resident's needs, which includes, but may not be limited to: Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; Diagnoses and allergies; Medications (including when last received). - For a transfer to another provider, ensure necessary information (as listed above) is provided along with, or as part of, the facility's transfer form. On 2/20/25 at approximately 4:20 PM during the exit conference, the NHA had nothing else to add or provide pertaining to this deficient practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness (MI)/ Intellectual Disability (ID)/ Related Conditions Identification (DCH-3877) document was completed and sent to the local state agency for an evaluation for a Level II determination for one (R1) of six residents reviewed for PASSARs, resulting in R1 not being screened for mental disorder or intellectual disability care needs and the potential for R1's care needs being unmet. Findings include: According to R1's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included bipolar disorder and schizophrenia. R1 admitted with the following psychoactive medications prescribed: - Duloxetine 60 mg (milligrams) QD (every day) for depression. - Sertraline 50 mg QD for obsessive compulsive disorder and depression. On 9/4/24 the Social Work (SW) progress notes documented the resident admitted with bipolar disorder, schizophrenia, and was prescribed psychotropic medications. There was no PAS/ARR DCH-3877 form in the resident's EHR. There was no documented evidence that R1 was screened for MI/ID or related conditions health care needs. There was no documented evidence that R1 was evaluated for a Level ll determination of MI/ID health care needs. On 10/09/24 at 11:26 AM Social Worker (SW) B reviewed R1's EHR and confirmed there was no DCH-3877 form. SW B said, It was missed. No we don't have one. The hospital did one and the resident may be exempt. SW B reported that R1 was going to be discharged back to her group home, but there were no progress notes to indicate R1 had discharge planning in progress. On 10/9/24 at 12:45 PM SW B presented a paper copy DCH-3877 form for R1 that indicated the resident had hospital exemption criteria. The form was incomplete and did not include a physician name, address, phone number, or physician signature. SW B presented a second paper copy DCH-3877 form for R1 that indicated a level l screening had occurred a the facility on 8/30/24. The form was incomplete and did not include the clinician's signature, address, or phone number. According to the facility's policy for Behavioral Health Service last revised on 7/8/24 in part reads; It is the policy of this facility that all residents receive necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. 2. The facility utilizes a comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. This process includes: . b. PASSAR screening.

Based on observation, interview, and record review, the facility failed to apply hand splinting as ordered for two (R18 amd R81) of five residents reviewed for Range of Motion (ROM), resulting in a potential loss of ROM to dependent residents with known contractures and the potential for decline in overall health status. Findings include: R18 On 10/08/24 at 9:54 AM, R18 was observed in the hallway propelling their wheelchair with their left hand. R18's right hand fingers were curled into the palm. R18 was asked if they could open their right hand and they said, No. I had a stroke and my fingers are stuck this way. R18 was asked if they had a splint and the resident said, They (staff) don't always put it (splint) on. On 10/09/2024 AM at 08:46 AM, R18 was observed in their room sitting in a wheelchair. R18's right hand was wrapped with a white kerlix dressing while holding an Adaptive utensil. R18 was asked why their hand was wrapped. R18 said it wrapped so that they could hold their fork. A review of R18's electronic medical records noted readmission of 1/19/2024 with the diagnosis of Hemiplegia and Hemiparesis (hemiplegia is a severe or complete loss of strength, while hemiparesis is a relatively mild loss of strength) following a Cerebral Infarct (cerebral infarction occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it.), Congestive Heart Failure (occurs when the heart can't pump enough blood to meet the body's needs), Anxiety, Glaucoma (eye Condition), Muscle Wasting (the decrease in size and wasting of muscle tissue), Stiffness of right elbow, Right Hand Contracture (the decrease in size and wasting of muscle tissue), and Type II Diabetes. R18's Brief Interview for Mental Status (BIMS) noted a score of 10 out of 15 that indicated a moderate cognitive impairment dated 7/30/2024. R18's Minimum Data Set (MDS) noted the resident required substantial/Maximum assistance with Activity of Daily Living. A review on R18's care plan noted the following, I have a right-hand contracture .Goal-To prevent further contracture in (their) right hand while maintaining ROM and flexibility .Interventions-Apply right hand splint palm protector every day .Notify Physician of refusals. R18's electronic medical records did not indicate the R18's refusal of wearing a splint. A review of R18's Occupational Therapy documentation noted a goal of the following: Patient will safely wear right hand resting hand splint during daily tasks .Dated 5/14/2024. A review of R18's electronic medical record indicated Order Details of: Restorative Nursing: To manage and wear splint every day for joint mobility .Dated 10/03/2024. R81 On 10/08/24 at 09:51 AM, R81 was observed in bed with their eyes closed. R81 did not answer to their name being called. R81 was wearing a gown. There was a wheelchair next to R81's bed. R81 was not wearing a splint. On 10/08/24 at 11:05 AM, in bed with eyes closed. R81 was asked how they were doing. R81 said, I'm alright. R18's right hand fingers were curled into their palm R81 was not wearing a splint. On 10/09/2024 at 09:10 AM, R81 was observed watching TV. R81 asked if they could open their hand and responded no. R81 asked if they wore a splint on their right hand and arm which they responded no. The Resident's right arm was slightly bent upward toward their chest at the elbow joint, and R18's right hand fingers remained curled into their palm. On 10/09/24 at 11:00 AM, R81 was observed in bed, receiving a bed bath. After their bath, Certified Nurse Assistant did not apply R81's splint. Certified Nurse Assistant (CNA) D was asked they were going to apply R81's splint. CNA D looked in the drawers and closet and said it was not in (R81) room and they would check with therapy. A review of R81's electronic medical records noted readmission of 5/14/2024 with the diagnosis of Renal Calculous, Chronic Fatigue, Heart Disease, Myocardial Infarct (heart attack), Kidney Failure, Depression, Hemiplegia and Hemiparesis (hemiplegia is a severe or complete loss of strength, while hemiparesis is a relatively mild loss of strength) following a Cerebral Infarct (cerebral infarction occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it.), Cerebrovascular Disease (stroke), and Muscle weakness. R18's Brief Interview for Mental Status (BIMS) noted a score of 10 out of 15 that indicated a moderate cognitive impairment dated 8/21/2024. R81's The Minimum Data Set (MDS) noted the resident required substantial/Maximum assistance with Activity of Daily Living. A review of the electronic medical record noted Order Details of: Restorative Nursing: To manage Contractures, Resident to donn (sic) right hand resting hand splint and right elbow extension splint everyday .Dated 06/10/2024 A review of R81's Occupational Therapy documentation noted a goal of the following: Patient will tolerate R [right] elbow extension splint .Patient will tolerate right resting hand splint .dated 08/15/2024 On 10/10/2024 at 11:14 AM, the Therapy Manager E was interviewed and asked about R18 and R81's ordered splints, and he said, They are both supposed to wear splints. On 10/10/2024 at 2:12 PM, the facility Nursing Home Administrator (NHA) was interviewed regarding expectations for staff applying ordered splints to residents with known contractors. The Administrator stated, We expect staff to apply the residents' ordered splints. A review of the facility's policy entitled, Restorative Nursing Programs dated October 2023 noted, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level .3. Nursing personnel are trained on basic, or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but is not limited to .e. Assisting residents in adjustment to their disabilities and use of any assistive devices.

Based on observation, interview, and record review the facility failed to establish a record of receipt, disposition, or reconciliation of controlled drugs (a drug that the government regulates for possession and use, i.e. narcotics) in the facility's back-up box (secured storage unit of controlled drugs), resulting in the facility being unable to account for the receipt of, disposition of, or discrepancies of controlled drugs in the facility's back-up box with the potential for drug diversion and controlled drugs being unavailable to administer to residents as prescribed. Findings include: On 10/08/24 at 3:36 PM the facility's back-up box designated for controlled drugs was observed to have a red plastic lock on it. There was no medication log or any documentation to record what medications were in the back-up box. There was no reconciliation log to determine receipt of, administration of, or disposition of any medication in the medication room. The interim Director of Nursing, Registered Nurse C was present during the observation of the back-up box. RN C said, We don't have a reconciliation log. It was accidentally locked inside this medication cart and nobody knows where the keys are. RN C pointed to a locked medication cart that was inside the medication storage room next to the back-up box. RN C left the room to get the current Director of Nursing (DON). At approximately 3:45 PM the current DON entered the medication room and confirmed there was no reconciliation log for any of the controlled drugs in the back-up box. The DON said, I just got here and there was no lock on the back-up box. I just put the red plastic lock on it before you came in here. I can't determine what medications have been taken out or administered at this time. I have no idea if there are discrepancies. Both RN C and the DON acknowledged that there was no way to determine what medications have been removed from the back-up box. Neither RN C or the DON could determine how long the medication cart had been locked without a key. RN C found some pharmacy slips that were illegible. There was no way to determine resident's name, the drug removed from the back-up box or which nurse removed the drug. On 10/9/24 at 9:03 AM the facility's back-up box for controlled drugs was observed to have a green plastic lock on it. There was no reconciliation log. The medication cart inside the medication room remained locked without ability to open it. There were no pharmacy slips or receipt that pharmacy had delivered medications to the facility. The DON was present and during interview could not determine if pharmacy had delivered any medications to the facility. The number to the facility's pharmacy was requested. On 10/8/24 at 9:30 AM and 3:30 PM the pharmacy number was called and a message was left requesting a return call. There was no return call from the facility's pharmacy prior to the end of the survey. According to the facility's Medication Storage policy (undated) read in part: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 2. Narcotics and Controlled Substances: a. Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. b. Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in refrigerator. c. Any discrepancies which cannot be resolved must be reported immediately as follows: i. Notify the DON, charge nurse, or designee and the pharmacy; ii. Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted; iii. The DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy, and possibly the State Licensure Board for Nursing Home Administrators. a. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00143461. Based on interview and record review, the facility failed to ensure resident's medical record accurately documented the administration of prescribed medications for one resident (R101) out of three residents reviewed for medical record documentation, resulting in the potential for staff and providers lacking accurate information to care for the resident. Findings include: A review of the admission Record for Resident #101 (R101) documented an initial admission into the facility on [DATE]. R101's clinical record documented multiple readmissions and discharges, including a readmission on [DATE] with a discharge on [DATE], a readmission on [DATE] with a discharge on [DATE], and finally a readmission on [DATE] with a discharge on [DATE]. R101's diagnoses included foreign body of alimentary tract, unspecified intestinal obstruction, specified eating disorder, non-suicidal self-harm, schizoaffective disorder, anxiety disorder, and bipolar disorder. A Minimum Data Set (MDS) dated [DATE] documented intact cognition. On 3/28/24 at 4:45 PM, an interview and record review were conducted with the Assistant Director of Nursing (ADON) and MDS Coordinator, Licensed Practical Nurse (LPN) I. A review of R101's Medication Administration Record (MAR) for March 2024 revealed the following: 1. An order for one 50 mg tablet of Briviact (used for seizure disorder) given twice daily at 9:00 AM and 9:00 PM was entered on the March 2024 MAR twice. Nursing documented that 50 mg of Briviact was administered twice at 9:00 AM from 3/1/24 through 3/10/24 and twice at 9:00 PM on 3/2/24, 3/3/24, 3/5/24, and 3/8/24. 2. An order for one 500 mg tablet of metformin (used for blood sugar management) given twice daily at 9:00 AM and 9 PM was entered on the March 2024 MAR twice. Nursing documented that 500 mg of metformin was given twice at 9:00 AM from 3/1/24 through 3/11/24 and twice at 9:00 PM on 3/2/24, 3/3/24, 3/5/24, 3/6/24, and 3/8/24. 3. An order for 50 mg topiramate (use for seizure disorder) given twice daily at 9:00 AM and 9:00 PM was entered on R101's March 2024 MAR twice. Nursing documented that 50 mg of topiramate was administered twice at 9:00 AM on 3/1/24 through 3/11/24 and twice at 9:00 PM on 3/2/24, 3/3/24, 3/5/24, 3/6/24, and 3/8/24. 4. An order for 40 mg pantoprazole sodium (used for gastroesophageal reflux) given at 9:00 AM was entered on R101's March MAR twice. Nursing documented that 40 mg pantoprazole sodium was administered twice at 9:00 AM on 3/1/24 through 3/19/24. The ADON and LPN I said when R101 was readmitted to the facility on [DATE], and the previous medication orders had not been discontinued, nursing should have discontinued the old orders, verified the new orders, and put the new orders in. If there were any questions about the medications, the doctor should have been called for clarification. This is a standard of practice for nursing. During an interview on 3/29/24 at approximately 8:45 AM, MDS Coordinator, Registered Nurse (RN) J said when a resident goes to the hospital and does not return within 24 hours, the resident's medications should be discontinued by nursing. A review of the facility policy titled, Documentation in Medical Record, dated 1/29/24, revealed in part the following: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. A review of the facility policy titled, Medication Administration, dated 1/29/24, revealed in part the following: Correct any discrepancies and report to nurse manager. On 3/29/24 at 11:15 AM during the exit conference, the Nursing Home Administrator was 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 repair an unattached closet door for one resident (R905) of three residents reviewed for environment, resulting in resident dissatisfaction with the living environment and concern over protection of personal belongings. Findings Include: On 3/7/24 at 10:10 AM, R905 was observed pointing at the closet door reserved for R905's belongings. The door was off the hinges and in front of the open closet. The closet items were visible. R905 expressed unhappiness with the condition of the closet door and the exposure of personal belongings. The resident said having the door unattached was upsetting because anyone could come inside the room and see and take personal belongings. The resident stated My Coca Cola was taken. R905 also said the door had been in this condition since his admission, date of, 1/15/24 (over two months). Review of the clinical record of R905 admitted [DATE] according to the MDS (Minimum Data Set) dated 1/22/24 documents that resident has intact cognition. Resident is able to make all needs known independently. On 3/7/24 at 10:50 AM, LPN (Licensed Practical Nurse) B was asked about the condition of the door. LPN B explained she had not noticed R905's closet door was missing. LPN B acknowledged that R905 should have a functional door for the closet. On 3/7/24 at 3:40 p.m. the Nursing Home Administrator (NHA) was interviewed and said daily rounds are made by the Maintenance Supervisor. The facility is working to get (Tels) back. Maintenance does not have a check list to use for repairs needed. We are currently working on replacing furniture however I was unaware of the closet prior to today. On 3/7/24 at 4:30 PM the Maintenance/Services Log Sheet was reviewed for dates 2/24/24 - 3/8/24. There was no entry for the broken closet door in R905's room. Review of the facility policy titled, Accommodation of Needs dated January 2024 states in part, The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom and the common living areas within the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI142286 and MI141954. Based on observation, interview, and record review, the facility failed to maintain a clean bathroom and comfortable water temperatures for one resident (R902) and failed to maintain a clean bathtub (in a tub room commonly used by residents for toileting) to include R905, resulting in dissatisfaction with facility cleanliness and resident comfort. Findings Include: On 3/7/24 at 10:10 AM R905, was interviewed and expressed dissatisfaction with the cleanliness of the facility, specifically mentioning the tub room, I won't go in there now. Review of the clinical record of R905 admitted [DATE] according to the MDS (MDS (Minimum Data Set) dated 1/22/24 documented that resident has intact cognition. Resident is able to make all needs known independently. On 3/27/24 at 10:25 AM, an observation of the tub room revealed a dry dark green, thick substance covering the area just above the drain for an area approximately the size of a dollar bill and extending side to side across the entire surface of that section of the tub. Splattered dark green areas and streaks of of dark green and brown splatter were observed throughout the tub extending top to bottom. On 3/7/24 at 10:59 AM, Housekeeper E was queried about the condition of the tub. During the observation of the tub Housekeeper E said the tub had been in the stained and uncleaned condition at least two weeks. Housekeeper E said attempts had been made to scrape the substance off. On 3/7/24 at 11:17 AM the Maintenance Supervisor (MS) A said the condition of the tub had been unknown to the department of maintenance. On 3/7/24 at 3:40 p.m. the Nursing Home Administrator (NHA) was interviewed and said daily rounds are made by the Maintenance Supervisor and Housekeeping Supervisor. The NHA added that Housekeeping has a check list they are to utilize for cleaning. R902 On 3/7/24 at 9:37 a.m., a complaint that was submitted to the state agency's complaint hotline on 1/8/24 at 16:55 (4:55 pm) was reviewed. The complainant who was also the resident (R902) alleged the facility did not have hot water and was not clean. Review of the clinical record documented R902 was admitted into the facility on [DATE] and discharged from the facility on 12/28/23. According to admission MDS assessment dated [DATE], R902 was cognitively intact and required supervision with ADLs. On 3/7/24 at 11:59 p.m., the bathroom sink in room [ROOM NUMBER] was observed with a single handle sink fixture. When the fixture was turned on, it was loose at the base. The hot water was turned on and ran with a low stream. The longer the water ran, the slower the stream became to nearly a slow drip. The water did not get warm. The cold water was turned on and ran with a steady stream. Further observation of the bathroom revealed dried, dark-colored solid material on the seat of the toilet. There was also a painted shelf-like board over the top of the toilet that was unevenly cut and exposed ragged edges. The wall near the base board had missing patches of paint. On 3/7/24 at 12:09 p.m. the binder for maintenance work orders was located at the nurse's station. There were no entries in the binder for room [ROOM NUMBER]. Review of the document titled Maintenance/Environmental Services Log Sheet for the month of December 2023 did not document a work order or repairs in room [ROOM NUMBER]. On 3/7/24 at 3:05 p.m. Maintenance Supervisor A was interviewed about the bathroom's disrepair and said maintenance rounds are completely every morning. The facility no longer utilizes the electronic maintenance data base (Tels) that would notify when repairs are required for residents. Maintenance Supervisor A acknowledged the bathroom water in room [ROOM NUMBER] should not have a slow drip, should be running, and supplying hot water along with the other general repairs. On 3/7/24 at 3:40 p.m. the Nursing Home Administrator (NHA) was interviewed and said daily rounds are made by the Maintenance Supervisor. The facility is working to get (Tels) back. Maintenance does not have a check list to use for repairs needed. The facility's policy titled Environmental Services Safety Procedures dated January 2024 was reviewed but did not document daily maintenance procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00140622. Based on interview and record review the facility failed to inform the resident representative for R901 of a change in condition out of three residents reviewed for hospitalization, resulting in R901's representative being unaware of a change in condition and transfer to the hospital. Findings Include: During an interview on 11/15/23 at 12:45 PM with Concerned Family Member A, it was reported that R901 was sent to the hospital on [DATE] and the facility did not make the family aware. Record review of Nursing Progress Notes dated 10/22/23 noted the following: Writer spoke with Dr (name redacted), regarding resident having diarrhea, and decreased appetite, patient is malaise (with discomfort). Resident stated he feels very ill. Resident requested to go to hospital. Dr (name redacted) gave order to send resident out, ADON (Assistant Director of Nursing) notified. Further record review revealed no documentation that a resident representative was made aware of the resident's change in condition and transfer to the hospital. Review of R901's face sheet revealed resident was admitted into the facility on 7/6/23 with a diagnosis of transient paralysis (part of the body's muscle control comes and goes periodically). According to the Minimum Data Set (MDS) dated [DATE], R901 had intact cognition and required extensive assistance with Activities of Daily Living (ADLS). During an interview on 11/15/23 at 1:15 PM, R901 verbalized that it was expected that the facility would have called a family member when he was sent to the hospital. In an interview on 11/15/23 at 2:45 PM, the Director of Nursing reported that nursing staff did not contact family when R901 went out to the hospital on [DATE]. In an interview with the Nursing Home Administrator on 11/15/2023 2:50 PM, it was reported when a resident has a change in condition and is transferred to the hospital a resident representative should be informed. Record review of policy Notification of Change (no date) noted the following: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R67 On 8/28/2023 at 8:43 a.m., R67 's room was observed with multiple pair of pants and sweaters folded on a wheelchair next to the bed, multiple pair of shoes on bedside table, pants and sweater stacked on pillows, towels and wash clothes hanging at the foot of the bed, and a bag of clothes on the bed against the wall. R67 's privacy curtain was observed with clothes, hats, towels, and wash cloths hanging on hangers from one end of the privacy curtain to the end. During an interview, R67 said the closet was too small to hold all the clothes and no one had offered any other accommodations to store clothes. R67 also said the staff sees the clothes all over the room every time they walk in but never offered to help put the clothes away. On 8/312023 at 231 p.m., during an interview, Nursing Home Administrator (NHA) said the resident supposed to have an armoire for their clothes, and the facility is talking about where the patients can keep their clothes and things. The NHA stated, We might have to buy some extra dressers long as it doesn't interfere with other resident's space. Their clothes should not be on the curtains. According to the EHR, R67 was admitted to the facility on [DATE] with diagnoses of heart failure, and chronic obstruction pulmonary disease. R67's annual Minimum Data Set (MDS) with a reference date of 8/11/2023 indicated R67 was cognitively intact with a BIMS (brief interview for mental status) score of 15. Review of the ADLS care plan-initiated date of 9/26/2022 revealed, R67 has the potential for a decrease ADLS assistance related to the diagnosis of heart failure, and generalized weakness .Anticipate resident's needs every shift and accommodate accordingly . This ciations pertains to Intake numbers MI00137230 and MI00137425. Based on observation, interview, and record review the facility failed to maintain a clean and homelike environment by providing storage space to put personal belongings in and remove trash and food off the floor for two residents (#33, #67) reviewed for safe, clean, comfortable homelike environment resulting unsanitary living conditions and the opportunity for missing personal items. Findings include: Resident #33 On 8/28/23 at 9:02 a.m. during the initial pool process, upon entering R33's room there were flies in the room landing on the resident's bed and privacy curtain. Upon further entrance, a pile dried food (noodles and vegetables), a dried red liquid, and plastic cup lids were observed on the floor from the night before. R33 was observed in the bed and asked what happened to the floor. The resident stated, It was an accident. I knocked my tray on the floor. They won't clean it up because I knocked it on the floor by mistake. It happened last night. Further observation of the room revealed broken blinds and a missing armoire (closet). There were two in the room, however there were three residents in the room. Neither belonged to R33. R33 was asked where his closet was. R33 stated, They didn't give me one. Prior to entering the room, a nurse and a nurse aide were observed going into the room. After leaving out of the room the nurse was observed going into the room then said to the nurse aide in the hall to get housekeeping to the clean the floor. On 8/29/23 at 1:16 p.m. review of the clinical record documented R33 was admitted into the facility on [DATE] with diagnoses that included schizoaffective disorder, delusional disorders, and atrial fibrillation. According to the quarterly Minimum Data Set assessment dated [DATE], R33 was cognitively intact and required total two-person assistance with activities of daily living (ADLs). Review of the ADL care plan dated 1/12/23 documented, Resident has impaired ability to complete ADL care and needs assistance related to impaired mobility . Intervention: Anticipate and meet the resident's needs. Assist resident with meals for adequate intake. On 8/31/23 at 3:15 p.m. Unit Manager J was interviewed about the missing armoire and the cleaning of the room. The Unit Manager said the aides are to clean up spills and pick up trash in the rooms. Housekeeping is responsible for deep cleaning and sanitizing the rooms. The Unit Manager reported not being aware the resident did not have a armoire in the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes #MI00137110 and MI00137114. Based on interview, and record review, the facility failed to timely investigate and submit to State Agency reports of abuse for 4 residents (R385, R536, R537, R2) out of 23 sampled residents for abuse resulting in the potential for further allegations of abuse to not be investigated timely. Findings include: R385 Review of the medical record revealed R385 was a [AGE] year old male resident admitted to the facility on [DATE] with diagnoses including postlaminectomy syndrome, abnormalities of gait, and low back pain. Review of the facilities incident report dated 4/20/23 revealed Resident reported to the administrator that he was jumped on by staff on midnight shift. When asked if he could explain what they did to him he expressed that they did like they did to him for 32.5 years that he was locked up. On the night he spoke off the staff at the facility had called the police because of (name of R385's) aggressive behavior; cursing at staff and threatening that he was going to beat them up. Police came to the building and interviewed (name of R385). Investigation on this matter has started. Review of the facilities investigation report dated 5/15/23 revealed On the day he reported that he was abused by staff; upon further interview the resident stated that a rhino and snake have been fighting him all night, when asked if he could describe who was beating him up he could not stay on topic. He wanted to talk about boxing or his military father. Interview with staff revealed that the previous night the resident was verbally abusive and had cornered staff at the nurses station until the police came to the building. Upon seeing the police the resident was calm and did not continue with his aggressive behavior. The detective made the decision to leave (name of R385) in the facility. A psychological evaluation on the resident indicated that the resident was delusional and was not able to stay on topic with the evaluator. He also kept interrupting the session by yelling for staff on the hallway. (Name of R385's brother) who is the support person for his brother planned to take him home after therapy and physician clearance, which occurred on 4/23/2023. Through interview with staff and the resident facility concludes that the allegation of abuse could not be substantiated. In an interview with the Nursing Home Administrator (NHA) on 8/31/23 at 1:45 PM revealed allegations of abuse should be reported within 2 hours to the State Agency and investigations should be reported by 5 days. The NHA agreed the investigation report for R385 was reported almost a month late. R537 Review of an admission record revealed, R537 admitted to the facility 8/27/22 with pertinent diagnosis which included Urinary Tract Infection (UTI) and Bacteremia (bacteria in the blood). Review of a MDS assessment, with a reference date of 9/13/22 revealed R537 was independent with cognition and required limited assistance with one staff for transfers and locomotion on the unit. Review of the Incident form provided to State Agency (SA) revealed the following details about the incident: Occurred on 10/3/22 Discovered on 10/7/22 Reported to SA on 10/17/22 Review of an Investigation Summary/Actions Taken with a date of 10/17/23 revealed, . On 10/07/2022 the facility was notified by hospital staff that resident had alleged that (R537) was roughed up and beaten at the facility and that (R537) did not fall . In an interview on 8/29/23 at 2:06 p.m., the NHA acknowledged R537's allegation of abuse was not reported to the SA within a two hour timeframe. Review of a Abuse, Neglect and Exploitation policy with a revised date of 7/25/23 revealed, It is the policy of this facility to provide protections for the health, wealth, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property . 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services . a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .

Based on interview and record review, the facility failed to develop a dialysis and activity daily living (ADLS) baseline care plan for one (R9) of one residents reviewed for baseline care plans, resulting in the potential for unmet needs of ADLS and dialysis care. Findings include: On 8/28/2023 at 10:28 a.m., R9 dialysis shunt dressing was observed with no date. Facility Staff confirmed later R9 gets dialysis at the facility and the shunt dressing get changed on dialysis days. According to the electronic medical record (EMR), R9 was admitted into the facility on 6/12/2023 with diagnoses of end stage renal disease, fluid overload, proteinuria (Protein in the urine), anemia, secondary hyperparathyroidism of renal origin, hypertension, hyperkalemia (high potassium level), diabetes mellitus type two, chronic diastolic heart failure, peripheral vascular disease, and major depressive disorder. R9's admission Minimum Data Set (MDS) assessment with a reference date of 6/18/2023 indicated R9 was cognitively intact with a BIMS (brief interview for mental status) score of 15/15, required extensive assistance of one person with bed mobility, required limited assistance of one person with transfers, toileting, and ADLS with impairment on both sides of the lower limbs. The Physician's orders revealed R9 received dialysis on Mondays, Wednesday's and Fridays located in the basement of the facility. Further review of the EMR revealed no ADLS and Dialysis care plans. On 8/31/2023 at 12:57 p.m., reviewed the EMR with the Administrator and the Director of Nursing (DON) confirmed there was no ADLS or Dialysis care plans for R9 observed. A request was made to the DON for hard copies of the ADL and the Dialysis care plan for R9. A hard copy of R9's ADLS and Dialysis care plan were brought to the conference room with the initiated date of 8/31/2023. In an interview, on 8/31/2023 at 2:31 p.m., the DON stated, The admitting nurse should put care plans in the resident's medical record at first and the MDS nurse does the comprehensive care plans. Every resident should have a baseline care plan starting. According to the facility's undated Baseline Care Plan policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: -1. a. The baseline care plan will be developed within forty-eight hours of a resident 's admission. b. Include the minimum healthcare information necessary to properly care for a resident .

This citation pertains to intake MI00137425. Based on observation, interview, and record review, the facility failed to ensure medication was administered timely and accurately per physician's orders for three residents (#30, #40, #284) of six residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not administered properly. Findings include: Resident #30 In an observation on 8/28/23 at 7:28 a.m. Licensed Practical Nurse (LPN) G prepared medication for Resident #30 (R30). LPN G placed a Ibuprofen (pain reliever) in the medication cup. LPN G then entered R30's room and administered the medication. In an observation and interview on 8/28/23 at 7:28 a.m. LPN G documented the medication administration in the MAR (Medication Administration Record). LPN G reported the MAR screen was red because R30's medications were late. Review of an admission record revealed, R30 admitted to the facility 12/10/14 with pertinent diagnosis which included Pain and Benign Prostatic Hyperplasia (BPH) Review of Physician orders revealed R30 had orders for 6:00 a.m. administration which included, IBU (Ibuprofen)Tablet 600 MG (milligram) Give 1 tablet by mouth every 8 hours for ble (bilateral lower extremities) pain. Resident #40 In an observation on 8/28/23 at 7:33 a.m. LPN G prepared medication for R40. LPN G placed a three pills (Pantoprazole, Phenytoin and HYDROCO/APAP-narcotic pain reliever) in a mediation cup. LPN G then entered R40's room and administered the medication. LPN G exited the room and documented the medication administration. Review of an admission record revealed, R40 readmitted to the facility 7/6/21 with pertinent diagnosis which included Pain in Right Foot and Gastro-Esophageal Reflux Disease (GERD). Review of Physician orders revealed R40 had orders for 6:00 a.m. administration which included, Pantoprazole (treats stomach ulcers) give 40 mg by mouth one time a day, Phenytoin (treat and prevent seizures) give 200 mg by mouth one time a day, HYDROCO/APAP 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for pain. Resident #284 In an observation on 8/28/23 at 8:54 a.m. LPN H prepared medication for R284. LPN H placed four pills in a medication cup which included Colace 250 mg. LPN H entered R284's room and administered the medication. LPN H exited the room and documented the administration. Review of an admission record revealed, R284 readmitted to the facility 8/18/23 with pertinent diagnosis which included Vascular Dementia and Type 2 Diabetes. Review of Physician orders revealed R284 had an order for Colace (Docusate Sodium) give 100 mg by mouth two times a day. Review of the MAR for 8/28/23 revealed LPN H documented the administration of Colace 100 mg. In an interview on 8/28/23 at 11:55 a.m. LPN H reported Colace 250 mgs (more than 2 x's what the physician ordered) was given instead of 100 mg because R284 is always constipated. In an interview on 8/29/23 at 1:59 p.m., the Director of Nursing (DON) reported the nurse must follow Physicians orders and give the ordered dose or call the physician for an order change. The DON reported medications should be administered one hour before or after scheduled time. Review of Medication Administration policy with a revised date of July 2023 revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 10. Review MAR to identify medication to be administered . 11. Compare medication source with MAR to verify . b. Administer within 60 minutes prior to or after scheduled time unless ordered by physician .

Based on observation, interview and record review the facility failed to ensure proper storage of insulin and disposal of expired insulin in one of two medication carts reviewed during inspection of medication carts, resulting in the potential for residents to receive expired medications with altered potency and efficacy. Findings include: In an observation on 8/28/23 at 7:48 a.m., a medication cart on the 1 South unit had undated and expired insulin which included: 1 Humalog Pen 3 Levemir Pens 5 Novolog Pens 3 Novolog vials, 1 vial dispensed on 6/18/23 and 1 vial with a open date of 7/25/23 1 Levemir vial 1 Humalog vial In an interview on 7:52 a.m., Licensed Practical Nurse (LPN) I reported insulin should have an open date when put it in the medication cart. LPN I then reported insulin expires in 28 days. In an interview on 8/28/23 at 11:46 a.m., the Director of Nursing (DON) reported insulin should be dated when opened and put in the cart. DON reported insulin expires 28 days after being in the cart. Review of an Medication Storage policy with a revised date of July 2023 revealed, It is the policy of this facility to ensure all medications housed on out premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations . Review of an Administration of Insulin policy with a revised date of July 2023 revealed, It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition . 6. Store unopened pens in a refrigerator 7. Once opened, clearly labeled insulin may be stored at room temperature in a locked medication cart. 8. Insulin should be disposed of after 28 days or according to manufacturer's recommendation. 9. Insulin must be dated by the nurse when opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00133617. Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) effectively maintain the food production kitchen physical plant effecting 80 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 08/28/23 at 06:57 A.M., An initial tour of the food service was conducted with Registered Dietetic Technician (DTR) C and Dietary [NAME] F. The following items were noted: The #1 hand wash sink hot and cold-water supplies were observed switched. The hot water supply was observed on the right-hand side and the cold-water supply was observed on the left-hand side. The cold-water supply should be on the right-hand side and the hot water supply should be on the left-hand side of the faucet assembly respectively. The #2 hand wash sink was observed with two actuation knobs, one for cold water and one for hot water. The Registered Dietetic Technician (DTR) C stated: The cold water combines with the hot water. Registered Dietetic Technician (DTR) C further stated: The cold-water valve is shut off. Cooks Sink: The faucet assembly was observed leaking water from the spout. The 2017 FDA Model Food Code section 5-201.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. The #1 hand wash sink was also observed loose-to-mount. The distance between the hand sink basin and the wall surface was observed to be approximately 0.5-1.0 inches. The #1 hand wash sink caulking bead, located between the wall surface and sink was also observed heavily soiled, stained, and separated from the hand wash sink backsplash. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. The Unit #5 Freezer was observed with accumulated ice-[NAME]. Registered Dietetic Technician (DTR) C stated: We need to defrost the unit. The South Bend convection oven interior and exterior surfaces were observed heavily soiled with food residue. The South Bend Select oven exteriors were observed heavily soiled with food residue. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Refrigerator/Freezer Room: The return-air ventilation grill, located directly above Unit #8 Freezer, was observed heavily soiled with accumulated dust and dirt deposits. The 2017 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. Forty 6 by 6 [NAME] tiles were observed cracked and/or missing, adjacent to the Dietary Manager's Office. Twenty 6 by 6 [NAME] tiles were observed cracked and/or missing, adjacent to the mechanical dish machine. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair 6 eight-foot-long fluorescent T12 light bulbs were observed missing from 3 overhead light fixtures, within the food production kitchen. Dry Storage Room: 5 of 8 four-foot-long fluorescent T8 light bulbs were observed non-functional. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. 16 eight-foot-long fluorescent T12 light bulbs were observed missing protective plastic sleeves and end caps, within the food production kitchen. One eight-foot-long fluorescent T12 light bulb was observed missing 2 end caps, within the food production kitchen. Dry Storage Room: 6 end caps were observed missing on the overhead light assemblies. The 2017 FDA Model Food Code section 6-202.11 states: (A) Except as specified in (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. (B) Shielded, coated, or otherwise shatter-resistant bulbs need not be used in areas used only for storing FOOD in unopened packages, if: (1) The integrity of the packages cannot be affected by broken glass falling onto them; and (2) The packages are capable of being cleaned of debris from broken bulbs before the packages are opened. (C) An infrared or other heat lamp shall be protected against breakage by a shield surrounding and extending beyond the bulb so that only the face of the bulb is exposed. The ice machine was observed impaired producing minimal amounts of ice. Registered Dietetic Technician (DTR) C stated: The parts are on backorder. Register Dietetic Technician (DTR) C further stated: We are currently purchasing ice from our supplier. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. The Dietary Manager's Office metal entrance door frame was observed heavily corroded and particulate. The metal door frame was also observed completely disintegrated approximately 10-12 inches from the flooring surface on both sides of the frame. The fresh air supply grill, located adjacent to the food production tray line, was observed heavily corroded and missing the center deflector plate. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. Janitor Closet: The mop sink basin was observed soiled with dirt and grime deposits. Registered Dietetic Technician (DTR) C stated: We will clean the mop sink and organize the room. The 2017 FDA Model Food Code section 4-602.13 states: NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 08/30/23 at 12:45 P.M., Record review of the Policy/Procedure entitled: Sanitation Policy dated 01/2023 revealed under Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. Record review of the Policy/Procedure entitled: Sanitation Policy dated 01/2023 further revealed under Policy Explanation and Compliance Guidelines: (1) All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, flies, and other insects. On 08/30/23 at 01:00 P.M., Record review of the Policy/Procedure entitled: Sanitation dated 01/2023 revealed under Policy: Sanitation is monitored on a regular basis. Record review of the Policy/Procedure entitled: Sanitation dated 01/2023 further revealed under Purpose: To provide an overview of sanitation and identify areas needing attention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00133617 and MI00134554. Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 80 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 8/28/23 at 6:08 AM during the initial tour of the Memory Care unit the following was observed. Two unidentified residents were observed awake and sitting in the Memory Care dining room. Gnats were observed in the dining room. The left side panel of the window air conditioning (AC) unit was not fully closed, creating about a six-inch opened area. A screenless upper window panel in the dining room was opened about six inches. The opened AC side panel and screenless upper window made it possible for flying insects to enter the dining room. On 08/29/23 at 09:00 A.M., An environmental tour of the facility Laundry Service was conducted with Director of Housekeeping and Laundry Services B. The following items were noted: Clean Laundry Room: The stationary wall fan was observed soiled with accumulated dust and dirt deposits. The flooring surface was observed (etched, scored, particulate), exposing the concrete sub-surface. Director of Housekeeping and Laundry Services B indicated he would have maintenance repaint the flooring surface as soon as possible. The walls and floors were observed heavily soiled with dust, dirt, and debris behind the three commercial driers. The walls and floors were observed heavily soiled with dust, dirt, and debris (paper products, plastic products, etc.) behind the commercial washers. 2 of 3 clean linen transportation cart covers were observed (worn, torn, particulate). 1 of 3 clean linen transportation carts were also observed broken (1 of 3 shelving units broken). Soiled Laundry Room: The stationary wall fan was observed soiled with accumulated dust and dirt deposits. The return-air ventilation grill was observed soiled with accumulated dust and dirt deposits. The two-compartment sink faucet assembly was observed leaking water from the spout. On 08/29/23 at 10:45 A.M., A common area environmental tour was conducted with Regional Maintenance Director A and Director of Housekeeping and Laundry Services B. The following items were noted: Basement Central Supply: The flooring surface was observed with numerous (cracked, chipped, missing) vinyl 9-inch-wide by 9-inch-long flooring tiles. Numerous 24-inch-wide by 24-inch-long acoustical ceiling tiles (18) were also observed severely stained from previous moisture leaks. The room was further observed in complete disarray. Cardboard boxes resting directly on the flooring surface. Regional Maintenance Director A indicated he would have staff make necessary repairs as soon as possible. Housekeeping Storage Room: The room was observed in severe disarray and soiled with accumulated dust, dirt, and debris (cardboard boxes, plastic bags, etc.). Staff Breakroom: Numerous 24-inch-wide by 24-inch-long acoustical ceiling tiles (14) were observed severely stained from previous moisture leaks. The microwave oven interior was also observed soiled with accumulated food residue. The refrigerator interior and exterior were further observed soiled with accumulated and encrusted food residue. The refrigerator was additionally observed missing the interior appliance bulb. The chest freezer interior was finally observed with accumulated ice [NAME]. Occupational Therapy/ Physical Therapy: The microwave oven interior was observed severely (etched, scored, corroded, particulate). The restroom toilet tissue was also observed resting on top of the plastic dispenser instead of within the dispenser. The paper towel was additionally observed resting on top of the commode tank cover, instead of within the plastic wall mounted dispenser. The commode tank cover was further observed ill-fitting to the existing stool tank. Human Resources/Admissions Office: The Human Resources flooring surface was observed severely (worn, etched, scored, sticky, particulate). Numerous vinyl flooring tiles were also observed missing, exposing the concrete subsurface. Medical Records: Numerous 24-inch-wide by 24-inch-long acoustical ceiling tiles (8) were observed severely stained from a previous moisture leak and/or missing. The room was also observed in severe disarray (cardboard boxes, medical records, etc.). First Floor (South) IT Room: Numerous empty cardboard boxes were observed resting directly on the flooring surface. The flooring surface was also observed soiled with accumulated dust and dirt deposits. The room was further observed in disarray. The metal entrance door was finally observed soiled with accumulated dust and dirt deposits between the door slab and frame. Nursing Supply Closet: The shelving unit was observed soiled with accumulated dust, dirt, and debris. One 24-inch-wide by 24-inch-long acoustical ceiling tile was also observed severely stained from a previous moisture leak. The supply closet was further observed in disarray. Clean Linen Room: The drywall surface was observed (etched, scored, particulate). The flooring surface was also observed severely worn and pitted, exposing the subsurface. Nurse Station: The stationary wall fan was observed soiled with accumulated dust and dirt deposits. Exposed telephone wiring was also observed dangling from the lower drywall surface. The drywall surfaces were further observed severely soiled and stained. Restroom: The flooring surface was observed missing ceramic tile squares in several locations. The commode base caulking was also observed (etched, stained, cracked). The commode base tank cover was further observed ill fitting. 1 of 2 overhead light fixtures were finally observed stained and corroded from a previous moisture leak. Business Office: The air conditioning filter and housing unit was observed heavily soiled with accumulated dust and dirt deposits. Main Dining Room: The air conditioning unit filter and housing cabinet were observed heavily soiled with accumulated dust, dirt, and food residue deposits. The Popcorn Machine interior ceiling and light bulb assembly were also observed heavily soiled with accumulated food and popcorn oil residue. First Floor (North) Bathroom: Six 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained from previous moisture leaks. The commode base caulking was also observed (etched, scored, particulate). The toilet tissue was further observed resting on top of the plastic wall mounted dispenser. The shower wand assembly was finally observed missing an atmospheric vacuum breaker to prevent a potential cross-connection between the potable (drinking) and non-potable (non-drinking) water supplies. Nurse Station: The hand sink basin was observed severely stained and corroded. The overflow plate was also observed enlarged from the excessive corrosion. The stationary wall mounted fan was further observed soiled with dust and dirt deposits. Soiled Utility Room: The sharps container was observed without a cover plate. The metal entrance door between the door slab and frame was also observed heavily soiled with accumulated dust and dirt deposits. The return-air ventilation grill was further observed heavily soiled with dust and dirt deposits. Second Floor (South) (Memory Care Unit) The entrance door magnetic security closure assembly was observed continuously buzzing when activated. Restroom: The return-air ventilation grill was observed soiled with dust and dirt deposits. Three 24-inch-wide by 24-inch-long acoustical ceiling tiles were also observed stained from a previous moisture leak. Oxygen Storage Room: The return-air ventilation grill was observed soiled with dust and dirt deposits. Nursing Supply Room: The flooring surface was observed soiled with dust, dirt, and debris (plastic spoon, plastic knife, plastic bag). The supply room was also observed in disarray. Nursing Station: The wall mounted stationary fan was observed soiled with dust and dirt deposits. The perimeter drywall surface was also observed scuffed and etched. Main Dining Room: The wall and flooring surfaces were observed soiled with dust, dirt, and food residue (sticky). The restroom was also observed soiled and in disarray. The air conditioner unit housing was further observed soiled with dust, dirt, and food residue. The air conditioner unit filter was further observed missing. Janitor Closet: The mop sink was observed partially filled with wastewater. The flooring surface was also observed heavily soiled, corroded, and extremely wet. The wall surfaces were additionally observed (etched, scored, particulate). The interior mop sink basin was further observed heavily soiled with dust, dirt, and grime. Regional Maintenance Director A indicated he would have staff make necessary repairs as soon as possible. Solid Waste Storage Room: The wall surfaces were observed (etched, scored, particulate). The flooring surface was also observed soiled with dust, dirt, and grime. Soiled Utility Room: One 24-inch-wide by 24-inch-long acoustical ceiling tile was observed missing. Two 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained from a previous moisture leak. Second Floor (North) Shower Room: 2 of 3 overhead light assemblies were observed non-functional. The shower wand assembly was also observed missing an atmospheric vacuum breaker, to prevent a potential cross-connection between the potable (drinking) and non-potable (non-drinking) water supplies. The restroom commode was further observed non-functional. Nursing Station: Exposed electrical wiring was observed on the wall surface, adjacent to the chair. The stationary wall fan was also observed heavily soiled with accumulated dust and dirt deposits. The hand sink basin overflow port was additionally observed heavily stained, corroded, and enlarged from excessive corrosion. One seven-foot section of vinyl base coving was further observed missing. The floor surface was finally observed severely worn, exposing the concrete subsurface. Workstation Alcove: The drywall surfaces were observed (etched, scored, particulate). Soiled Utility Room: The flooring surface was observed soiled with dust, dirt, and debris (paper products, vinyl gloves, etc.) The return-air ventilation grill was also observed heavily soiled with accumulated dust and dirt deposits. One 24-inch-wide by 24-inch-long acoustical ceiling tile, located adjacent to resident rooms [ROOM NUMBERS], was observed stained from a previous moisture leak. On 08/30/23 at 08:45 A.M., An environmental tour of sampled resident rooms was conducted with Regional Maintenance Director A and Director of Housekeeping and Laundry Services B. The following items were noted: 105: The restroom commode base caulking was observed (etched, scored, particulate). 1 of 2 overhead light bulbs were also observed non-functional. The hand sink faucet aerator was additionally observed faulty. The return-air ventilation grill was further observed heavily soiled with accumulated dust and dirt deposits. 1 of 3 bedside table slabs were finally observed (etched, scored, particulate). 110: The window air conditioner unit filter was observed heavily soiled with accumulated dust and dirt deposits. The restroom return-air ventilation grill was also observed soiled with dust and dirt deposits. The commode base caulking was additionally observed (etched, cracked, stained). 1 of 2 restroom overhead light bulbs were also observed non-functional. 2 of 3 overhead light fixtures were also observed non-functional. The bed 3 floor fan was additionally observed heavily soiled with dust and dirt deposits. The resident room flooring surface was further observed heavily soiled with accumulated dust, dirt, and food residue. The restroom metal door frames were also observed (etched, scored, chipped). 111: The restroom entrance door metal threshold plate was observed extremely soiled with accumulated dirt and grime deposits. The restroom hand sink basin was also observed heavily soiled with accumulated dirt and grime deposits. 1 of 2 restroom overhead light bulbs were additionally observed non-functional. The restroom flooring surface was also observed soiled with dirt and grime deposits. The commode base caulking was further observed (etched, chipped, cracked, stained). The flooring surface was also observed soiled with dust and dirt deposits. The air conditioner filter was finally observed soiled with accumulated dust and dirt deposits. 114: 1 of 4 overhead light fixtures were observed non-functional. The perimeter vinyl wall/floor base coving was also observed missing. The restroom commode base caulking was additionally observed (etched, scored, particulate). 117: The perimeter vinyl wall/floor base coving was observed missing. The air conditioner unit filter was also observed heavily soiled with dust and dirt deposits. 120: 1 of 4 overhead light fixtures were observed non-functional. The flooring surface was also observed soiled with accumulated dirt and grime deposits. 1 of 2 restroom overhead light bulbs were additionally observed non-functional. The restroom flooring surface was further observed (cracked, chipped, missing), adjacent to the commode base. 121: The air conditioner unit filter was observed extremely soiled with accumulated and encrusted dust and dirt deposits. 1 of 2 overhead light assembly plastic protective lens covers were also observed missing. 1 of 2 restroom overhead light bulbs were additionally observed non-functional. The restroom hand sink basin was further observed with standing water within the basin. The restroom return-air ventilation grill was also observed heavily soiled with dust and dirt deposits. 125: The air conditioner unit filter was observed heavily soiled with dust and dirt deposits. The flooring surface was also observed soiled with accumulated dust, dirt, and food residue. 201: The air conditioner unit filter was observed heavily soiled with dust and dirt deposits. Numerous dead insect carcasses were observed within the overhead light fixtures. The air conditioner unit sliding side panels were further observed loose-to-mount and open. 204: The call system pull extension cord was observed dangling from the overbed light assembly. The call system metal protective face plate cover was also observed dangling from the pull extension cord within the overbed light assembly. 1 of 2 overhead light fixtures were also observed non-functional. The television set was further observed resting at a 45-degree angle on top of the bedside table. 208: The air conditioning unit filter was observed soiled with accumulated dust and dirt deposits. 3 of 3 desk fans were also observed soiled with dust and dirt deposits. The restroom commode base was additionally observed loose-to-mount. The commode base could be moved from side to side approximately 3-6 inches. 211: The window shade panel was observed broken. A hole was also observed behind the restroom commode base. The hole measured approximately 6-inches-wide by 6-inches-long. 212: A hole was observed behind the restroom commode base. The hole measured approximately 6-inches-wide by 6-inches-long. Eight 12-inch-wide by 12-inch-long vinyl flooring tiles were also observed cracked, chipped, missing. 214: 1 of 5 overhead light fixtures were observed non-functional. The air conditioner unit filter was also observed heavily soiled with accumulated dust and dirt deposits. The restroom return-air ventilation grill was additionally observed soiled with dust and dirt deposits. 215: 2 of 4 overhead light assembly fixtures were observed non-functional. The air conditioner unit filter was also observed missing. The air conditioner unit internal coil fins were additionally severely soiled with accumulated dust and dirt deposits. 220: 3 of 4 overhead light assemblies were observed non-functional. The air conditioner unit filter was also observed heavily soiled with accumulated dust and dirt deposits. The restroom flooring surface was additionally observed soiled and malodorous (urine odor). The flooring surface was further observed missing, adjacent to the commode base. The restroom call system panel protective metal cover plate was finally observed dangling from the pull cord extension. 222: Five 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained from previous moisture leaks. The restroom flooring surface was also observed soiled and malodorous (urine odor). The flooring surface was additionally observed missing, adjacent to the commode base. The restroom call system panel protective metal cover plate was further observed dangling from the pull cord extension. Note: Finer detailed cleaning, within resident rooms and common areas, is essential to reduce bacterial harborage and cross-contamination inoculations. On 08/30/23 at 01:30 P.M., Record review of the Policy/Procedure entitled: Cycle Cleaning dated 01/2023 revealed under Policy: It is the policy of this facility to identify the functional areas in the facility that require cleaning and to use cycle cleaning schedules to outline the frequencies and maintain regularly scheduled environmental service tasks. Record review of the Policy/Procedure entitled: Cycle Cleaning dated 01/2023 further revealed under Policy Explanation and Compliance Guidelines: (1) Routine cleaning of environmental surfaces and non-critical resident care items shall be performed according to a predetermined schedule and shall be sufficient enough to keep surfaces clean and dust free. (5) Specific areas include: (a) Hallways/Dayrooms/Dining Rooms, (b) Offices/Support Rooms/Exterior, (c) Showers/Utility/Bathrooms, (d) Resident Rooms. On 08/30/23 at 01:45 P.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide hair grooming for one resident (R102) out of three residents reviewed who were depended upon staff for performance of activities of daily living (ADLs), resulting in untimely and unmet care needs regarding personal grooming and the resident feeling dissatisfaction. Findings include: On 7/12/2023 at 10:35 AM, Resident #102 (R102) was observed awake and sitting up in her bed. R102's hair had been separated into two sections each secured with a rubber band. R102's hair looked uncombed, tangled, and knotted. When asked why staff had not combed her hair, R102 stated, They didn't try. R106 said she (R102) wanted her hair combed. A review of the admission Record for R102 documented an initial admission date of 4/2/2004 and readmission date of 6/30/2023. R102's diagnoses included chronic obstructive pulmonary disease, chronic kidney disease-stage 3, cerebral infarction, and hemiplegia/hemiparesis. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment and extensive one-person physical assistance for hygiene. Review of R102's care plans documented in part the following: Focus: R102 requires assistance from staff secondary to CVA (medical term for a stroke) with right hemiplegia and contracture. Dated 9/5/2021. Interventions included: One person assist in personal hygiene such as shaving, brushing teeth, etc. Dated 11/21/2018. A review of a CNA (Certified Nurse Aide) task related to providing personal hygiene, that included combing the resident's hair, was reviewed, and indicated the task had been completed for the day at 8:14 AM. On 7/12/2023 at 2:26 PM, CNA O stated I have pretty much cared for (R102) every day. CNA O said she had already documented the care she provided for R106 today. CNA O stated a resident's hair should be combed every day. CNA O admitted that R102's hair was matted and unkempt. R102 stated, That hurts, when CNA O began to comb and brush her hair. On 7/12/2023 at 2:34 PM, CNA P had observed the condition of R102's hair and stated, Her hair is matted. During an interview on 7/12/2023 at 5:12 PM, the Director of Nursing (DON) said her expectation for resident hair care was to make sure their hair was groomed. A review of a policy titled, Activities of Daily Living (ADLs), dated January 2023, documented in part the following, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal or oral hygiene. On 7/12/2023 at 5:45 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** This citation has two deficient practices. Deficient practice #1. Based on interview and record review, the facility failed to ensure vital signs were consistently obtained and documented according to physician's orders for one resident (R106), out of three residents reviewed that died in the facility, resulting in a lack of clinical information for health care providers and the potential for unmet care needs. Findings include: A review of the admission Record for Resident #106 (R106) revealed an admission date of [DATE] and death in the facility on [DATE]. R106's diagnoses included hydrocephalus (accumulation of fluid in the brain), seizures, quadriplegia, and PEG-tube (Percutaneous Endoscopic Gastrostomy - a tube inserted into the stomach to provide a means of feeding). A review of physician's orders included the following: take resident's vitals two times a day. Order date [DATE]. A nursing note of [DATE] at 5:05 PM documented in part the following: Writer called to room, As resident was receiving care by staff, Staff noticed no rise and fall from residents chest, staff immediately came to get writer no pulse noted, code called, CPR (cardiopulmonary resuscitation) initiated at 1610 (4:10 PM), EMS contacted arrived approx. 1620 (4:20 PM) taking over cpr, 5 rounds on resident done by EMS, Pronounced By EMS approximately, 1645 (4:45 PM) . During an interview and record review on [DATE] at 4:15 PM, the Unit Manager/Licensed Practical Nurse (UM/LPN) H said vitals are to be taken every shift and recorded in the electronic Medication Administration Record (MAR). UM/LPN H stated it was standard nursing practice to take vitals every shift for a new resident because we want to make sure they are stable and then monitor them for the next few days to make sure they are stable. The only vitals available for review on R106 were obtained during his admission assessment on [DATE] at approximately 6:20 PM. When UM/LPN H was queried if R106 was stable on [DATE], she referenced the nursing progress note of [DATE] at 7:09 AM, Resident in my care this shift in no apparent distress. Routine assessment performed. resident resting in bed with call light in reach and bed in lowest setting with hob (head of bed) raised. UM/LPN H said it was a concern the resident died, and we don't have more vitals on him. During an interview on [DATE] at 4:53 PM, the Director of Nursing (DON) said resident vitals should be documented in the medical record. When queried about R106's vitals on [DATE], the DON stated, I would expect vitals to be taken early in the nurse's shift if possible. During the DON's interview, R106's [DATE] MAR was reviewed and documented the following: 1. [DATE] 6:00 PM dose of metoprolol (used to manage high blood pressure) - not given - medication unavailable. 2. [DATE] 6:00 AM dose of metoprolol - not given - medication unavailable. The DON stated that even though R106's high blood pressure medication, metoprolol, was not administered, the nurse should still have taken and documented the resident's blood pressure. That's part of (what we do), we monitor the vital signs. A review of a policy titled, Medication Administration, dated [DATE], documented in part the following, Obtain and record vital signs, when applicable or per physician orders. Deficient practice #2. Based on interview and record review, the facility failed to ensure timely administration of prescribed medications, levetiracetam (seizures), quetiapine fumarate (anti-psychotic), and metoprolol (blood pressure) for one resident (R106), out of three residents reviewed that died in the facility, resulting in the potential for unmet health care needs. Findings include: A review of the admission Record for R106 revealed an admission date of [DATE] and death in the facility on [DATE]. R106's diagnoses included hydrocephalus, seizures, quadriplegia, and PEG-tube. A review of physician's orders included the following: 1. Levetiracetam solution 100 mg/ml, give 7.5 ml two times a day for seizure. Order date [DATE]. 2. Metoprolol tartrate tablet 25 mg, give 1 tablet every 12 hours for hypertension. Order date [DATE]. 3. Quetiapine fumarate tablet 100 mg, give 1 tablet two times a day for anti-psychotic. Order date [DATE]. During the DON's interview, R106's [DATE] MAR was reviewed and documented the following: 1. [DATE] 6:00 PM dose of levetiracetam - not given - medication unavailable. 2. [DATE] 6:00 PM dose of metoprolol - not given - medication unavailable. 3. [DATE] 6:00 PM dose quetiapine - not given - medication unavailable. 4. [DATE] 6:00 AM dose of levetiracetam - not given - medication unavailable. 5. [DATE] 6:00 AM dose of metoprolol - not given - medication unavailable. 6. [DATE] 6:00 AM dose quetiapine - not given - medication unavailable. The DON said levetiracetam, metoprolol, and quetiapine were available in the facility's back-up box of medications (a supply of medications available for use in the facility). If the resident's medications were not available from the pharmacy, the nurse should have contacted the doctor/pharmacy for permission to get the medications from the back-up box. A review of R106's clinical record provided no evidence that the physician or pharmacy were contacted regarding this concern. On [DATE] at 5:45 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.

This citation pertains to MI00137329. Based on observation, interview, and record review, the facility failed to properly dispose of rubbish and maintain cleanliness of the outside garbage area and an outside stairwell, resulting in a visually unappealing property and the potential for harborage of pests. This deficient practice had the potential to affect all 83 residents that resided in the facility. Findings include: During an observation of the outside dumpster area on 7/12/2023 at 2:56 PM, Maintenance Director (MD) L stated, There's a lot of trash, branches, and a broken bench out here. Additional items observed outside of the dumpsters included several disposable gloves, old boxes, three wooden pallets, a broken tabletop, and a gas can with liquid inside. MD L stated, This makes the building look crappy. MD L agreed that the debris observed may also provide harborage for pests. On 7/12/2023 at 3:02 PM, an outside stairwell leading to the facility's lower level was observed with MD L. The stairwell was littered with trash such as used disposable gloves, empty plastic bottles and cigarette packaging, aluminum foil, bags, and a broken cinder or concrete block. During an interview on 7/12/2023 at 5:18 PM, the Nursing Home Administrator (NHA) stated she expected maintenance to check the grounds daily for debris, that is their responsibility. A review of a facility policy titled, Preventative Maintenance Program, dated January 2023, documented in part, A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The 2013 FDA Food Code was reviewed and revealed the following: - 5-501.110 Storing Refuse, Recyclables, and Returnables: Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. - 6-501.114 Maintaining Premises, Unnecessary Items and Litter: The premises shall be free of: (B) Litter. On 7/12/2023 at 5:45 PM, during the exit conference, the NHA and Director of Nursing 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** This citation pertains to Intake number MI00136275. Based on interview, and record review, the facility failed to ensure the legal guardian (LG) consented for one resident (#301) to leave the facility on a leave of absent (LOA) out of three residents reviewed for LOA's, resulting in the inability of the LG to exercise the right to participate in #301's health care and activity decisions. Findings include: On 5/15/2023 at approximately 3:00 P.m., a Facility Reported Incident (FRI) for R#301 revealed an incident that occurred at approximately 11:30 AM that morning. The FRI investigation revealed R301 went out on a leave of absence with his girlfriend on 5/3/2023 before lunch expecting to return the same day but did not return to the facility. According to the electronic medical record, R301 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of nontraumatic subdural hemorrhage, localization-related (focal), (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, diffused traumatic brain injury, and mood disorder. The undated 'face sheet' indicated that R301 had a spouse who was his (LG) and Emergency contact person #1. R301's 'quarterly' Minimum Data Set (MDS) with a reference date of 4/20/23 indicated R301 had moderate cognitive impairment with a BIMS (brief interview for mental status) score of 12/15. Review of the progress notes revealed as following: -There was no progress note from 5/3/23 indicating what time R301 left on LOA. - On 5/4/2023 at 06:46 AM, Patient has been out on a leave and has not returned, patient left facility at 4p.m. as from (per) previous (prior shift) staff. Patient has not returned from outing. - On 5/4/2023 at 07:38 AM called family no answer and also called physician two times no answer and left message. - On 5/4/2023 Social Service note - Resident was moved back to the elopement unit due to not wanting to return to the facility after being out (sic) an LOA visit .'. A review of the medical record did not reveal R301's LG gave consent on 5/3/2023 of R301's LOA with GF B. Reviewed of the State of Michigan Probate Court documents revealed the spouse was the LG with expiration date of July 3rd, 2023. On 5/15/2023 at 3:30 p.m. R301 was asked to recall the LOA that occurred on 5/3/2023. R301 stated, I left the facility with my girlfriend. R301 was asked what time R301 stated, In the afternoon. I wanted to go with her, I've gone with her before. I don't know why it's a big deal. My wife knew I left with the girlfriend (GF B) because I told her through a text message .I go with my wife sometimes too. I spent the night over (GF B) that night. I have put in my paper at the probate court to make my own decisions and go where I want to go. On 5/15/2023 at 4:27 p.m., the legal guardian (Spouse) was called via telephone for an interview. The LG was asked was she aware of R301's LOA on 5/3/2023 with GF B. The LG said she was okay with R301 going out with the girlfriend. The LG explained there was no consent given to the facility to let R301 go out of the facility on that day. GF B was called on 5/15/2023 at 4:40 p.m. however, the phone number was non-working. On 5/15/2023 at 4:57 p.m., the Administrator was interviewed. The Administrator was queried regarding the occurance on 5/3/2023 regarding R301's LOA. The Administrator stated, The girlfriend came and picked up the resident on a LOA about 3:00 p.m. (Name of R301) was expected to return by midnight and usually he comes back by 8:00 p.m. The facility called me that night and told me the resident did not come back. The nurse attempted to get in touch with the girlfriend unsuccessfully. They called me again about 11:00 p.m. The Administrator confirmed that R301's LG was the spouse listed on the face sheet adding, We should have got a consent from the guardian. On 5/16/2023 at 9:37 a.m., an interview with Social Service staff (SS) A confirmed there was no documentation from R301's LG given consent for R301 to leave the facility on a LOA with GF B. According to the facility's undated Therapeutic Leave policy, Compliance Guidelines: 2. The facility will coordinate with the resident and/or representative the length of time the resident will be gone to ensure that adequate amounts and appropriate medication is ready for administration while on the leave .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide evidence that a resident was issued a NOMNC (Notice of Medicare Non-Coverage - Form 10123 [explanation of appeal rights]) and SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice - Form 10055) for one resident (R50) of three residents who were reviewed for notices of Medicare non-coverage and appeal rights, resulting in the resident not being fully informed of their Medicare rights or the potential liability of estimated cost in order to make a decision to appeal or continue therapy treatments. Findings include: On 9/2/2022 at 10:34 AM, the Minimum Data Set (MDS) Coordinator, Licensed Practical Nurse I indicated that Resident #50 (R50) was discharged from a Medicare covered Part A stay, had Medicare benefit days remaining, and continued to reside in the facility past the last covered day for their Medicare services. When MDS Coordinator I was queried about the NOMNC and SNF ABN for R50 she stated, I just got here, and we did not have a business office manager. So (R50's) was not done. A review of the clinical record for R50 revealed an initial admission date of 9/28/2018 and readmission date of 8/23/2022. R50's diagnoses included schizophrenia, dementia, and epilepsy. A MDS assessment dated [DATE] documented severe cognitive impairment. During an interview beginning on 9/8/2022 at 12:08 PM the Nursing Home Administrator said ABN notifications are necessary so the residents can know exactly when they will be cut from Medicare and to give them options. The facility policy titled, Advance Beneficiary Notices, dated 9/2/2022, was reviewed and revealed in part the following: - It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. - The facility shall inform Medicare beneficiaries of his or her potential liability for payment. - A NOMNC, Form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if resident is leaving the facility or remaining in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet the medical and psychosocial needs for two (R14, R19) of 22 residents reviewed for care planning, resulting in the potential for R14 not receiving proper psychosocial care and R19 not receiving proper urinary catheter care. Findings Include: Resident 14: During an observation on 8/31/22 at approximately 9:30 AM R14 was observed wandering throughout the second floor secured unit. R14 was oriented to self only. During interview R14 said, I don't know what I'm suppose to be doing here. Review of the Electronic Medical Record (EMR) revealed R14 was admitted to the facility on [DATE] with diagnoses that included psychotic disorder with delusions, anxiety, depression, and unspecified dementia with behaviors. The Minimum Data Set (MDS) dated [DATE] indicated R14 had severe cognition impairment with a Brief Interview for Mental Status (BIMS) score of 2/15 along with behaviors of rejecting care 4-6 days per week and wandering 1-3 days per week. Section V, Care Area Assessment indicated 'use of antipsychotic medications', and 'behavioral symptoms'. R14 was prescribed two separate antipsychotic medications every day of the week. On 4/10/22 the physician ordered a psychiatric consult for R14. On 4/12/22 a social work note documented the following; Resident is prescribed antipsychotic medications r/t (related to) his diagnoses. He will be followed by psychiatric services and all care plans followed. There was no documentation to support R14 was seen by psychiatric services. There was no care plan to address R14's use of antipsychotic medications or behavioral needs. There were no psychiatric assessments or progress notes. There were no further social service assessments or progress notes in R14's EMR after 4/12/22. On 9/07/22 at 9:48 AM Social Worker (SW) C confirmed there was no psychosocial care plan for R14 to address his psychiatric or behavioral needs. SW C said there was no documented evidence to support that R14 had been seen by Psychiatric services, screened for Mental Illness or Intellectual Disability, or assessed for any potential psychiatric needs. Resident 19: On 8/31/22 at 11:20 AM R19 was observed laying in bed. R19 was observed to have a supra-pubic urinary catheter (an indwelling flexible tube that is surgically inserted through the abdomen directly into the bladder to drain urine into a collection bag) attached to a leg bag (a small urinary collection bag that is attached to the leg) that was strapped to his left thigh. There was no anchoring device to secure the catheter to the resident's thigh. On 9/07/22 at 11:28 AM R19 was observed laying in bed with a supra-pubic urinary catheter draining into a leg bag attached to his left thigh/knee area. Certified Nursing Assistant (CNA) F repositioned resident and confirmed that R19 had a urinary catheter that was draining into a leg bag while laying in bed and did not have any anchoring device. CNA F said R19 did not have any other type of urinary collection bag in his room, only a leg bag. Review of the EMR revealed R19 admitted to the facility on [DATE] with multiple diagnoses that included benign prostatic hyperplasia, urinary tract infection, and end stage renal failure. The MDS dated [DATE] indicated R19 had severe cognition impairment and required extensive assistance from one staff person for all activities of daily living. R19 was identified to have an indwelling urinary catheter. Section V Care Area Assessments indicated 'urinary incontinence/indwelling urinary catheter'. On 7/30/22 the physician ordered urinary catheter care every shift and to change the urinary catheter every 30 days on the 1st of each month. There was no care plan related to indwelling urinary catheter care. There were no progress notes regarding indwelling urinary catheter care. On 9/7/22 at 11:37 AM during an interview with unit manager Licensed Practical Nurse (LPN) J she reviewed R19's EMR and confirmed there was no 'urinary catheter' care plan or documentation to indicate urinary catheter care had been provided to the resident. According to the facility's policy for Comprehensive Care Plans revised on 5/24/22: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure appropriate monitoring and timely treatment for a resident with projectile vomiting of coffee ground emesis (coagulated [thick like gel] blood in vomit) for one (R4) of one resident reviewed for quality of care, resulting in a delay in medical treatment and the potential for unmet care needs. Findings include: A review of the clinical record for Resident #4 (R4) documented an initial admission date of 4/15/2020 and readmission date of 9/16/2020. R4's diagnoses included human immunodeficiency virus, gastrointestinal hemorrhage, and schizophrenia. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A further review of the clinical record documented the following nursing progress notes: - 4/30/2022 at 11:40 PM: Resident observed having coffee ground emesis, and projectile vomiting. Unable to notified (sic) Dr. Left a message to call regarding resident. Vital signs are as follow 108/74 (blood pressure), 98% (oxygen saturation), 98.2 (body temperature), 18 (respiratory rate). DON (Director of Nursing) notified will continue to monitor patient. - 5/1/2022 at 8:14 AM: Received a new order to send resident out. All care will be endorsed to oncoming nurse. - 5/1/2022 at 12:09 PM: Per report from previous nurse, resident had two episodes of brown emesis and orders was given to send resident out 911. EMS (Emergency Medical Service) called and resident left the building and was transferred to (local hospital) at 0830. - 5/1/2022 at 1:39 PM: Resident returned from (local hospital) ER (Emergency Room), MD made aware and verified medication orders that the resident returned with, new medication orders placed into (electronic health record). During an interview and review of R4's clinical record on 9/8/2022 beginning at 11:28 AM, the DON said R4 did not receive follow up monitoring on 5/1/2022 related to the coffee ground emesis, and there should have been documentation of nursing observations. The resident's doctor should have been notified right away and if that doctor was not available, the nurse should have called our medical director but did not. The DON stated, I would not have waited, (R4) would have gone right out. I would not have endorsed (this situation/concern) to the next shift. The DON said there was a possibility that R4 was bleeding on the inside, and this required immediate care. The DON stated, It's an urgent need. The DON indicated this was a delay in treatment. On 9/8/2022 at approximately 2:50 PM, an interview and review of R4's 5/1/2022 Emergency Department (ED) visit was conducted with the DON. The hospital document titled Final Report revealed the following: Reason for visit: Vomiting History of present illness: .Nursing home reports 1 or 2 episode of coffee-ground emesis yesterday/overnight . Examination: Gastrointestinal .A digital rectal examination was performed Stool burden in rectal vault. Attempted digital disimpaction. [NAME] stool was present on gloved finger. No frank blood noted. FOBT (fecal occult blood test to determine if blood was in the stool) negative. Medical decision making and course in the ED: .Concern for constipation or obstruction, though less concern for the latter given vital signs, non-toxic appearance, and benign abdominal exam. FOBT was negative but there is appreciable firm but not hard stool in the rectal vault. Some digital disimpaction performed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to address range of motion (ROM) concerns for one resident (R13) out of three residents reviewed for ROM, resulting in the potential for contracture development to occur. Findings include: During an observation and interview on 8/31/2022 at 10:16 AM, Resident #13 (R13) was observed awake and lying in her bed. R13's left hand appeared to be slightly bent at the wrist and the fingers on her left hand were noted to be flexed over and towards her palm. When asked if she was able to open and spread her fingers on her left hand without assistance, R13 said she was not. R13 demonstrated that she was able to open her fingers on the left hand using her right hand. During an observation and interview on 9/8/2022 beginning at 9:27 AM, R13 was awake and lying in her bed. R13 said she used her hands to move about the building in her wheelchair and wanted to keep the current ability of her hands. During an interview on 9/8/2022 at 9:40 AM, Rehab Manager (RM) S said R13's left hand was not contracted because you can range it out, but it's not in great shape. Performing range of motion (exercises) with her hand daily will prevent contractures. We want (R13) to start getting out of bed to be more active and as functional as possible. (R13's) left hand needs (ROM exercises) to maintain current ROM and prevent her from becoming contracted. A review of the clinical record for R13 revealed an initial admission date of 2/9/2022 and readmission date of 5/15/2022. R13's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment and no current functional limitation in ROM. During an interview and record review on 9/08/2022 beginning at 11:57 AM, the Director of Nursing (DON) said they were revamping the restorative program and that there was a restorative aide that primarily obtains resident's weights. A review of R13's clinical record revealed there were no CNA (Certified Nurse Aide) tasks designated to perform ROM activities with R13. The DON stated, There should have been because the CNAs have more contact with the resident. They more often notice changes in the patient, and they can alert the nurse to put interventions in place. The DON stated R13 would benefit from ROM activities because she's prone to contractures due to limited mobility. Doing the ROM motion would help to prevent contactures and increase mobility and circulation. A review of R13's current care plans did not include a focus or intervention related to increasing and/or maintaining ROM. A review of the facility policy titled, Prevention of Decline Range of Motion, dated 9/8/2022, revealed in part the following: - Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. - The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion including the assessment, appropriate care planning, and preventive care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide appropriate supra-pubic (s/p) indwelling urinary catheter (tube inserted through the abdominal wall into the bladder to drain urine) care for one (R19) of two residents reviewed for indwelling urinary catheter care resulting in R19's supra-pubic catheter not being changed according to physician's orders, not being kept below the level of his bladder, not being securely anchored to his thigh with the potential for injury to the stoma, (insertion site of the catheter) dislodgement, and urinary tract infection. Findings include: Resident 19: On 8/31/22 at 11:20 AM R19 was observed laying in his bed on his right side. R19 was observed to have a supra-pubic urinary catheter attached to a leg bag (a small urinary collection bag that is attached to the leg) that was secured to the outside of his left thigh, which was higher than the level of his bladder. The catheter was pulled tight from out the top of his brief to his leg bag. There was no securement device anchoring the catheter to his thigh, the tubing went directly from the stoma to the leg bag. The leg bag contained a small amount of dark amber colored urine. On 9/07/22 at 11:28 AM R19 was observed laying in bed on his left side with a supra-pubic urinary catheter draining into a leg bag attached to his left thigh/knee area. The resident was laying on the leg bag. At this time Certified Nursing Assistant (CNA) F repositioned resident and confirmed that R19 had a urinary catheter that was draining into a leg bag while laying in bed and did not have any anchoring device. The leg bag contained a small amount of dark amber colored urine. CNA F said R19 did not have any other type of urinary collection bag in his room and always used a leg bag even when laying in bed. CNA F said that R19 usually had a securement device to anchor the catheter tubing, but it may have been removed for a shower. Review of the Electronic Medical Record (EMR) revealed R19 admitted to the facility on [DATE] with multiple diagnoses that included benign prostatic hyperplasia, urinary tract infection, and end stage renal failure. The Minimum Data Set (MDS) dated [DATE] indicated R19 had severe cognition impairment and required extensive assistance from one staff person for all activities of daily living. R19 was identified to have a supra-pubic indwelling urinary catheter. On 7/30/22 the physician ordered; urinary catheter care every shift, and to change the urinary catheter every 30 days on the 1st of each month. A review of R19's July 2022, August 2022, and September 2022 Medication Administration Records (MAR) and Treatment Administration Records (TAR) had no documentation to indicate R19's urinary catheter care was completed every shift or that the catheter was changed every 30 days. There were no progress notes, assessments, or any documentation regarding R19's indwelling urinary catheter care. There was no care plan related to indwelling urinary catheter care. On 8/19/22 R19 was diagnosed with a urinary tract infection and was prescribed an antibiotic from 8/12/22 - 8/18/22. There was no additional documentation in the EMR regarding the urinary tract infection aside from antibiotic administration on the MARs. On 9/7/22 at 11:37 AM during an interview with unit manager Licensed Practical Nurse (LPN) J she reviewed R19's EMR and confirmed there was no 'urinary catheter' care plan or documentation to indicate urinary catheter care had been provided to the resident. LPN J said the physician's order for catheter care was not transcribed onto the resident's MAR or TAR. On 09/08/22 at 11:35 AM during an interview with Regional Clincial Nurse Consultant Registered Nurse H she confirmed that physician's order had not been transcribed onto R19's MAR or TAR and no care plan had been implemented for R19's catheter care. According to the facility's Catheter Care policy revised on 5/24/22. Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 1. Catheter care will be performed every shift and as needed by nursing personnel. 4. Leg bags may be used for ambulatory residents or per resident request. 5. Legs bags may be worn during the day, but need to be removed and a bedside drainage bag replaced on the catheter at night. 6. Legs bags will be attached to the resident ' s thigh or calf making sure to have slack on the tubing to minimize pressure and tension. Ensure straps are snug but not tight. 7. Leg bags may be stored in a clean, plastic bag when not in use or as per facility policy. 8. Empty drainage bags when bag is half-full or every 3 to 6 hours. 9. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. A review of the web site Agency for Healthcare Research and Quality accessed on 6/6/22 and located at https://www.ahrq.gov/hai/quality/tools/cauti- Itc/modules/resources/tools/prevent/maintenanc e-checklist.html, read in part: With regard to care and maintenance of a urinary catheter in long-term care, you should ensure: .3. A catheter securement device is in place to prevent catheter movement and urethral traction . 10. Ensure that the drainage bag is secured below the level of the bladder at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake# MI00126926. Based on observation, interview, and record review, the facility failed to obtain a physician's order for colostomy care and failed to provide care for a colostomy for one (R61) of one resident reviewed for a colostomy, resulting in the potential for excoriation of the skin and the potential for infection. Findings include: On 9/1/2022 at 2:51 p.m., R61 was observed lying in bed alert and able to be interviewed. A colostomy bag half filled with feces was observed on the right side of R61's abdomen. During an interview, R61 stated, They (the nurses) never change it or even ask to change my colostomy bag. I change my colostomy bag myself. According to R61's electronic medical record, he was initially admitted to the facility on [DATE]and readmitted on [DATE] with diagnoses of quadriplegia C5-C7 and colostomy status (a colostomy is an opening to divert one end of the colon (part of the bowel) through an opening in the abdomen. The opening is called a stoma. A pouch can be placed over the stoma to collect stool). R61's quarterly Minimum Data Set (MDS) with a reference date of 8/4/2022 indicated R61 was moderately impaired cognition with a BIMS (brief interview for mental status) score of 12. The MDS also indicated R61 required extensive assistance with Activity Daily Living (ADLs), had an indwelling catheter for urine, and a colostomy for bowel. A review of R61's care plan, initiated on 10/19/2021, documented the following: - R61 has a self-care deficit and needs assistance with ADLs related to impaired physical mobility, weakness, and quadriplegia right and left phalanges (fingers) contracture near palm, hand deformities. -Colostomy care plan interventions: Observe for diarrhea, constipation, dehydration, pain, and abdominal swelling. Observe skin around stoma for breakdown. Staff to empty the pouch when it's a third half full. -Nutritional care plan focus: R61 has altered nutritional status as evidence by and related to having a colostomy .constipation. -Skin care plan focuses: R61 is at risk for skin breakdown .Interventions: Assess skin during care, report any redness, bruised, or open areas promptly to the charge nurse. Further review of the electronic medical records revealed no active physician's orders for colostomy care. No colostomy care was noted on the medication administration records. No progress notes documented colostomy care. During an interview on 9/1/2022 at 3:30 p.m., the Director of Nursing (DON) confirmed residents with colostomies should have physician's orders for continuing care and for the stoma site to be assessed by the nurses. The DON was informed that there were no physician's orders for the care of R61's colostomy for the months of July, August, and September and no documentation of the colostomy care on the medication administration records. The DON was asked to review the physician's orders and the medication administration record for validation and to present a hard copy of the physician's orders for the month of July, August, and September and the medication administration records. The DON presented hard copies of R61's physician's orders and the medication administration records with no physician's orders and documented care for R61's colostomy care. According to the facility's Pouch Changes-Colostomy, Urostomy, and Ileostomy policy, reviewed May 24, 2022: It is the policy of this facility to ensure that residents who require colostomy, urostomy, or ileostomy services receive pouch changes consistent with professional standards of practices to minimizes occupational exposure and the resident's skin exposure to fecal matter or urine. Policy Explanation and compliance Guidelines:1. Ostomy care will be provided by licensed nurses under the orders of the attending physician. The order should include the type of ostomy, frequency of pouch change, and type of equipment. 2. The frequency of pouch changes will depend on the unique characteristics of the resident, including but not limited to: A. The type and location of the stoma. B. The type and amount of drainage from the stoma. C. The resident's activity level, body shape, and amount of perspiration. D. the type of pouching system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a social service assessment, treatment, and individualized dementia care interventions for one of one resident (R14) reviewed for dementia care, resulting in the lack of identification of resident's needs and treatments with the potential for inadequate medical care and services. Findings include: Resident 14: During an observation on 8/31/22 at approximately 9:30 AM R14 was observed wandering throughout the second floor secured unit. R14 was oriented to self only. During interview R14 said, I don't know what I'm suppose to be doing here. Review of the Electronic Medical Record (EMR) revealed R14 was admitted to the facility on [DATE] with diagnoses that included psychotic disorder with delusions, anxiety, depression, and unspecified dementia with behaviors . The Minimum Data Set (MDS) dated [DATE] indicated R14 had severe cognition impairment with a Brief Interview for Mental Status (BIMS) score of 2/15 along with behaviors of rejecting care 4-6 days per week and wandering 1-3 days per week. Section V, Care Area Assessment indicated 'use of antipsychotic medications', and 'behavioral symptoms'. R14 was prescribed two separate antipsychotic medications every day of the week. R14's social service assessment was incomplete and 205 days past due. On 4/10/22 the physician ordered a psychiatric consult for R14. On 4/12/22 a social work note documented the following; Resident is prescribed antipsychotic medications r/t (related to ) his diagnoses. He will be followed by psychiatric services and all care plans followed. There was no documentation to support R14 had ever been seen by psychiatric services. There was no care plan to address R14's use of antipsychotic medications, dementia, or behavioral needs. There were no PASSAR screenings (Preadmission Screening and Resident Review for Mental Illness/Intellectual Disability), psychiatric assessments or progress notes related to psychosocial needs of the resident. There were no social service progress notes in R14's EMR after 4/12/22. On 9/07/22 at 9:48 AM Social Worker (SW) C confirmed there were no PASSAR assessments, psychosocial/dementia care plan for R14 to address his psychiatric or behavioral needs. SW C said there was no evidence to support that R14 had been seen by Psychiatric services, screened for Mental Illness or Intellectual Disability, or assessed for any potential psychiatric/psychosocial needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor for the effectiveness of an antidepressant and ensure mental health services for one resident (#28) of five residents reviewed for unnecessary medications, resulting in the potential for serious side effects, adverse reactions and inability to monitor the effectiveness of the prescribed treatment. Findings include: According to R28's electronic medical records, he was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of encephalopathy, acute respiratory failure, diabetes mellitus type 2, Alzheimer's disease, osteoarthritis, depressive episodes, heart disease, hypertension, hepatitis C, and chronic kidney disease stage 1. R28's annual Minimum Data Set (MDS) with a reference date of 6/4/2022 indicated R28 had moderate cognitive impairment with a BIMS (brief interview for mental status) score of 11. Review of the Mood Care plan initiated 4/27/2022 documented, I am at risk for changes in my mood/behavior/psychosocial well-being related to restrictions of visitors and outside activities from the community. Interventions: Observe and report changes in mood or stressors .refer to psych services as needed. On 9/2/2022 at 11:30 a.m., review of the physician's orders dated 4/27/2022 documented, Psych consult, Mirtazapine tablet (used to treat depression) 15 mg give .05 mg tablet by mouth at bedtime for depression. Review of the social services progress notes revealed no documentation that R28 was evaluated by psych. No psych evaluation or GDR notes were available in the electronic medical records related to the diagnosis of depression and the antidepressant medication Mirtazapine. No documentation was available regarding monitoring the medication effectiveness or side effects was noted in the electronic medical records. On 9/2/10 at 10:34 AM, during an interview, the administrator stated that R28 should be seen by the psychiatrist due to the antidepressant medication and a psychiatrist is scheduled to visit the facility monthly. According to the facility's Behavioral Health Services policy with revised date of May 24, 2022, documented, policy: - It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. - Policy explanation and compliance Guidelines: Behavioral health encompasses a resident's whole emotional and mental well-being .11. The Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologists. During an interview with Chief Operating Officer (COO) G and the Regional Clinical Nurse Consultant (RN) H on 9/08/22 at 10:50 AM, they reported that the facility had been attempting to hire a full time Social Worker since the last Social Worker left on 6/17/22 (over 2 months ago). COO G reported that the facility had hired 2-3 full and part time Social Workers, all who have quit. RN H reported that she and the DON have been filling in working as Social Workers. COO G acknowledged that all aspects of the Social Service department were bigger than we thought and had not been completed timely (per facility's policies).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #28 According to R28's electronic medical record, he was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of encephalopathy, acute respiratory failure, diabetes mellitus type 2, Alzheimer's disease, osteoarthritis, depressive episodes, heart disease, hypertension, hepatitis C, and chronic kidney disease stage 1. R28's annual Minimum Data Set Assessment (MDS) with a reference date of 6/4/2022 indicated R28 had moderate cognitive impairment with a BIMS (brief interview for mental status) score of 11. On 9/2/2022 at 10:06 a.m., review of R28's MRR by a licensed pharmacist from dates of 7/30/2022, 6/22/2022, and 5/22/2022 revealed a pharmacy recommendation of irregularities found. Irregularities on 5/22/2022 documented,TDM (Therapeutic drug monitoring): need Q6 month (Every 6 month) HgA1c (a hemoglobin A1C test is a common blood test used to diagnose type 1 and 2 diabetes .Also used to monitor how well you're managing blood sugar levels), CMP (A comprehensive metabolic panel is used to check several body functions and processes, including: Liver and kidney health, blood sugar levels, blood protein levels, acid and base balance). On 6/22/2022 and 7/30/2022, the MRR revealed another irregularities recommendation of TDM still needed. Review of the physician's orders dated 4/23/2022, 4/26/2022, and 8/22/2022 for labs were as follow: A1C, CMP, CBC (A complete blood count is a blood test used to evaluate your overall health and detect a wide range of disorders, including anemia, infection and leukemia), TSH (A blood test that measures the hormones), Lipid Panel, Vitamin D, (for diabetes mellitus type 2). No labs results were noted in the electronic medical records for the above dates. Based on interview and record review the facility failed to ensure labs (blood draws) were obtained for two (R55 and R28) of 2 residents reviewed for Laboratory services per physician orders, resulting in the potential for ineffective therapeutic drug levels and ineffective treatment. Findings include: R55 On 9/7/22 at 11:50 A.M., review of the admission Record for R55 documented the resident was admitted to the facility 9/30/21, with diagnoses that included: Fusion of spine, anxiety disorder, convulsion, major depression, epilepsy, abnormal weight loss and covid-19. Review of the Physician Orders dated 4/19/22 : Keppra Level every 3 Months. Review of the monthly Pharmacy Medication Regimen Review (MRR) from 4/24/2022 -8/27/2022 revealed the facility did not follow through on the recommendations of the pharmacists. The irregularities identified were: 4/24/22 Irregularities found, Pharmacy response: Therapeutic Drug Monitoring (TDMs) due. 5/22/22 Irregularities found, 1. Still need TDMs (Registered Pharmacist) 6/23/22 Irregularities found, 1. Still need TDMs (request #3) 7/31/22 Irregularities found, 1. Still need TDMs (Registered Pharmacist). 8/27/22 Irregularities found 1. No (weights) in Point Click Care (PCC). 1. Still need TDMs (request #5). On 9/8/22 at 10:00 A.M., the Director of Nursing (DON) said she had just received computer access to review labs for the residents and there were no base line labs for R55 or any of the residents in the facility. The DON explained the only labs the facility ordered were identified as Stat Labs, any other labs requested were not done because the Laboratory was not allowed to enter the building. When queried about the recommendations from the monthly pharmacy reviews the DON acknowledged the irregularities and repeated requests for therapeutic drug monitoring but admitted she had not followed through because she had to start from scratch in establishing systems to follow up with the pharmacist recommendations.

Based on observation, interview, and record review the facility failed to ensure resident equipment was in good, clean condition for one of two crash carts resulting in the potential for injury due to lack of equipment maintenance. Findings Include: Obervation of the second floor nursing unit emergency crash cart with Registered Nurse (RN) D on 9/02/22 at 9:33 AM, the crash cart was observed to have on top, next to the back board, a foam bowl of black molded food, several cracker wrappers, several straw wrappers, a dried up slice of tomato, and an empty can of pop tipped on its side with mold noted where the sticky pop syrup spilled out. At this time RN D was asked about the monitoring for cleanliness of the crash cart to which she said, Midnight staff is supposed to clean it. There was no crash cart check off log (a log that documents that staff checked the crash cart nightly). At 10:35 AM during an interview with the Director of Nursing (DON), she reported that the midnight staff nurse is responsible for checking the crash cart nightly, It's part of they're duties.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #13 - A review of the clinical record for Resident #13 (R13) documented an initial admission date of [DATE] and readmission date of [DATE]. R13's diagnoses included hemiplegia and hemiparesis, cerebral infarction, and schizoaffective disorder bipolar type. A MDS dated [DATE] documented moderate cognitive impairment. The clinical record identified R13 had a LG. The Code Status on R13's Face Sheet was blank and an AMD was not available upon review of R13's clinical record. Review of the facility policy titled, Resident's Rights Regarding Treatment and Advanced Directives dated [DATE] documented, 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. R31 According to R31's face sheet he was a CPR/full code. There was no 'code status' or AMD form in R31's EMR. R31 was identified to have a LG and Family Representative with contact information on the face sheet. Review of the EMR revealed R31 admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia without behavior disturbance, anxiety and restlessness. The MDS dated [DATE] indicated R31 had severe cognition impairment. There are no social work notes or assessments in R31's EMR regarding the formulation of an AMD. R65 According to R65's face sheet she was a CPR/full code. There was no 'code status' or AMD form in R65's EMR. R65 was identified to have a LG and Family Representative with contact information on the face sheet. Review of the EMR revealed R65 admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included asthma, Schizophrenia (mental health disorder), and seizures. The MDS dated [DATE] indicated R65 had intact cognition. There are no social work notes or assessments in R65's EMR regarding the formulation of an AMD. On [DATE] at 9:19 AM, during an interview with the Administrator, it was reported that R31 did not have any advanced directives, and will have the Social Worker get resident advanced directives. On [DATE] at 9:21 AM, during an interview with Social Worker C it was reported to her to get the residents advanced directives. Based on interview and record review, the facility failed to ensure competent residents and/or the resident's legal representatives were involved in the formulation of an advance medical directive (AMD) 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 for 9 residents (R13, R14, R31, R36, R38, R41, R62, R65, and R66) of 17 residents reviewed for AMDs, potentially resulting in the denial of the resident's right to formulate an advance medical directive and the potential for unmet resident health care decisions. Findings include: On [DATE] at 3:18 PM the Nursing Home Administrator (NHA) was asked where the resident's AMDs forms were located. The NHA explained the AMD forms should be in the resident's Electronic Medical Record (EMR) but the facility recently hired a Social Worker and some (AMDs) may be in her office. The NHA was asked to locate the following 9 residents AMD forms. Resident 14: According to R14's face sheet he was a full code (all resuscitation procedures will be provided). There was no 'code status' or Advance Medical Directive (AMD) form in R14's EMR. There was no documentation or information to indicate R14 had a Legal Guardian (LG) or Family Representative. R14 was identified as his own financial responsible party. Review of the EMR revealed R14 admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavior disturbance. The Minimum Data Set (MDS) dated [DATE] indicated R14 had severe cognition impairment with a Brief Interview for Mental Status (BIMS) score of 2/15. There are no social work notes or assessments in R14's EMR regarding the formulation of an AMD. On [DATE] at 1:00 PM the NHA provided a paper AMD form dated [DATE] signed by a Legal Guardian service organization that indicated R14 was a full code. The Administrator could not provide any documentation to support R14 had a valid LG. The NHA acknowledged that R14's EMR indicated that the resident was his own responsible party. Resident 36: According to R36's face sheet he was a full code (all resuscitation procedures will be provided). There was no 'code status' or Advance Medical Directive (AMD) form in R36's EMR. R36 was identified to have a LG and Family Representative with contact information on the face sheet. Review of the EMR revealed R36 admitted to the facility on [DATE] with diagnoses that included schizophrenia and vascular dementia. The Minimum Data Set (MDS) dated [DATE] indicated R36 had severe cognition impairment with a Brief Interview for Mental Status (BIMS) score of 7/15. There were no social work assessments or progress notes in R36's EMR. On [DATE] at approximately 1:00 PM Social Worker (SW) C confirmed there was no AMD form and no social service progress note or assessment for R36 at this time. Resident 41: According to R41's face sheet he was identified as a CPR/full code (all resuscitation procedures will be provided). R41 was identified to have a LG and Family Representative with contact information. Review of the EMR revealed R41 had an AMD form dated [DATE] signed by R41, his LG, a family member, and a public notary that indicated he was a Do Not Resuscitate (an order that instructs healthcare provided not to do CPR if a person's heart stops beating or they stop breathing). The Minimum Data Set (MDS) dated [DATE] indicated R41 had no cognition impairment with a Brief Interview for Mental Status (BIMS) score of 15/15 without behaviors. There were no social work notes or assessments regarding R41's AMD form. On [DATE] at 1:37 PM the NHA acknowledged the discrepancy of code status for R41 in the EMR. The NHA said the Social Worker would Look into the resident's code status with R41's LG and update the medical record. R38 On [DATE] at 2:14 P.M. review of the admission Record, revealed the resident was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, dementia, heart failure, peripheral vascular disease, type 2 diabetes mellitus, epilepsy, convulsion, chronic kidney disease, dependence on renal dialysis and deformity of the lower leg. According to Minimum Data Set (MDS) dated [DATE], R38 was moderately impaired in cognition, had a deficit in memory, judgement and decision-making and required limited assistance with set up for Activities of Daily living (ADL's). Further record review documented on the Resident's Profile, the Resident's Code Status as Full Code/CPR, however there was no evidence of an Advance Directive, or any information provided or presented to the resident's current legal guardian. R62 On [DATE] at 2:30 P.M. review of the admission Record, for R62 revealed the resident was admitted to the facility on [DATE], with diagnoses of contusion and laceration of cerebrum, dementia with behavioral disturbance, hypertension, heart failure and atherosclerotic heart disease According to the quarterly MDS dated [DATE] R62 alert and oriented 1-2, able to make his needs known, required assistance and supervision, and set up for all activities of daily living. The Resident's Profile documented the resident's Code status as Full code/CPR. Review of the Clinical record documented the facility had applied for guardianship for the resident. There was no evidence( Copy) of Advanced Directive or discussion of facility's staff informing the resident's representative of their right to establish and Advanced Directive on behalf of the resident. R66 On [DATE] at 4:00 P.M. Review of the admission record for R66 revealed the resident was admitted to the facility on [DATE], with diagnoses quadriplegia, central cord syndrome, cervical myelopathy, and idiopathic peripheral neuropathy. The quarterly Minimum Data Set (MDS) dated [DATE], indicated the resident was independent in cognition and required extensive assistance with one-person physical assist with Activities of daily living (ADLs). Review of the Advance Directive section of the admission Record documented CPR/full Code. There was no evidence that the resident (who was his own responsible party) was given an opportunity to formulate and discuss an Advance Directive until [DATE] when a request was made from Social Worker to review the document. A Social Service note dated [DATE] indicated the resident had decline a full code.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #4 - A review of the clinical record for Resident #4 (R4) documented an initial admission date of 4/15/2020 and readmission date of 9/16/2020. R4's diagnoses included human immunodeficiency virus, gastrointestinal hemorrhage, and schizophrenia. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A further review of R4's clinical record documented the following: 1. Nurse progress note of 4/30/2022 at 11:40 AM: Resident observed having coffee ground emesis, and projectile vomiting. Unable to notified (sic) Dr. left a message to call regarding resident .DON notified will continue to monitor patient. 2. Nurse progress note of 5/1/2022 at 8:14 AM: Received a new order to send resident out. All care will be endorsed to oncoming nurse. 3. Nurse progress note of 5/1/2022 at 12:09 PM: Per report from previous nurse, resident had two episodes of brown emesis and orders was given to send resident out 911. EMS (emergency medical service) called and resident left the building and was transferred to (local hospital) at 0830. During an interview and review of R4's clinical record on 9/8/2022 beginning at 11:28 AM, DON said the guardian was not notified when R4 went to the hospital. The DON stated it was important to notify the resident representative because they may have a preference of hospital and or treatment. A review of the facility policy titled, Notification of Changes, dated 9/2/2022, was reviewed and revealed in part the following: - The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. - Circumstances requiring notification include .A transfer or discharge of the resident from the facility. R25 Record review revealed that R25 moved from room [ROOM NUMBER]-1 to room [ROOM NUMBER]-1 on 7/2/22. According to the medical record R25 admitted to the facility on [DATE] with multiple diagnoses that included dementia, kidney disease and alcohol abuse. R25 had a LG with the accurate contact information on the 'face sheet'. The MDS dated [DATE] indicated R25 had severely impaired cognition. There was no documented evidence in the medical record that the resident's LG was made aware of the room change. R31 Record review revealed that R31 moved from room [ROOM NUMBER]-3 to room [ROOM NUMBER]-2 on 7/2/22. According to the medical record R31 admitted to the facility on [DATE] and re-admitted on [DATE] with multiple diagnoses that included dementia, protein calorie malnutrition and anxiety. R31 had a LG with the accurate contact information on the 'face sheet'. The MDS dated [DATE] indicated R31 had severely impaired cognition. There was no documented evidence in the medical record that the residents LG was made aware of the room change. R34 Record review revealed that R34 moved from room [ROOM NUMBER]-1 to room [ROOM NUMBER]-1 on 7/2/22. According to the medical record R34 admitted to the facility on [DATE] with multiple diagnoses that included Schizophrenia (mental health disorder), pain and muscle wasting. R34 had a LG Company with the accurate contact information on the 'face sheet'. The MDS dated [DATE] indicated R34 had severely impaired cognition. There was no documented evidence in the medical record that the resident's LG was made aware of the room change. R51 Record review revealed that R51 moved from room [ROOM NUMBER]-1 to room [ROOM NUMBER]-1 on 7/2/22. According to the Medical Record R51 admitted to the facility on [DATE] with multiple diagnoses that included chronic obstructive pulmonary disease (COPD), heart failure, and liver disease. R51 had a LG Company with the accurate contact information on the 'face sheet'. The MDS dated [DATE] indicated R51 had intact cognition. There was no documented evidence in the medical record that the resident's LG was made aware of the room change. R52 Record review revealed that R52 moved from room [ROOM NUMBER]-3 to room [ROOM NUMBER]-2 on 7/2/22. According to the medical record R52 admitted to the facility on [DATE] with multiple diagnoses that included high blood pressure, Schizophrenia, and high blood sugars. R52 had a LG Company with the accurate contact information on the 'face sheet'. The MDS dated [DATE] indicated R52 had intact cognition. There was no documented evidence in the medical record that the resident's LG was made aware of the room change. R70 Record review revealed that R70 moved from room [ROOM NUMBER]-3 to room [ROOM NUMBER]-3 on 7/2/22. According to the Medical Record R70 admitted to the facility on [DATE] with multiple diagnoses that included Schizophrenia, high blood pressure and hallucinations. R70 had a LG Company with the accurate contact information on the 'face sheet'. The MDS dated [DATE] indicated R70 had severely impaired cognition. There was no documented evidence in the medical record that the resident's LG was made aware of the room change. On 9/2/22 at 10:35 AM during an interview with the facility's Administrator, it was reported that the Legal Representatives were notified of the room changes. The Administrator was unable to provide documentation of the room change notification for R25, R31, R34, R51, R52 and R70. Review of the facility's policy titled, Change of Room or Roommate: dated 5/24/22 documented, .4. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible. This citation pertains to intakes; MI00130207, MI000126155 and MI00130261. Based on observation, interview, and record review, the facility failed to notify Legal Guardians (LG)/ Resident Representatives of a change in condition or room change for eight residents (R4, R25, R31, R34, R51, R52, R70, and R123), out of 11 residents reviewed for notification of changes resulting in the LG/Resident Representatives being unaware of a change in the resident's medical condition or physical location (room change) and therefore unable to participate in resident care decisions. Findings include: Resident 123: On 9/1/22 at approximately 11:00 AM, R123's LG said resident (R123) was sent out to the hospital on 8/1/22 and the facility staff did not notify him. The LG said he was made aware on 8/3/22 when the hospital staff notified him that the resident (R123) had been in the hospital for two days. According to the Electronic Medical Record (EMR) R123 admitted to the facility on [DATE] with multiple diagnoses that included Cerebral Insufficiency and History of Alcohol Dependence. R123 had a LG with the accurate contact information on the 'face sheet'. The Minimum Data Set (MDS) dated [DATE] indicated R123 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15/15 and no behaviors. A nursing note on 8/1/22 at 12:18 PM indicated R123 was transferred to the local hospital by the local police because of aggressive behaviors. There was no documentation to support the resident's LG was notified of the 'change in condition' in the resident's medical condition or transfer out of the facility. A psychiatric note on 8/1/22 at 12:20 PM documented R123 was transferred out to the local hospital due to aggressive behaviors by local police. There was no documentation to support the resident's LG was notified of the 'change in condition' in the resident's medical condition or transfer out of the facility. On 9/1/22 at approximately 2:00 PM Social Worker (SW) C was asked if R123's LG had been notified of the change in his condition. SW C said she was not working at the facility during that time, but could not provide any documentation to support the resident's LG had been notified. SW C confirmed that all resident representatives should be notified if there is a change in condition which included transfers out of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake number MI00126409. Based on observation and interview, the facility failed to ensure residents' bed linens were in good condition and bed was free from excessive dirty linen and clothes for resident (R48), bed side tables were clean, floors free from trash, trash cans overflowing with garbage, and rooms free from urine like smell for residents (R55, R57, and R59) and failed to maintain furniture in good condition for residents (R23 and R49) from a total of 22 residents reviewed for safe, clean, comfortable homelike environment, resulting in a resident expressing displeasure and residents' environment not being homelike. Findings include: R48 During the initial tour of the facility on 8/31/2022 at 9:37 a.m., R48 was lying in bed alert and able to be interviewed. R48 was observed lying on dirty sheets, pillowcases, and a pile of what appeared to be dirty linen and clothes on the bed. During an interview, R48 said, They change my bed linen sometimes, but I would like to be lying on clean linen. I will get around to washing those clothes on the bed soon. R48 was informed the facility will wash his clothes for him. R48 said, Okay, I didn't know. R48 was unable to recall the last time his bed linen was changed, and someone assisted him with washing and putting his clothes away. On 8/31/2022 at 9:44 a.m., room [ROOM NUMBER], with three occupants, was observed with sticky substances on overbed tables, garbage cans were filled and overflowing, paper and other trash was on the floor, and a urine like smell was noted. The occupants of room [ROOM NUMBER] were not in the room and not available for interviews. Certified Nursing Assistant (CNA) L walked into the room picking up paper and other trash off the floor and cleaning off the overbed tables. During an interview CNA L said, Housekeeping should be doing this. During the initial tour of the facility on 8/31/2022 at 10:20 AM, Resident #23 (R23) was observed awake and sitting in her room. The closet for R23 was missing a door. R23 stated, I need one (a closet door) because my roommate gets into my stuff. R23 said she has been without a closet door since February 2022. On 8/31/22 at 11:03 AM, the closet door for Resident #49 was observed propped up against a wall. During an interview on 9/8/2022 beginning at 12:08 PM the Nursing Home Administrator mentioned the importance for residents to have a comfortable and homelike environment. R55 On 8/31/22 at 9:30 A.M., in R55's room the resident complained the room was nasty and there was an odor in the room. The resident's floor was littered with pieces of paper and track marks from a wheelchair. The resident stated, This room should be cleaned every day but once you all leave it will go back. The staff will come in here now and clean, but it will not last. R55 was observed with a bag of dirty laundry positioned in the corner which he indicated he sent out for cleaning rather than the facility laundry clean his clothing. R57 On 8/31/22 at 10:00 A.M., in the resident's room, the overbed table had an opened carton of milk. On the window seal an opened pop bottles, snack foods and a urinal that was half filled with dark yellow urine were observed. A strong urine odor permeated the room. The blinds had gapping holes and missing slots. The resident's floor was observed sticky. R59 On 9/2/22 at 1:13 P.M. during an interview on the left side of R59's bed was a pile of personal clothing which the resident had stored with opened cans of pop and snacks (crackers, chips, and milk). Flies were observed flying in the room resting on the opened pop container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to periodically release a restraint (secured table top attached over a recliner) for one (R31) of one resident reviewed for restraint use resulting in the restriction of freedom of movement. Findings include: During observations on the second floor nursing unit the following was observed for R31. Day 1: -8/31/22 at 10:10 AM, R31 was in the Memory Lane dining room sitting in recliner with table top secured over the resident's midsection. R31 was pulling on the secured table, and yelling out. R31 was asked to release the table and continued to incoherently pull at the table. -8/31/22 at 12:18 PM, R31 remained in dining room with table top over the recliner. R31 was noted sleeping in the recliner at this time. -8/31/22 at 2:15 PM, R31 remained in the recliner in the dining room with the table top secured at the midsection region. Day 2: -9/01/22 at 8:58 AM, R31 observed awake and fidgety, up in recliner in Memory Lane dining room with the table top secured over the recliner. -9/01/22 at 9:15 AM, Certified Nurse Aide (CNA) E was observed feeding R31 with table top over the recliner. When queried, CNA E reported that R31 could ambulate with 1 person staff assistance. CNA E was asked about the table top restraint and reported It was to keep her from falling. -09/01/22 at 11:14 AM, R31 remained in Memory Lane dining room, sleeping with top table in place over recliner. Staff members observed walking in and out of room. -09/01/22 at 1:16 PM, R31 observed being fed lunch by CNA E with the table top restraint in use. -09/01/22 at 3:16 PM, R31 observed pulling on table top restraint and yelling out. Day 3: -09/02/22 at 9:22 AM, R31 in Memory Lane dining room with table top restraint over recliner. Day 4: -09/07/22 at 9:26 AM, R31 in her room in recliner with table top restraint in place. R31 appeared restless, pulling on table and talking nonsensically. -09/07/22 at 11:26 AM, R31 remained in her room in recliner with table top restraint in place. R31 was anxiously pulling on the table. During the 4 days of observation, the table top restraint was not observed to be released or offered to be released. Review of the clinical record for R31 revealed an admission into the facility on 5/11/20 and re-admission on [DATE] with pertinent diagnoses which included dementia and behavioral disorder, anxiety, and restlessness and agitation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition. The MDS documented R31 required one person staff assistance for ambulation. Review of a 10/11/21 care plan titled, Use of Restraint(s) for safety and comfort of (name of R31), related to: (Name of recliner) with tray, (name of resident) rocks and pounds on chair while up in wheelchair and table top use keeps her positioned in place while up in chair. Interventions included: Offer and encourage to ambulate as tolerated every 2 hours during restraint release, offer and encourage to be toileted at least every (q) 2 hours, and reposition in chair or device after release period and as needed, to improve comfort and safety of (R31's name) while restraint device is being used. Review of a 9/6/21 physician's order documented, (Brand name of recliner) with table top as needed throughout the day, check every 15 minutes & release every 2 hours. Along with the Director of Nursing (DON) on 9/07/22 at 1:04 PM, R31 was observed restrained with the table top in place while CNA F was feeding resident. The DON asked CNA F how often R31 was released from restraints, to which the CNA responded, On day shift, once a day when we change her. The DON said she was going to check the CNA task guide (a guide for the CNA to use to provide individualized resident care) to see if releasing the restraint every 2 hours was on the guide. The DON confirmed the CNA task guide dated 8/31/21 for R31 did indicate, Release restraint at least every 2 hours, ROM (range of motion) or assist ambulate, check resident every 15 minutes while up in chair. Promote rest periods. There was no documentation of the release of the restraint prior to 9/7/22. Review of the facility's policy tiled, Restraint Free Environment dated 5/24/22 documented, 5. Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine: .b. The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released, as this will vary with each individual .

Based on interview and record review, the facility failed to submit Minimum Data Set (MDS) assessments in a timely manner, affecting 4 residents (R1, R2, R6, R16) out of 4 residents reviewed for resident assessments, resulting in the delay of time sensitive information used to monitor each residents decline or progress overtime. Findings include: Record review on 9/2/22 at 12:30 P.M. of residents' MDS data revealed the following: R1= admission MDS assessment, admission date 5/9/2018, MDS record revealed overdue 120 days, completed 7/6/22, but the facility could not verify submission date. R2= Quarterly MDS assessment, admission date 1/19/22, MDS record revealed overdue 180 days Completed 8/9/22, but the facility could not verify submission date. R6= Annual MDS assessment, admission date 7/7/2021, MDS record revealed 120 days overdue, Completed 8/9/22. The facility could not verify the submission date, only the completion date could be viewed. R16= Quarterly MDS assessment, admission date 3/29/22, MDS record revealed overdue 180 days. The facility could not verify the submission date. During the record review of the MDS assessments for the residents, MDS Coordinator I was queried concerning the delay in submitting of the MDS assessments to the State Agency and Centers for Medicare & Medicaid Services. The MDS coordinator stated prior to her accepting the current position, the position was vacant. When she assumed the position there was a back log of MDS assessments not completed. The MDS coordinator would not provide a number or quantify the number of incomplete MDS assessments left. On 9/8/2022 at 1:00 P.M. a policy was requested. The Administrator indicated there was no policy, but the facility followed the guidelines developed by the Center for Medicare and Medicaid (CMS). The Administrator commented the Corporate Office was aware of the delay in submitting the MDS assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #58 According to the EMR, R58 was admitted to the facility on [DATE] with diagnoses of generalized anxiety, adjustment disorder with mixed anxiety and depressed mood, and other specified depressive episodes. R58's quarterly MDS with a reference date of 7/22/22 indicated intact cognition with a BIMS (brief interview for mental status) score of 15. A care plan initiated on 7/23/22 for Mood/behavioral/psychosocial well-being documented, I am at risk for changes in my mood/behavior/psychosocial well-being related to restrictions of visitors and outside activities from the community .Interventions: Refer to psych services as needed. Review of the physician's medication orders revealed, Lorazepam tablet 1 milligram give one tablet by mouth every 12 hours for anxiety, and psych consult. Review of R58's 5/28/2021 Level I PASARR-Form 3877, dated 8/31/2022, revealed, Section II, Numbers 1, 2 and 3 were checked Yes with the diagnoses of Mental Illness circled. The explanation for the Yes responses included: Major Depressive Disorder, anxiety and one anti-anxiety medication that R#58 was prescribed. According to the Level I PASARR-form 3877 Notes: The person screened shall be determined to require a comprehensive level II OBRA evaluation if any of the above items are Yes Unless a physician, nurse practitioner or physician's assistant certifies on form DCJ-3877 that the person meets at least one of the exemption criteria. section II: 1. The person has a current diagnosis of mental illness: Yes. 2. The person has received treatment for mental illness: Yes. 3. The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days: Yes. The explanation for the Yes responses included: Bipolar II disorder, adjustment disorder with mixed anxiety and depressed mood. RX (medication): Alprazolam, Ativan (Anxiety medications). Being that Section II (Numbers 1, 2 and 3) were checked Yes, the Level II OBRA 3878 was searched for in the EMR but could not be located. The EMR revealed a written request Facility Intake Referral for the Level II (3878) dated 5/28/2021. On 8/31/2022 at 1:10 PM during an interview with the Director of Nursing (DON), a hard copy of R58's Level II (3878) was requested. On 8/31/2022 at 2:30 p.m. a copy of the Level I (3877) was presented but no Level II (3878). According to the facility's Resident Assessment - Coordination with PASARR Program, last revised on 9/1/22; This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. a. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. 3. A record of the pre-screening shall be maintained in the resident ' s medical record. 4. Exceptions to the preadmission screening program include those individuals who: a. Are readmitted directly from a hospital. b. Are admitted directly from a hospital, requires nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. 5. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state- designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. Resident #10 - Review of the clinical record for Resident #10 (R10) documented an initial admission date of 11/25/2016 and readmission date of 8/23/2018. R10's diagnoses included major depressive disorder, alcohol abuse with alcohol-induced psychotic disorder with delusions, and bipolar disorder. A MDS dated [DATE] documented intact cognition. A review of R10's most current Level 1 Annual Resident Review (Form 3877), dated 12/22/2020, revealed Section II, Numbers 1, 2, 3, and 4 were checked Yes and R10 had a current diagnosis of and was receiving treatment for mental illness. The explanation for the Yes responses included: - a diagnosis of major depression and bipolar disorder - medication regimen included Seroquel, Trazadone, and Mirtazapine There was no Level II Screening (Form 3878) available for R10. Resident #13 - Review of the clinical record for Resident #13 (R13) documented an initial admission date of 2/9/2022, discharge date of 5/8/2022, and readmission date of 5/15/2022. R13's diagnoses included schizoaffective disorder bipolar type. A MDS dated [DATE] documented moderate cognitive impairment. A review of R13's most current Level 1 Annual Resident Review (Form 3877), dated 4/6/2021, revealed Section II, Numbers 1, 3, and 4 were checked Yes and R13 had a current diagnosis of mental illness and dementia. The explanation for the Yes responses included: Pt has a limited history of psychiatric hospitalization. Recent medical challenges are representing the need for supervised medical and psychiatric care. The most current Level II Screening (Form 3878) available for R13 was dated 4/6/2021. Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Mental Illness/Intellectual Disability Related Condition Level 1 Screening and/or failed to complete a Level II evaluation for four (R10, R13, R14, and R58) of six residents reviewed for PASARR screening, resulting in the potential for unmet mental health and psychiatric care needs. Findings include: According to the PASARR form, if a resident had a Mental Illness or Dementia diagnosis, The person screened shall be determined to require a comprehensive Level II OBRA evaluation if any of the above items are Yes UNLESS a physician, nurse practitioner or physician's assistant certifies on form DCH-3878 (Level II exemption form) that the person meets at least one of the exemption criteria. (OBRA, Omnibus Budget Reconciliation Act of 1993, evaluates persons with MI diagnosis to determine most appropriate 'placement' for services to receive specialized behavior programs) . Resident 14: Review of the Electronic Medical Record (EMR) revealed R14 was admitted to the facility on [DATE] with diagnoses that included psychotic disorder with delusions, anxiety, depression, and unspecified dementia with behaviors . The Minimum Data Set (MDS) dated [DATE] indicated R14 had severe cognition impairment with a Brief Interview for Mental Status (BIMS) score of 2/15 along with behaviors of rejecting care 4-6 days per week. R14 was prescribed two antipsychotic medications every day of the week. On 4/10/22 the physician ordered a psychiatric consult for R14. There were no PASSAR screenings, no psychiatric assessments or progress notes, and no social service assessments or progress notes in R14's EMR. On 9/07/22 at 9:48 AM Social Worker (SW) C confirmed there were no PASSAR assessments in R14's EMR. SW C said there was no evidence to support that R14 had been screened for Mental Illness or Intellectual Disability or assessed for any potential psychiatric needs.

Based on interview and record review the facility failed to ensure nursing competencies were performed for 5 of 5 current nurse aide staff resulting in the potential for unmet care needs. Findings Include: On 9/2/2022 at 11:00 A.M., a list of Nurse Aides names was presented to the Administrator for review of Nurse Aide competencies. The list provided included a random selection of Nurse Aides with the dates of hire for each staff member. A. DOH- 9/5/2000 B. DOH- 4/7/2021 C. DOH- 3/3/2021 D. DOH-8/21/2006 E. DOH- 1/3/2019. On 9/2/22 at 3:30 P.M. it was disclosed via an confidential interview the Nurse Aide competencies were not available. On 9/7/2022 at approximately 11:00 A.M., the Director of Nursing (DON) presented two large notebooks, titled: Staff Education Record and Inservice Book. Review of the notebooks provided, did not correspond to the list of nurse aides presented on 9/2/2022. On 9/8/2022 at 12:30 P.M., further review of the Inservice notebooks outlined training schedules for the entire facility. There was no evidence or documentation of evaluation of the current Nurse Aides clinical skills and techniques used for rendering resident care. In a follow-up interview at 12:50 P.M, the DON acknowledged no other information was available related to nurse aide competencies. The facility's policy was requested related to Nurse Aide competencies, but not provided upon exiting the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to respond timely to monthly medication regimen review (MRR) recommendations for noted irregularities for six residents (R14, R38, R47, and R65) of 24 residents reviewed for MRR, resulting in unnecessary and unmonitored medication use. Findings include: R47 Review of the clinical record for R47 revealed an admission into the facility on 4/18/19 and re-admission on [DATE] with diagnoses which included gastro-esophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented moderately impaired cognition. The MDS documented R47 required one person staff assistance for all activities of daily living (ADL's). Review of the Pharmacy Medication Regimen Reviews dated 4/24/22, 5/21/22, 7/24/22 and 8/27/22 revealed pharmacy recommendation to change prescribed medication, Pepcid (Famotidine-used for the treatment of gastric reflux disease) from morning (AM) to prior to bedtime (HS). Review of the Medication Administration Records (MAR's) from May, June, July, and August 2022 revealed Pepcid was being administered daily to R47 at 9:00 AM. R65 Review of the clinical record for R65 revealed an admission into the facility on 1/29/22 and re-admission on [DATE] with diagnoses which included age related osteoporosis (low bone mass). Review of the quarterly MDS assessment dated [DATE] documented intact cognition. The MDS documented R65 required one person staff assistance for all ADL's. Review of the Pharmacy Medication Regimen Review's dated 6/21/22, 7/30/22, and 8/27/22 revealed pharmacy recommendation to reduce dose and obtain 25 OH D (Vitamin D blood level) for prescribed medication, Ergocalciferol Capsule (vitamin D) 1.25 MG (50000 UT). Give 1 capsule by mouth every day shift. Review of the June, July, and August 2022 MARS revealed R65 received the same dose of Vitamin D each month. The clinical record revealed no order to check the Vitamin D level. During a phone interview on 9/07/22 at 11:15 AM with RPh A, he reported that he believed pharmacy recommendations had not been followed up due to a high turnover of Administrators and Director of Nursing (DON's). The physicians are not addressing the recommendations either. During an interview with the DON on 9/07/22 at 11:35 AM, she reported, We are going to hold the medication (Vitamin D) at this time (for R65), and draw the blood level. I don't know why it (pharmacy recommendations) were not done, I was not here at that time. That will not happen again on my watch. Resident 14: Review of the clinical record documented R14 admitted to the facility on [DATE] with pertinent diagnoses of unspecified dementia with behaviors and adult failure to thrive. The MDS dated [DATE] indicated R14 had severe cognition impairment with behaviors of rejecting care 4-6 days a week. Review of R14's Pharmacy Medication Regimen Review's dated 5/21/22, 6/21/22, 7/24/22 and 8/27/22 revealed pharmacy recommendation to change prescribed medication, Docu Liquid 50 MG (milligram)/5 ML (milliliter) (Docusate Sodium, a stool softener), from Give 5 ml by mouth two times a day to Give 10 ml one time a day. Review of the Medication Administration Records (MAR's) from May, June, July, and August 2022 revealed Docu Liquid 50 MG /5 ML was being administered twice a day. On 9/2/22 at 1:57 PM the Director of Nursing (DON) said that she had recently been hired at the facility and was unaware of who had been managing the Pharmacist's monthly medication recommendations. The DON said she would ask the Corporate Nurse, Registered Nurse (RN) H how that process has been handled. On 9/2/22 at 2:09 PM The DON said, Going forward I will be receiving the Pharmacists's monthly reports and review them. Review of the facility's policy titled, Medication Regimen Review dated 5/24/22 documented, 1. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes: a. Review of the medical record in order to prevent, identify, report, and resolve medication- related problems, medication errors, or other irregularities. b. Collaboration with other members of the interdisciplinary team, including the resident, their family, and/or resident representative .Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. R38 On 9/8/22 at 9:30 A.M. review of the admission Record, revealed R38 was admitted to the facility on [DATE], with diagnoses which included: chronic obstructive pulmonary disease, heart failure, peripheral vascular disease, Type 2 diabetes mellitus, epilepsy, convulsion, chronic kidney disease, dependence on renal dialysis and deformity of lower leg. Review of the monthly Pharmacy Medication Review dated 6/21/22 Irregularities found, Pharmacy summary: Diagnoses (Dx) : Apixaban should not be Heart Failure. (What is the proper diagnosis?). The recommendation from the pharmacist had not been acted upon or responded to by the facility staff. On 9/8/22 at 10:00 A.M., when the DON was queried about the recommendations from the monthly pharmacy reviews, the DON acknowledged the irregularities .but admitted there was no follow through because there was no system established in place to follow up with the pharmacist recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide alternate means of alerting staff when the Resident Call System did not function as designed on 2 of 3 hallways (1 North and 2 South), resulting in the potential for delayed ability to contact staff for care needs. Findings Include: Upon entrance into the facility on [DATE] at 8:15 AM, it was noted that the facility was experiencing a power outage and the facility's power was being supplied by a generator. At 10:07 AM, during the entrance conference with the facility's Administrator she reported that part of the resident call light system was not on the generator, and residents with non-functioning call lights should have a bell (so they can call for assistance). At 10:35 AM, the 1 North and 2 South nursing units were checked for functioning call lights along with the Administrator. The call lights were non-functioning, nor did the residents have bells to call for assistance. At 11:10 AM, 1 North residents (R19) and (R51) were both interviewed regarding the non-functioning call light system to which they reported they had no way to get ahold of staff, so they wheel themselves into the hallway to get staffs attention. At 11:28 AM, 2 South resident (R35) was interviewed regarding the non-functioning call light to which she said she walks down to the nurses station to get ahold of staff. During an interview on [DATE] at 8:50 AM, with Maintenance Director (MD) B he reported the power outage started on [DATE] approximately between 1 am and 6 am. MD B confirmed part of the call light system was not on the generator. He reported that Units 1 North (25 residents) and 2 South (24 residents) call lights were non-functioning saying, We were trying to find bells, but we just got them in (2 days after power outage began). Review of the facility's policy titled, Call Lights: Accessibility and Timely Response dated [DATE] documented, .8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 8/31/2022 at 11:20 AM, Resident #10 (R10) stated, I get my nighttime pain meds late; about two to three hours late. Review of the clinical record for R10 documented an initial admission date of 11/25/2016 and readmission date of 8/23/2018. R10's diagnoses included major depressive disorder, alcohol abuse with alcohol-induced psychotic disorder with delusions, and bipolar disorder. A MDS dated [DATE] documented intact cognition. A further review of R10's clinical record revealed that the following medications were not documented as administered on 8/27/2022: - Aspercreme lidocaine patch for pain at 8:00 AM - Atorvastatin for cholesterol maintenance at 9:00 PM - Clopidogrel for prevention of blood clots at 9:00 AM - Cyclobenzaprine for muscle spasm at 6:00 AM and 2:00 PM - Glipizide for blood sugar management at 9:00 AM and 5:00 PM - Novolog, insulin given according to a sliding scale for blood sugar management, at 6:30 AM, 10:30 AM, and 4:00 PM. This citation pertains to intakes: MI00130869, MI00124940. Based on interview and record review the facility failed to maintain sufficient nursing staff to administer medications for 5 (R10, R46, R55, R57, and R59) of 24 residents, resulting in a potential for compromised health status and well- being. Findings include: On 8/31/22 at 8:30 A.M., R55 stated, The past weekend (8/26, 8/27, 8/28) all the nurses called off and the residents did not get their medications. R55 commented he searched the building and could not find a nurse or anyone to give him his medications. The corporate nurse and Director of nursing came in to help but neither one passed medications. When we realized, we were not going to get our medications some of us began calling our families, ombudsman and/or 911, hoping someone would come and see what was happening. R55 explained Saturday 8/27/22 as the day residents did not get medications. R55 continued to explain stating, I was not the only resident that did not receive medications and other residents should be asked if they received theirs. R46 who was the roommate of R55 interjected during the interview, he is telling the truth, we did not get our medications, I did not get my pain medication until early afternoon. I asked for it in the morning when I was scheduled to get the medicine. R55 On 8/31/22 at 2:00 p.m., Review of the admission Record for R55 documented the resident was admitted to the facility on [DATE], with diagnoses which included: Fusion of the spine, Convulsion, epilepsy, Seizure disorder, and adjustment disorder. On 9/1/22 at 1:00 P.M., review of the Medication Administration Record (MAR) for 8/27/22 the following pertinent medications were not administered: Tegretol Tablet 200 milligram (mg) 1 Tablet (T) morning dose, (medication given to control epilepsy). Letiracetum Tablet 500 mg 1 T morning dose, (used to control convulsions). Amitriptyline HCL 25 mg 1 T bedtime dose, (used for antidepressant) Toprol Tartrate Tablet 50 mg morning and afternoon dose, (used to control hypertension). R46 On 9/1/22 at 2:00 P.M. review of the admission Record documented R46 was admitted to the facility on [DATE], with diagnoses of complete traumatic amputation at the knee level, hypertension, atrial fibrillation, heart failure, and peripheral vascular disease. Review of the MAR for 8/27/22, indicated the following pertinent medications were not administered to the resident: Amlodipine Tablet 10 mg 1 T, morning dose for hypertension. Gabapentin capsule 400 mg 1 T a day, morning dose (used for nerve pain) Xarelto 20 mg 1 T one time a day for Atrial fibrillation, morning dose (used for irregular heart rate, blood thinner) Amiodarone Tablet 200 mg 2 tablets one time a day, morning dose ( used for Atrial fibrillation.) Norco Tablet 7.5-325 mg 1 T every 4 hours and as needed for pain , documented as given at 10:51 P.M. R46 had requested pain medication that morning. R57 On 9/1/22 at 9:40 A.M., review of the admission Record for R57 documented the resident was admitted to the facility on [DATE] with diagnoses which included: chronic obstructive pulmonary disease, diabetes mellitus with diabetic polyneuropathy, chronic kidney disease, stage 3, Peripheral vascular disease, hypertension, acquired absence of left leg above the knee. Review of the MAR for 8/27/22, indicated the following pertinent medications were not administered to R57. Amlodipine Besylate Tablet 5 milligram 1 T once a day, morning dose ( used to control hypertension) Aspirin 81 milligram 1 T, morning dose (used for heart failure) Colace capsule 200 milligram, morning dose (used to avoid constipation in residents with heart disease). Nedipine ER tablet 60 milligram 1 T one time a day, morning dose (used for hypertension) Brilinta 90 milligram (Ticagrelor) 1 T two times a day, morning or evening dose (used to prevent blood clotting) Lactulose Solution 30 milliliter every 12 hours, morning or evening dose (used to prevent constipation) Toprol Tartrate Tablet 50 milligram 1 T two times a day, morning or evening dose (used for hypertension). R59 On 9/2/22 at approximately 12:30 p.m. R59 entered the surveyor's room insisting to speak with a surveyor. The resident was directed to go to his room where an interview was conducted. R59 reported on 8/27/22 he did not receive his medications and wanted to report what had happened. The resident explained he called 911 trying to get some help but was not sure if they responded. Review of the admission Record for R59 documented the resident was admitted to the facility on [DATE], with diagnoses which included: pain, diabetes mellitus, primary hypertension, chronic Kidney disease, atherosclerotic heart disease. Review of the MAR for 8/27/22 the following pertinent medications were not administered: Gabapentin Cap 100 milligram 1 Capsule three times a day, morning and evening dose (used for neuropathy (nerve) pain. Paroxetine tab 30 mg 1 T, morning dose (used to treat generalized Anxiety). Trazadone 1 Capsule twice a day, eveing dose (used for depression). On 9/8/22 at 9:00 A.M. during an interview the Director of Nursing (DON) acknowledged the weekend of 8/26, 8/27, and 8/28, the facility had experienced a challenge with staffing. The DON stated, on 8/26/22 all the nurses on the first and second shift called off and the facility wasn't able to acquire anyone from the Agency to fill in and work. (This was part of the facility's emergency plan to address staffing shortages). The DON explained a staff nurse from their sister facility did come and assist the nurses on the unit for a while but could not stay for the entire shift. When the facility was informed of the staffing shortage a staff E- mail was sent out for all managers to return to the building. The DON reported Regional Clinical Nurse Consultant (RCNC) H and herself came into the facility and stayed and assisted staff. In a confidential complaint made on 8/27/22 by DD while in the facility responding to a resident who called to 911, there was no nurse to be found. Upon further investigation, DD found that there was one nurse for both floors and the one nurse was on break. The complainant reported an estimated census of about 80 residents with no nurse. In a subsequent interview RCNC Hverbally verified her present in the facility stating she worked on the locked unit on 8/26- 8/27/22 and left early in the morning on 8/27/ 22 . When asked were medications passed to all the residents RCNC H responded I am not sure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #28 - Review of the clinical record for Resident #28 (R28) documented an initial admission date of 4/1/2020 and readmission date of 4/26/2022. R28's diagnoses included Alzheimer's disease and Major Depressive Disorder. A MDS dated [DATE] documented R28 was moderately cognitively impaired. R28's current medication regimen included Mirtazapine (an antidepressant) for depression. The Social Service Evaluation indicated, R28's assessment was 124 days overdue. R28's clinical record documented that a Social Service Evaluation was due on 5/1/2022. Resident #29 - Review of the clinical record for Resident #29 (R29) documented an initial admission date of 12/16/2016. R29's diagnoses included mood disorder due to known physiological condition with depressive features. A MDS dated [DATE] documented intact cognition. The Social Service Evaluation indicated R29's assessment was 206 days overdue. R29's clinical record documented that a Social Service Evaluation was due on 2/8/2022. Resident #45 - Review of the clinical record for Resident #45 (R45) documented an initial admission date of 4/6/2022. R45's diagnoses included chronic viral hepatitis c and congestive heart failure. A MDS dated [DATE] documented intact cognition. R45's current medication regimen included Ambien (sedative hypnotics). The Social Service Evaluation indicated R45's assessment was 144 days overdue. R45's clinical record documented that a Social Service Evaluation was due on 4/11/2022. Resident #58 - Review of the clinical record for Resident #58 (R58) documented an initial admission date of 9/7/2018. R58's diagnoses included generalized anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and malignant neuroleptic syndrome. A MDS dated [DATE] documented intact cognition. R58's current medication regimen included Lorazepam (antianxiety). The Social Service Evaluation indicated R58's assessment was 87 days overdue. R58's clinical record documented that a Social Service Evaluation was due on 6/7/2022. Resident #61 - Review of the clinical record for Resident #61 (R61) documented an initial admission date of 10/19/2021 and a readmission date of 5/16/2022. R61's diagnoses included anxiety disorder. A MDS dated [DATE] documented R61 was moderately cognitively impaired. R61's current medication regimen included Buspirone HCL (antianxiety), duloxetine HCL (antianxiety). The Social Service Evaluation indicated R61's assessment was 131 days overdue. R61's clinical record documented that a Social Service Evaluation was due on 4/24/2022. Review of the undated document titled Social Service Director job description documented, The Social Services Director is responsible for overseeing the development implementation, supervision and ongoing evaluation of the Social Services Department designed to meet and assist residents in attaining or maintaining their highest practicable well-being. This includes identifying the need for medically-related social services and ensuring that these services are provided in accordance with State and Federal regulations .The Social Services Director will complete and/or direct/delegate the completion of the social services component of the comprehensive assessment . Resident #4 - Review of the clinical record for Resident #4 (R4) documented an initial admission date of 4/15/2020 and readmission date of 9/16/2020. R4's diagnoses included schizophrenia and anxiety disorder. A MDS dated [DATE] documented severe cognitive impairment. R4's current medication regimen included quetiapine fumarate (an antipsychotic) for schizophrenia. The most recent Social Service Evaluation for R4 was dated 12/15/2021. R4's clinical record documented that a Social Service Evaluation was due on 3/15/2022. Resident #9 - Review of the clinical record for Resident #9 (R9) documented an initial admission date of 8/20/2010 and readmission date of 10/18/2021. R9's diagnoses included major depressive disorder, anxiety disorder, and Alzheimer's disease. A MDS dated [DATE] documented severe cognitive impairment. R9's current medication regimen included alprazolam (sedative to treat anxiety) for major depressive disorder. The most recent Social Service Evaluation for R9 was dated 10/22/2021. R9's clinical record documented that a Social Service Evaluation was due on 4/22/2022. Resident #10 - Review of the clinical record for Resident #10 (R10) documented an initial admission date of 11/25/2016 and readmission date of 8/23/2018. R10's diagnoses included major depressive disorder, alcohol abuse with alcohol-induced psychotic disorder with delusions, and bipolar disorder. A MDS dated [DATE] documented intact cognition. R10's current medication regimen included mirtazapine (an antidepressant) for depressive disorder, quetiapine fumarate for psychotic disorder with delusions, and trazodone (an antidepressant and sedative) for major depressive disorder. The most recent Social Service Evaluation for R10 was dated 11/25/2021. R10's clinical record documented that a Social Service Evaluation was due on 2/25/2022. Resident #13 - Review of the clinical record for Resident #13 (R13) documented an initial admission date of 2/9/2022, discharge date of 5/8/2022, and readmission date of 5/15/2022. R13's diagnoses included schizoaffective disorder bipolar type. A MDS dated [DATE] documented moderate cognitive impairment. R13's current medication regimen included olanzapine (antipsychotic) for behaviors. No Social Service Evaluations were completed for R13's per review of the resident's clinical record. R13's clinical record documented that a Social Service Evaluation was due on 5/20/2022. Resident #23 - Review of the clinical record for Resident #23 (R23) documented an admission date of 2/9/2022. R23's diagnoses included alcohol abuse, opioid abuse with intoxication, and end stage renal disease. A MDS dated [DATE] documented intact cognition. No Social Service Evaluations were completed for R23's per review of the resident's clinical record. R23's clinical record documented that a Social Service Evaluation was due on 2/14/2022. Resident #35 - Review of the clinical record for Resident #35 (R35) documented an admission date of 12/3/2021, discharged date of 3/17/2022, readmission date of 4/6/2022, discharge date of 6/16/2022, and readmission date of 6/17/2022. R35's diagnoses included bipolar disorder, schizophrenia, and anxiety disorder. A MDS dated [DATE] documented intact cognition. R35's current medication regimen included citalopram hydrobromide (antidepressant) for depression, lorazepam (antianxiety) for anxiety, olanzapine for anxiety, ativan gel (a combination of lorazepam, diphenhydramine, and haloperidol) for agitation, and depakene solution for schizophrenia. The most recent Social Service Evaluation for R35 was completed on 12/8/2021. R35's clinical record documented that a Social Service Evaluation was due on 3/8/2022. This citation pertains to Intake numbers MI00130207 and MI00130261. Based on interview and record review, the facility failed to timely complete comprehensive Social Service (SS) assessments for 23 residents (R1, R4, R9, R10, R12, R13, R14, R19, R23, R28, R29, R31, R35, R38, R45, R46, R47, R55, R57, R58, R61, R65, and R123) out of 24 residents reviewed for assessments resulting in the potential for unmet resident needs related to advocation for residents, assistance with grievance procedures, mental and psychosocial health needs, education on healthcare options, assistance with referral services, assistance with financial and legal matters, and/or assistance with discharge planning. Findings include: R1 Review of the clinical record for R1 revealed an admission into the facility on 5/9/18 and re-admission on [DATE] with pertinent diagnoses which included dementia and psychotic disorder with delusions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition. The MDS documented R1 required one person staff assistance for all activities of daily living (ADL's). Review of a comprehensive assessment titled, Social Service Evaluation was last completed on 9/28/2021 (one year prior to the survey). R31 Review of the clinical record for R31 revealed an admission into the facility on 5/11/20 and re-admission on [DATE] with pertinent diagnoses which included dementia, anxiety disorder, restlessness and agitation, and mood disorder. Review of the quarterly MDS assessment dated [DATE] documented severely impaired cognition. The MDS documented R31 required one person staff assistance for all ADL's. Review of a comprehensive assessment titled, Social Service Evaluation was last completed on 12/17/2021 (9 months prior to the survey, 169 days overdue). R47 Review of the clinical record for R47 revealed an admission into the facility on 4/18/19 and re-admission on [DATE] with pertinent diagnoses which included restlessness and agitation, Schizoaffective Disorder (mental health disorder), and dementia with behavioral disturbance. Review of the quarterly MDS assessment dated [DATE] documented moderately impaired cognition. The MDS documented R47 required one person staff assistance for all ADL's. Review of a comprehensive assessment titled, Social Service Evaluation was last completed on 10/10/2021 (11 months prior to the survey). R65 Review of the clinical record for R65 revealed an admission into the facility on 1/29/22 and re-admission on [DATE] with pertinent diagnoses which included Schizoaffective Disorder and psychotic disorder with hallucinations. Review of the quarterly MDS assessment dated [DATE] documented intact cognition. The MDS documented R65 required one person staff assistance for all ADL's. Review of the Initial Social Service assessment was not completed and was 211 days overdue. During an interview with the facility's Administrator on 9/02/22 at 9:19 AM, she reported that comprehensive Social Service Assessments should be done on admission, quarterly and with a significant change in a resident's status. The Administrator acknowledged that some aspects of the Social Service role were not being completed. During an interview with the Social Service Director (SSD) C on 9/02/22 at 9:21 AM, she confirmed that she had only worked at the facility for 4 days and had not gotten to the (SS) assessments. During an interview with Chief Operating Officer (COO) G and the Regional Clinical Nurse Consultant (RN) H on 9/08/22 at 10:50 AM, they reported that the facility had been attempting to hire a full time Social Worker since the last Social Worker left on 6/17/22 (over 2 months ago). COO G reported that the facility had hired 2-3 full and part time Social Workers, all who have quit. RN H reported that she and the DON have been filling in working as Social Workers. COO G acknowledged that all aspects of the Social Service department were bigger than we thought and had not been completed timely (per facility's policies). Resident 12: Review of the clinical record documented R12 admitted to the facility on [DATE] with pertinent diagnoses of vascular dementia with behaviors and end-stage renal disease that required dialysis. The Minimum Data Set (MDS) dated [DATE] indicated R12 had severe cognition impairment with verbal behaviors 4-6 days per week and was prescribed antipsychotic medications daily. The last Social Service assessment was on 11/11/21 with the next assessment due on 5/5/22. R12 had no care plan that addressed behaviors, mood, use of antipsychotic medications, or psychosocial needs. There was no documentation to support behavior monitoring, psychiatric services, or ancillary services had been provided. Resident 14: Review of the clinical record documented that R14 admitted to the facility on [DATE] with pertinent diagnosis of unspecified dementia with behavioral disturbances and major depressive disorder. The MDS dated [DATE] indicated R14 had severe cognition impairment with verbal behaviors 4-6 days a week, wandering 1-3 days a week, and was prescribed antipsychotic medications daily. The resident had no Social Service assessment nor any care plans that addressed behaviors, mood, use of antipsychotic medications, or psychosocial needs. There was no documentation to support behavior monitoring, psychiatric services, or ancillary services had been provided. Resident 19: Review of the clinical record documented that R19 admitted to the facility on [DATE] with pertinent diagnoses of unspecified dementia and seizures. The MDS dated [DATE] indicated R19 had severe cognition impairment with verbal behaviors 4-6 days a week and was prescribed antipsychotic medications daily. The resident had a Social Service assessment on 11/29/21 and the next assessment was due on 5/17/22. Resident 123: On 9/1/22 at approximately 11:00 AM R123's Legal Guardian (LG) said that the Social Worker had never contacted him even though requests were left on the social worker's voice mail. R123's LG said he was not able to participate in any plan of care for the resident. Review of the clinical record documented that R123 admitted to the facility on [DATE] with pertinent diagnoses of cerebral insufficiency and history of alcohol dependence. The MDS dated [DATE] indicated that R123 had intact cognition without behaviors. R123 was prescribed antipsychotic medications daily. On 4/22/22 the physician ordered for a psychiatric consult. There was no documentation to support there was psychiatric consultation, social service assessment, or social service progress notes for R123 from 4/22/22 - 8/1/22. On 8/1/22 R123 was petitioned out to the local hospital for aggressive behaviors and did not return to the facility. R38 On 9/1/22 at 2:14 P.M. review of the admission Record, revealed the resident was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, dementia, heart failure, peripheral vascular disease, type 2 diabetes mellitus, epilepsy, convulsion, chronic kidney disease, dependence on renal dialysis and deformity of the lower leg. A Minimum Data Set (MDS) dated [DATE], R38 was moderately impaired in cognition, had a deficit in memory, judgement and decision-making and required limited assistance with set up for Activities of Daily living (ADL's). The last Quarterly Social Service Evaluation was completed on 2/8/21, There were no other Social Service notes. R46 On 9/1/22 at 2:00 P.M., review of the admission Record documented the resident was admitted to the facility on [DATE], with diagnoses of complete traumatic amputation at the knee level, hypertension, atrial fibrillation, heart failure, and peripheral vascular disease. A Quarterly MDS dated [DATE] indicated R46 was cognitively intact ( thought process), required supervision and one-person physical assistance with ADLs. Review of the Social service Evaluation dated 6/9/22, was incomplete. The last completed Social Service Evaluation was dated 11/1/21. No other assessments were documented from the social Worker. R55 On 8/31/22 at 2:00 P.M., review of the admission Record documented the resident was admitted to the facility on [DATE], with diagnoses which included: Fusion of the spine, convulsion, epilepsy, seizure disorder, adjustment disorder and somatization disorder. A Quarterly MDS dated [DATE] indicated the resident was cognitively intact (thought process) and required limited assistance with one-person physical assistance to perform ADL's. Review of the Social Service Evaluation indicated, R55 assessment was 160 days overdue. R55's clinical record documented that a Social Service Evaluation was due 4/5/22. R57 On 9/1/22 at 9:00 A.M. review of the admission Record for R57 documented the resident was admitted to the facility on [DATE], with diagnoses which included: chronic obstructive pulmonary disease, diabetes mellitus with diabetic polyneuropathy, chronic kidney disease. According to Quarterly MDS dated [DATE], R57 was cognitively intact (thought process), required supervision and one-person physical assist to perform ADL's Review of the Social Service Evaluation indicated the last Quarterly assessment was completed 10/21/21. No other notes or evaluations by the Social worker were documented.

Based on observation, interview, and record review, the facility failed to properly implement the three-step manual warewashing procedure while using the three-compartment sink in the kitchen, resulting in the increased potential for food borne illness for all residents that eat from the kitchen. Findings include: During the initial observation of the kitchen on 8/31/2022 beginning at 8:40 AM the following occurred: 1. Kitchen staff were observed moving about the kitchen using flashlights due to an area wide power outage. The only items inside the kitchen hooked up to the emergency generator was a reach-in cooler and reach-in freezer. 2. AM [NAME] P said they were using disposable service ware such as hinged lid food containers, eating utensils, cups, and napkins. The facility did not have disposable serving trays and they were using the reusable fiberglass meal trays. The three-compartment sink was used to clean and sanitize the fiberglass trays. 3. Dietary Aide (DA) Q was observed using the three-compartment sink to wash, rinse, and sanitize soiled pots/pans and cooking utensils. Cleaned and rinsed pots/pans and cooking utensils were dipped in the sanitizing solution and immediately removed. During an interview and record review on 9/8/2022 at 9:48 AM, Dietary Director (DD) R said a quaternary solution was used to sanitize dishware in the three-compartment sink. DD R said the specific sanitizing contact time was not met when DA Q immediately removed the kitchen ware items out of the sanitizing solution. DD R said dishware had to remain in the quaternary solution for some time to be effectively sanitized. The label of the sanitizing solution used in the kitchen was reviewed with DD R and revealed the following: To sanitize mobile items such as drink glasses and eating utensils, immerse in a 200 ppm (parts per million) active quaternary solution for at least 60 seconds making sure to immerse completely. According to the 2013 FDA Food Code: Section 4-703.11 Hot Water and Chemical. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: .(C) Chemical manual or mechanical operations, including the application of sanitizing chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, using a solution as specified under § 4-501.114. Contact times shall be consistent with those on EPA-registered label use .

Based on interview, and record review, the facility's managing corporation failed to effectively administer daily operational processes to provide for the needs of residents, ensure they attain or maintain the highest practical physical, mental and psychosocial well-being for 73 of 73 Residents residing in the facility, resulting in insufficient weekend staff (8/26/22), Director of Nursing unable to perform her job duties (reviewing Pharmacist recommendations), and the Social Service Director unable to perform her job duties (assessments, preadmission screening and resident review -PASARR, Advanced Directives, psych referrals, notification of room changes). Findings include: During a phone interview on 9/07/22 at 11:15 AM with Registered Pharmacist (RPh) A, he reported that he believed pharmacy recommendations had not been followed up on due to a high turnover of Administrators and Director of Nursing (DON's) . A review of State Agency records revealed that since the facility's previous recertification date of 6/17/21, the position of Administrator was occupied by 5 different individuals for the duration indicated: Former Administrator K 6/17/21 to 8/8/21 Former Administrator T 8/9/21 to 1/23/22 Former Administrator U 1/24/22 to 2/7/22 Former Administrator V 2/8/22 to 5/17/22 Current Administrator 5/18/22 to present. Additionally, the position of DON was occupied by 8 different individuals for the duration indicated since the facility's previous recertification date of 6/17/21: Former DON W 6/17/21 to 9/1/21 Former DON X 9/2/21 to 9/22/21 Former DON Y 9/23/21 to 10/4/21 Former DON Z 10/5/21 to 3/7/22 Former DON AA 3/8/22 to 3/25/22 Former DON BB 3/26/22 to 4/20/22 Former DON CC 4/21/22 to 8/9/22 Current DON 8/10/22 to present. On 9/2/22 at 1:57 PM the Director of Nursing (DON) said that she had recently been hired at the facility and was unaware of who had been managing the Pharmacist's monthly medication recommendations. The DON said she would ask the Regional Clinical Nurse Consultant H how that process had been handled. On 9/2/22 at 2:09 PM The DON said, Going forward I will be receiving the Pharmacists's monthly reports and review them. On 9/8/22 at 9:00 A.M. during an interview the Director of Nursing (DON) acknowledged the weekend of 8/26, 8/27, and 8/28, the facility had experienced a challenge with staffing. The DON stated, on 8/26/22 all the nurses on the first and second shift called off and the facility wasn't able to acquire anyone from the Agency to fill in and work. (This was part of the facility's emergency plan to address staffing shortages). The DON explained a staff nurse from their sister facility did come and assist the nurses on the unit for a while but could not stay for the entire shift. When the facility was informed of the staffing shortage a staff E- mail was sent out for all managers to return to the building. The DON reported Regional Clinical Nurse Consultant (RCNC) H and herself came into the facility and stayed and assisted staff. After the weekend staffing shortage the facility indicated that they went back to utilizing agency staff again. During an interview with Chief Operating Officer (COO) G and the Regional Clinical Nurse Consultant (RCNC) H on 9/08/22 at 10:50 AM, it was reported that COO G had been assisting at the facility since March of 2022 and RCNC H since May of 2022. They both reported the most important issue were policies and updating them to make sure they made sense and establish consistencies. COO G and RCNC H said they were at the building 3 days a week to provide oversight and support administration. RCNC H acknowledged that it was going to take time to get staff to take ownership and set a standard for the facility. COO G reported that facility administrative staff and Regional Operations staff met with the owner once a week to keep her informed of any concerns. They reported that the facility had been attempting to hire a full time Social Worker since the last Social Worker left on 6/17/22 (over 2 months ago). COO G reported that the facility had hired 2-3 full and part time Social Workers, all who have quit. RN H reported that she and the DON have been filling in working as Social Workers. COO G acknowledged that all aspects of the Social Service department were bigger than we thought and had not been completed timely (per facility's policies). A policy regarding expectations of administrative oversight for daily operations was requested, but not received by the end of the survey.

Based on observation, interview, and record review, the facility failed to track staff COVID-19 vaccination status and implement a process ensuring that all staff were fully vaccinated for COVID-19, resulting in multiple staff and contract worker vaccination status being undocumented for monitoring and the potential for the spread of the COVID-19 virus infection to all residents. Findings include: On 8/31/2022 at 11:10 a.m., a request was made to the administrator for the facility's COVID-19 Staff Vaccination spread sheet. During an observation and interview on 9/1/2022 at 12:10 p.m., the Registered Nurse/Regional Clinical Nurse Consultant (RN/RCNC) H, identified as the Infection Control nurse, was sitting in the dining area working on the staff vaccination spread sheet. A second request was made to RN/RCNC H who at the time stated, The matrix for the staff vaccination status was not ready because it had some employees on the list that are not employed at the facility anymore. I am working on it now. I will have to go through and make sure the new employees are listed and take off the old employees. I do not know how to use that matrix they want us to use. I am over infection control now, but we had someone else doing infection control before me. The person that was over infection control left about three months ago. RN/RCNC H was asked, How are you tracking and monitoring the staff and contract workers vaccination status? RN/RCNC H stated, The new employees have to give their vaccination information at the time of hire. I know there is about six or seven exemptions, but I can't tell you who they are right now. We don't have anyone in the facility that's COVID positive. RN/RCNC H verbalized the interventions the non-fully vaccinated staff had to take to prevent the spread of the COVID-19 infection. RN/RCNC H was unable to provide a copy of the staff and contract workers vaccination status on this day. During an interview on 9/2/2022 at 12:18 p.m., RN/RCNC H was approached in the dining room and another request for the staff vaccination spread sheet was made. RN/RCNC H said, It is taking me longer than I thought to get this information for you because I had to go to MCIR (Michigan Care Improvement Registry) to get the staff information off there and then I had to get a copy of all the employees from Human Resource (HR). RN/RCNC H was unable to provide a copy of the staff and contract workers vaccination status on this day. During an interview on 9/2/2022 at 12:36 p.m., the administrator and the Chief Operating Officer (COO) G was informed of the staff vaccination information was not available. COO G stated, There should be a spread sheet with that information on it. COO G was asked to present the sheet but did not. According to the facility's policy, Employee COVID-19 Vaccinations, revised date of May 24, 2022: It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and Local guidelines. Compliance Guidelines: The facility will ensure that all eligible employees are fully vaccinated (CMS term) or up to date (CDC term) against COVID-19, unless religious or medial exemptions are granted as per CMS guided timeframes.