**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #139: Review of the Face Sheet, care plans dated 4/22/25 and 4/23/25, nursing notes dated 4/22/25 through 4/23/25, revealed Resident #139 was [AGE] years old, admitted to the facility on [DATE], was confused, had a tube feeding and was dependent on staff for Activities of Daily Living/ADL's. The resident's diagnosis included diabetes, Dementia, stroke, and hemiplegia and hemiparesis. Observation of the resident was done on 4/24/25 at 10:28 a.m., she was in her wheelchair ready for her facility care conference; staff had gotten her up and got her ready for the conference. The resident's hair was not combed at all, sticking up and her fingernails had black under them. The resident was presented in this manner for the care conference. A second observation of the resident was done on 4/24/25 at approximately 12:20 p.m., the resident was in her room, in her bed and her hair was still not combed and he nails still had black underneath them. Review of the facility Activities of Daily Living (ADL's) policy dated 12/24, stated Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care). Based on observation, interview and record review, the facility failed to provide timely assistance with activities of daily living (ADL) including showers, nail care and hair care for two residents ( #52 and #139), from a sample of 20 residents. Findings Include: Resident #52: Activities of Daily Living On 4/23/2025 at 1:15 PM, Resident #52 was observed lying in bed in her room. She said she had itching on her face and leg and said it was horrible. She said they gave her something for the itching, but the itching would come back frequently. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, depression, anxiety, diabetes, chronic kidney disease, arthritis, blindness right eye and hypothyroidism. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 10/15 and the resident was independent with most care but needed some assistance and oversight with bathing/showering. On 4/24/2025 at 10:30 AM, Resident #52 was observed in the hallway with the same dress that she had on the day before. On 4/25/2025 at 12:45 PM, Resident #52 was observed in the hallway sitting in a wheelchair with the same dress she had worn for the past 3 days. She was rubbing her face and there was a strong odor noticed near the resident. A record review of the electronic medical record/EMR Tasks tab for Shower/bed bath for Resident #52 over a 30 day time period from 3/27/2025 to 4/24/2025, revealed the resident had not had a shower or bed bath since 4/14/2025. It indicated her Shower/Bath days were Monday/Thursday evenings and as needed. There were 2 dates: 4/17/2025 and 4/24/2025 with the heading No bath given attempted x2 and one entry dated 4/21/2025 for Resident Refused. A review of the progress notes for Resident #52 identified the following: 4/14/2025, a nursing clinical note, Pt (patient) receive shower today, today tolerated, offers no concerns up ad lib walking. 4/18/2025 at 11:28 AM, a nursing/clinical note, Pt alert and was encouraged to do adl's (activities of daily living), was given wash cloths and towels and cued to go into restroom to clean up, pt stated 'Am sleeping. Will continue to encourage . 4/19/2025 at 3:18 PM, a nursing/clinical note, Pt encourage to participate in her own adl's, bathing material given to pt and she went in bathroom . 4/19/2025 at 9:54 PM, a nursing/clinical note, Resident participated with her ADL's with help, cueing, and supervision of CNA (certified nursing assistant). Resident accepted help and guidance. 4/21/2024 at 8:57 PM, a nursing/clinical note, Resident encouraged by RN and CNA to take a shower to perform ADLs. Resident adamantly refused each attempt. Not participating with own ADLs. 4/22/2025 at 12:33 PM, Patient was assisted by staff to complete personal hygiene. A review of the Care Plans for Resident #52 identified the following: Resident requires staff oversight for safety and to ensure ADL needs are met due to dementia with severe cognitive deficits. Resident will be clean and dressed appropriately. Often refuses assistance from caregivers . Patient will frequently refuse a shower stating she does not like being cold and does not need a shower too often, date initiated 5/19/2023 and revised 7/27/2023. The interventions were all dated 2023 and were last updated 10/4/2023. On 4/25/2025 at 1:00 PM, during an interview with the Director of Nursing/DON reviewed with her Resident #52 was observed scratching her face in the hallway. The DON reviewed the orders for the resident and said she had Benadryl oral and Cetaphil face cream for the itching. Also discussed the resident had a strong body odor and had been wearing the same dress for 3 days. The DON said the resident refused a bath or shower at times and would put on soiled clothes. Reviewed the care plan , does not suggest alternate options for encouraging the resident to bathe. Does the resident still prefer evening baths/showers. Does she prefer certain staff members. Tasks reviewed: resident's last bath or shower was 4/14/2025. The notes were reviewed, and there were no alternate suggestions for encouraging the resident to bathe and change her clothes. Prior to 4/14/2025 it appeared in the Task charting the resident was bathing/showering twice a week and after 4/14/2024 was not. A review of the facility policy titled, Activities of Daily Living (ADL), Supporting, dated reviewed 12/2024 provided, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate . The resident's response to interventions will be monitored, evaluated and revised as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor weights timely for a Resident who had a hospitalization and return with a Percutaneous Endoscopic Gastrostomy ) (PEG) tube for feeding for one resident (Resident #62) of two residents reviewed for weight loss. Findings include: Resident #62: A review of Resident #62's medical record revealed the Resident had an admission into the facility on 6/26/24 and readmission on [DATE] with diagnoses that included intracerebral hemorrhage (stroke), gastrostomy, abdominal aortic aneurysm, dysarthria, aphasia, hemiplegia and hemiparesis affecting the left non-dominant side, Alzheimer's disease, and muscle wasting and atrophy. A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognition and was dependent on staff for activities of daily living. A review of the medical record revealed the Resident had a change in condition on 3/10/25 and was transferred to the hospital and returned on 3/20/25 with a PEG tube for feeding. A review of Resident #62's hospital discharge records of consult to Nutrition Services revealed, Nutrition Diagnosis: Increased Nutrient Needs (Protein) related to increased demand AEB (as evidence by) current medical condition (brain bleed) . Intervention/Plan/Goal: Goal tube feeding is Jevity 1.5 bolus 4 cartons daily with 4 packets protein powder. Providing: 1520 kcal, 84 gm protein. A review of Resident weights revealed a weight on 3/9/25 (prior to discharge to hospital) of 131.6 lbs (pounds) and re-admission weight of 118.4 lbs on 3/21/25 and 18 days later 4/8/25 a weight of 114.2 lbs. A review of Resident #62's Nutritional Evaluation, effective date on 3/24/25 revealed the Resident's Tube Feeding Order: Jevity 1.5; 4 cartons daily; Enteral Composition of Calories: Calories 1420, Calories/Kg (kilograms) 26 kcal/kg, Protein 60; Weight Status: Loss, Enter % of weight loss or gain 12.6 (weight loss); Estimated Nutritional Needs: Calorie needs: 1340-1610, Protein needs: 54-65; Additional detail: Patient with dysphagia and need for nutrition support via PEG to meet nutritional needs; Additional comments/information: .Nutrition/Monitoring Recommendations: Weight per policy-Will monitor weights/PO intake/skin/labs-Monitoring tube feeding tolerance and need to adjust . A review of Resident #62's Nutritional Evaluation, effective date on 4/10/25 revealed the Resident's Tube Feeding Order: Jevity 1.5; 4 cartons daily with Enteral Composition of Calories: 1420 and Protein 60; Weight Status: Loss, Enter % of weight loss or gain 13.6 (weight loss); Estimated Nutritional Needs: Calorie needs: 1554-1813, Protein needs: 67-78; Additional detail: Patient with dysphagia and need for nutrition support via PEG to meet nutritional needs; Additional comments/information: .Nutrition/Monitoring Recommendations: Weight per policy, Recommend increasing tube feeding to Jevity 1.5; 5 cartons total daily 2/2 (due to) continued weight loss. Provides 1775 kcal, 76 gms protein . On 4/24/25 at 3:14 PM, an interview was conducted with Dietitian P who was the interim Dietician at the time of the survey. A review of Resident #62's weight (wt) loss from 3/9/25 of 131.6 lbs. to 3/21/25 of 118.4 lbs (13.2 lbs wt loss) and on 4/8/24 of a weight of 113.2 (an additional 5.2 lbs wt. loss). When asked when a Resident readmitted with a change in nutritional status of enteral feedings and a 13.2 weight loss upon return would weight monitoring be completed, the Dietitian stated, For the first 4 weeks typically we do weights weekly. The Dietitian reported that the Resident should be getting that weight done today. When asked if the Resident got missed with monitoring weights, the Dietician stated, Yeah that's what it looks like. The Dietician indicated that they did not anticipate further weight loss now that the Resident was increased to 5 cartons of the enteral feeding. A review of the enteral orders revealed the Resident was on 4 cartons from 3/21 to 4/10 and the Dietitian reported that with that weight loss, the Dietitian had increased the tube feeding by another carton, we just did not check her weight after that carton. The Resident's weights were not monitored weekly after the 5th carton was started. On 4/24/25 at 3:32 PM, the Dietitian informed the surveyor that the Resident's weight had gone up to 116 pounds today. On 4/25/25 at 12:42 PM, an interview was conducted with the Director of Nursing (DON) regarding concern of Resident #62 returning from the hospital with weight loss and ordered enteral nutrition, weights not monitored timely, and the Resident had additional weight loss. The DON reported she documents all the weights and that they missed the weekly weights on Resident #62. A review of facility policy titled, Weight Policy, reviewed 1/25, revealed, Purpose: Weight changes have significant nutritional implications. The purpose of this policy is to help maintain acceptable parameters of nutritional status. Procedures: .2.Weekly weights are obtained on those residents within the first 4 weeks of admission and those residents deemed appropriate per the assessment of the dietitian, dietary manager, physician or as determined by IDT (Interdisciplinary Team) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8: A review of Resident #8's medical record revealed an admission into the facility on 8/2/224 and readmission on [DATE] with diagnoses that included cervical spinal stenosis, diabetes, and methicillin susceptible staphylococcus aureus infection. A review of the Minimum Data Set assessment revealed the Resident had intact cognition and was dependent on a helper for toileting hygiene, bathing, lower body dressing, mobility and transfer. The Resident was sent to the hospital on 3/3/25 and returned to the facility on 3/24/25 with diagnosis of bacteremia, urinary tract infection and had a PICC line in the upper right arm for IV antibiotics. The PICC line was discontinued after conclusion of IV antibiotic regimen on 4/16/25. A review of Resident #8's orders for PICC line dressing, dated 3/25/25, revealed, PICC/Midline: change dressing q (every) 7 days, every night shift, every Mon (Monday). A review of Resident #8's Treatment Administration Record (TAR)/Medication Administration Record (MAR) for documented dressing changes, revealed a dressing change completed on 3/31/25, 4/7/25 and 4/14/25. There were no documented measurements of the external catheter length in the TAR /MAR or the progress notes. On 4/24/25 at 2:38 PM, an interview was conducted with the Director of Nursing (DON) and Unit Manager, Nurse G regarding Resident #8's PICC line monitoring while the Resident had been receiving IV antibiotics. The Unit Manager was unsure about facility policy of monitoring the external catheter with dressing changes but indicated that the arm circumference was to be done on admission. The DON indicated she would look up the policy. A review of the medical record with the Unit Manager revealed a lack of measurements of the arm circumference and no documentation on the TAR, progress notes, care plan or admission assessment of the assessment of the external catheter. On 4/24/25 at 3:00 PM, an interview was conducted with the DON and Infection Control Preventionist, Nurse Q regarding the PICC line policy. A review of the policy revealed a lack of directive for the PICC line measurements of the external catheter. The DON indicated that an order populates to do the arm circumference on admission and that the measurement for the circumference was a one-time measurement on admission to the facility. The order for the arm circumference had not been triggered on admission for Resident #8. The DON was asked for the standards of practice for PICC line dressing changes and monitoring/assessment of the PICC line. A review of the facility document received for PICC line care, titled, Central Vascular Access Device (CVAD)/Midline Care and Maintenance Standard Operating Procedure, revised 3/30/24, revealed, Introduction: The purpose of this standard operating procedure is to access and maintain a Central Vascular Access Device (CVAD) and midline for administration of medications, and blood draws safely and aseptically. This standard operating procedure is in support of the following policy (s): . ISO3 - PICC Insertion and Maintenance Policy . Standard Operating Procedure-Dressing Changes . 2. Complications: .d. Measure the external CVAD length at each dressing change or when catheter dislodgement is suspected and compare to the external CVAD length documented at insertion . Based on observation, interview and record review the facility failed to 1) Monitor a PICC (Peripherally Inserted Central Catheter) line placement for Resident #8; 2) Monitor antibiotic administration and notify the physician of three missed doses for Resident #289; and 3) Document the clinical rationale for an increase in the Vancomycin dose for Resident #84 for three of four residents reviewed for PICC lines. Findings Include: Resident #84: On 4/23/2024 at approximately 3:35 PM, Resident #84 was observed ambulating down the hallway into her room. She stated she developed osteomyelitis and is here for IV antibiotics. On 4/24/2025 at approximately 9:30 AM, a review was conducted of Resident #84's medical records and it indicated she readmitted to the facility on [DATE] with diagnoses that included, Osteomyelitis, Diabetes, Asthma, Heart Disease and Atrial Fibrillation. Resident #84 is her own person and able to make her needs known to staff. Further review of her record yielded the following: Physician Orders: Vancomycin HCl (hydrochloride) Intravenous Solution 1500 MG/400ML (Vancomycin HCl)-Use 1500 mg intravenously one time a day for osteomyelitis. Ordered on 4/17/2025. Vancomycin HCl Intravenous Solution 2000 MG/400ML (Vancomycin HCl)-Use 2000 mg intravenously one time a day for osteomyelitis. Ordered on 4/19/2025. Review was conducted of Resident #84's chart and there was no subsequent documentation of the clinical rationale for the increase in the Vancomycin dosage. On 4/24/2025 at 10:20 AM, Unit Manager K was asked about rationale regarding the change in Vancomycin dosage. The Manager stated typically it would be due to lab values as pharmacy doses the Vancomycin for residents. Review was completed of Resident #84's chart and there were no other documents located that provided documentation for the increase. The Manager stated she would follow up. On 4/25/2025 at approximately 5:00 PM, Unit Manager K explained labs were completed for Resident #86 on 4/17/2025 but her Vancomycin level was not completed. The manager provided a document from pharmacy which was faxed on 4/18/2025 at 2:07 PM. The document stated, .Low trough-please call pharmacy .4/18/25 increase dose to 2g iv qd) . The document this information was located on, was the residents lab results from her most recent hospital stay. Manager K stated this was the reason the dosage was increased but agreed there should have been documentation in the chart to this fact. It can be noted this document was not accessible in the resident's medical record. On 4/25/2025 at 11:40 AM, the DON (Director of Nursing) stated she was made aware of the concern and spoke to the nurse regarding it. The nurse told her she received something from pharmacy but failed to complete a progress note. The DON expressed understanding of the concern. Resident #289: On 4/24/2025 at approximately 9:30 AM, Resident #289 was observed resting in bed. He shared he was diagnosed with pneumonia, but it continued to progress in the community, and he ended up in the hospital for an extended stay. He developed a secondary infection in his shoulder as well and is here for his IV antibiotics course. On 4/24/2025 at approximately 10:30 AM, a review was conducted of Resident #289's medical records and it indicated he was admitted to the facility on [DATE] with diagnoses that included Arthritis due to bacteria in right shoulder, Pneumonia, Hypertension, Anxiety and Depression. Resident #289 is his own person and is able to make his needs known to facility staff. Further review yielded the following: Physician Orders: Cefepime HCI Intravenous Solution Reconstituted 2 GM (gram)-Use 2 grams intravenously every 8 hours for septic joint until 5/8/2025 (3 times a day) Vancomycin HCI Intravenous Solution 1250 MG (milligram)/250 ML (milliliters) - use 1250 mg This citation has intravenously two times a day for septic join until 5/8/2025. Progress Notes: 4/20/2025 13:02: Cefepime HCl Intravenous Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for septic joint until 05/08/2025 23:59 LOA. 4/20/2025 21:52: Note Text: Vancomycin HCl Intravenous Solution 1250 MG/250 ML Use 1250 mg intravenously two times a day for septic joint until 05/08/2025 23:59 Resident out with family and has not returned. 4/20/2025 21:53: Note Text: Cefepime HCl Intravenous Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for septic joint until 05/08/2025 23:59 LOA with family and has not returned at this time. 4/20/2025 21:54: Note Text: Flush IV line with 5ml NS before and after medication administration. every shift Resident LOA with family and not back at this time. 4/20/2025 21:59: Note Text: Vitals q shift every shift Resident went LOA and not back as this time. 4/20/2025 22:00: Resident went out LOA (leave of absence) with family and left approx. 8:00 am. This writer called resident on his cell phone at 9:30 PM to ask what time he will be back. Resident apologized for not being back he had fallen asleep. Resident stated that he would leave 30-45 min to come back to facility. No meds were given this shift. 4/20/2025 22:31: Patient arrived back to facility via self. Patient is pleasant. Patient is alert and orientated x 4. Vitals obtained and WNL (within normal limits). Will continue to monitor. On 4/20/2025, Resident #280 missed three antibiotic doses - one Vancomycin dose and two Cefepime doses. There was no documentation of notification to his practitioners or infection preventionist regarding the missed doses and possible next steps. On 4/24/2025 at 2:45 PM, Nurse Manager K was asked the process when residents are LOA and miss medications due to their absence. The manager explained upon their return the nurse would contact the doctor to inform them of which medications were missed and wait for instructions and there would be a subsequent progress note. Resident #289's three missed antibiotic doses were discussed by the manager, and she stated she would follow up after further investigation. On 4/24/2025 at approximately 5:00 PM, Nurse Manager K reported they were not able to find any documentation that Resident #289's doctor was informed regarding his missed doses. They will be following up regarding this. On 4/25/2025 at 11:45 AM, the DON (Director of Nursing) stated she was aware of the concerns and their Infection Control Nurse contacted the Infectious Disease doctor for further direction. Review was completed of the facility policy entitled, Therapeutic Durg Monitoring (TDM) Policy for skilled Nursing Facility, reviewed 5/24. The policy stated, .All TDM results, recommendations and adjustments in therapy should be documented in the residents medical record .

Based on interview and record review, the facility failed to 1) Identify a medication order discrepancy and 2) Address the pharmacy monthly medication regimen review timely for one resident (Resident #18) of five residents reviewed for medication regimen review, resulting in a medication ordered with the previous order not discontinued. Findings include: Resident #18: A review of Resident #18's medical record revealed an admission into the facility on 6/11/24 with diagnoses that included hypertension (high blood pressure) atherosclerotic heart disease, atrial fibrillation and presence of coronary angioplasty implant and graft. A review of the Minimum Data Set assessment revealed the Resident had intact cognition and needed partial/moderate assistance with eating, oral hygiene, dependent on a helper for other activities of daily living, mobility and transfers. A review of Resident #18's medication orders revealed an order dated 6/11/24, Diltiazem 60 mg (milligrams), take 1 tablet by mouth four times daily. A review of Resident #18's Physician/Practitioner Progress Note dated 2/1/25 at 6:15 AM, revealed, . Patient currently on diltiazem 60 mg 4 times a day will switch to Cardizem CD 240 mg once a day . A review of Resident #18's medication orders revealed an order dated 2/2/25, Cardizem LA oral tablet Extended Release 24 Hour 240 mg (Diltiazem HCl), Give 1 tablet by mouth one time a day for HTN (hypertension), with a start date on 2/3/25. The order for the Diltiazem 60 mg, four times daily was not discontinued. A review of Resident #18's Medication Administration Record (MAR) revealed that Cardizem LA 240 MG (Diltiazem HCl) was scheduled/administered at 9:00 AM and the Diltiazem HCl 60 MG was scheduled/administered at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. A review of Resident #18's medication regimen review (MRR) on 3/3/25 revealed a February MRR performed, but the double order for the Diltiazem 60 mg four times a daily that was not discontinued and the Cardizem CD 240 mg once a day that was started on 2/3/25 was not addressed. On 3/30/25, Pharmacy Consultant note revealed a March MRR was completed. The facility document titled, Pharmacist Recommendations (DON/Medical Director Copy) dated 3/31/25 revealed, .Resident prescribed the following medications: 1. Cardizem LA oral tablet Extended Release 24 Hour 240 MG (Diltiazem HCl)-Give 1 tablet by mouth one time a day for HTN. 2.dilTIAZem HCl Oral Tablet 60 MG (Diltiazem HCl)-Give 1 tablet by mouth four times a day for HTN. PLEASE VERIFY THAT THIS DRUG REGIMEN IS REQUIRED. If not, adjust therapy as necessary . The document did not have a response or was signed by the physician. On 4/25/25 at 2:05 PM, an interview was conducted with the Director of Nursing regarding Resident #18's Medication Regimen Reviews and the Resident receiving both the Cardizem LA 240 mg daily and the Diltiazem 60 mg four times a day. The DON reported that the Doctor had not addressed the pharmacy recommendations but that he had them with him. The order for the Diltiazem 60 mg four times a day had not been discontinued. The DON stated, That is a med error. A concern that the MRR was dated for 3/31/25 and today's date was 4/25/25 and the recommendations had not been addressed. A review of facility policy titled, Medication Regimen Reviews, revealed, .policy Interpretation and Implementation . 4. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. 5. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication-related problems, medication errors and other irregularities, for example: a. medications ordered in excessive doses or without clinical indication; .c. duplicative therapies or omissions of ordered medications; . h. other medication errors, including those related to documentation . 10. If the identified irregularity represents a risk to a person's life, health, or safety, the consultant pharmacist contacts the physician immediately (within one hour) to report the information to the physician verbally, and documents the notification. 11. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to 1) Obtain a signed consent for treatment with antipsychotic medications for Resident #52 and 2) Prevent the duplication of medications administered to Resident #18. Findings Include: Resident #52: Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, depression, anxiety, diabetes, chronic kidney disease, arthritis, blindness right eye and hypothyroidism. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 10/15 and the resident was independent with most care but needed some assistance and oversight with bathing/showering. A review of the physician orders for Resident #52 revealed the resident received Fluoxetine/Prozac for depression, start date 11/15/2024. A review of the medical record did not identify a consent form for treatment with Fluoxetine. A review of the Care Plans for Resident #52 identified the following: At risk for falls due to impaired balance/poor coordination, potential medication side effects . date initiated 5/18/2023 and revised 2/4/2025. At risk for changes in mood related to depression, cognitive impairment . date initiated 5/18/2023 and revised 10/23/2023. There was no mention of medication for depression. On 4/25/2025 at 2:06 PM, during an interview with the Director of Nursing/ DON about the consent to treat form for Resident #52's Fluoxetine, the DON said she could not find one. A review of the facility policy titled, Medication Regimen Reviews, dated reviewed 11/2024 provided, . The medication regimen and associated treatment goals involve collaboration with the resident (or representative), family members, and the interdisciplinary team (IDT). As such, the MRR includes a review of the resident's (or representatives) stated preferences, the comprehensive care plans and information provided about the risks and benefits of the medication regimen . Resident #18: A review of Resident #18's medical record revealed an admission into the facility on 6/11/24 with diagnoses that included hypertension (high blood pressure) atherosclerotic heart disease, atrial fibrillation and presence of coronary angioplasty implant and graft. A review of the Minimum Data Set (MDS) assessment revealed the Resident had intact cognition and needed partial/moderate assistance with eating, oral hygiene, dependent on a helper for other activities of daily living, mobility and transfers. A review of Resident #18's medication orders revealed an order dated 6/11/24, Diltiazem 60 mg (milligrams), take 1 tablet by mouth four times daily. A review of Resident #18's Physician/Practitioner Progress Note dated 2/1/25 at 6:15 AM, revealed, . Patient currently on diltiazem 60 mg 4 times a day will switch to Cardizem CD 240 mg once a day . A review of Resident #18's medication orders revealed an order dated 2/2/25, Cardizem LA oral tablet Extended Release 24 Hour 240 mg (Diltiazem HCl), Give 1 tablet by mouth one time a day for HTN (hypertension), with a start date on 2/3/25. The order for the Diltiazem 60 mg, four times daily was not discontinued. A review of Resident #18's Medication Administration Record (MAR) revealed that Cardizem LA 240 MG (Diltiazem HCl) was scheduled/administered at 9:00 AM and the Diltiazem HCl 60 MG was scheduled/administered at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. Resident #18 had been receiving both the Cardizem LA 240 MG daily and the Diltiazem 60 MG four times from when the Cardizem LA had been started on 2/3/25 with one Cardizem LA dose not given on 2/12/25. On 4/25/25 at 2:05 PM, an interview was conducted with the Director of Nursing regarding Resident #18's Medication Regimen Reviews and the Resident receiving both the Cardizem LA 240 mg daily and the Diltiazem 60 mg four times a day. The order for the Diltiazem 60 mg four times a day had not been discontinued, the practitioner's progress note was that the medication was to be switched to the Cardizem LA. The DON stated, That is a med error. A review of facility policy titled, Adverse Consequences and Medication Errors, revealed, Policy Statement: The interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects . 2. The staff and practitioner strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; .(2) Is not taking other medications . that would be incompatible with the prescribed medication . Medication Errors 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services . 3. A significant medication-related error is defined as: a. Requiring medication discontinuation or dose modification .

Based on observation, interview and record review, the facility failed to ensure that 3 medication carts (Halls 300, 400 and 500) of 4 medication carts observed were maintained clean and sanitized, free of crushed pills, pieces of loose papers and dust in the drawers. Findings Include: Observation of facility medication carts done on 4/23/25 starting at 10:55 a.m., revealed the following: 500 Hall Med Cart: Observation was done on 4/23/25 at approximately 10:40 a.m., accompanied by Nurse, RN B revealed the following: -The second and third drawer's had pieces of crushed medications/meds and paper on the bottom back. During an interview done on 4/23/25 at 10:45 a.m., Nurse B stated Third shift cleans it, but we can all clean it. During an interview done on 4/23/25 at approximately 10:55 a.m., Nurse, LPN C was asked by this surveyor if the drawers of the med cart could have been cleaned better and she stated ya, a bit; third shift cleans it and anyone can clean it. 400 Hall Med Cart: Observation was done on 4/23/25 at 11:09 a.m., accompanied by Nurse, LPN D revealed the following: -The second and third drawer's had an excessive amount of crushed pills and pieces of paper on the bottom in back and 1/4 of a white pill was found. 300 Hall med Cart: Observation was done on 4/23/25 at 12:28 p.m., accompanied by Nurse, LPN F revealed the following: -The second and third drawers had crushed meds and small pieces of paper on the bottom in the back. During an interview done on 4/23/25 at 12:28 p.m., Nurse F stated Third shift cleans it (facility med carts). 300 Hall med Cart: Observation was done on 4/23/25 at 12:28 p.m., accompanied by Nurse, RN E revealed the following: -The second and third drawer's had med pieces and dust on the bottom in the back; the third drawer had an excessive amount of crushed meds and one whole round yellow pill was found loose. During an interview done on 4/23/25 at 12:35 p.m., Nurse E said the med cart could have been wiped down for sure. During an interview done on 4/23/25 at 12:31 p.m., the Director of Nursing confirmed third shift nursing staff were assigned to clean the medication carts. Review of the facility Medication Storage policy (un-dated) revealed nurses are responsible to clean the medication carts.

Based on observation, interview and record review, the facility failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, resulting in an increased likelihood for food borne illnesses with hospitalization, and cross contamination affecting 82 residents who consumed oral nutrition from the facility kitchen and ice machine of a total census of 84 residents. Findings include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. On 4/23/25 at 10:15 a.m., a kitchen tour was done accompanied by Dietary Manger A. The following concerns were identified during the walk-through: -At 10:15 a.m., the large can opener was observed to have a dark colored sticky substance directly behind the blade. -At 10:18 a.m., the large counter mixer that was clean and ready for use had dried batter-like substance on the attachment directly over the mixing bowl. During an interview done on 4/23/25 at 10:18 a.m., Dietary Director A stated I see it, needs to be cleaned. -At 10:20 a.m., a carving knife and a bread large knife that were clean and ready for use sitting on the bottom shelf of the food prep table, had dried-on food on the blades. -At 10:22 a.m., on the clean and ready for use meat slicer, the blade was observed to have an oily substance on it, and a small amount of dried food. -At 10: 40 a.m., 6 clean and ready for use plate covers were found stacked inside one another and had water inside (increases bacterial growth). -At 10:43 a.m., 3 clean and ready for use coffee cups were found on a tray ready for serving they had water still inside. Review of the facility Dietary Manager Job Description dated 2/22/23, stated Provides training, direction and guidance for the dietary staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #2: Review of the Face Sheet, care plans and nurses progress notes dated 3/28/25 through 4/23/25, revealed Resident #2 was [AGE] years old, admitted to the facility on [DATE], was totally dependent on staff for all Activities of daily Living/ADL's and was cognitively impaired (BIMS-cognitive assessment score of 3). The resident's diagnoses included, peritoneal abscess, adult failure to thrive, Parkinson, diabetes, lack of normal physiological development, Schizophrenia, Dementia, major depression, Bipolar and anemia. The resident was unable to be interviewed due to their decreased cognition status. Observation was done on 4/23/25 at 11:23 AM of Resident #2 in his bed dressed. He had a soiled gown sitting on the bottom of his bed and the top white blanket had a large brown smear on the top near his face. Also the resident's room walls near the bathroom and the outside of the bathroom door had several black wheelchair marks on it, with paint chipping off the walls and door. Environment: On 4/23/2025 at 11:20 AM, the bathroom in room [ROOM NUMBER] was observed to have a variety of items on the bathroom sink, including an uncovered toothbrush. There was also a bed pan upside down on the floor underneath a commode chair. One resident was in the 2-resident room and said none of the items were hers and they belonged to her roommate who was in the hospital. On 4/23/2025 at 11:32 AM, room [ROOM NUMBER] was observed to have cluttered items lying on the floor. During the tour of the 100 hall on 4/23/2025, several resident rooms were noted to have resident items stacked on the floor and sometimes large stacks of items were on other surfaces in the rooms. They appeared very cluttered and unkempt. Some of the rooms had space for additional storage or shelving and some had less room. Based on observation, interview and record review, the facility failed to: (1) Ensure proper cleaning of therapy gym equipment for all residents utilizing the equipment; (2) Ensure the timely removal of Resident #2's soiled gown, blanket and linen , (3) Ensure the timely disposal of daily hygiene products of a discharged resident (Resident #15) and the cleaning of the room prior to admittance of a new resident and (4) Ensure the decluttering of residents' items throughout the rooms on the 100 Hall. Findings Include: Therapy Gym During initial tour a resident shared a peddle on the bike in the therapy room gym, was not safe for residents to utilize and requested it be observed for functionality and safety. On 4/24/2025 at 1:10 PM, an observation was conducted of the facility therapy gym. Therapy Director S provided an overview of the equipment and stated each machine is wiped down between each resident, but deep cleaning is completed by housekeeping. The following was observed: 2- Nu Step Machines: -Foot pedals had debris and sand like build up inside both pedals. -In between the foot pedals (at the base of the machine) there were white flecks of debris, hair and sand like particles. -The seat on one machine was ripped and the yellow foam exposed. -The back part of one machine had green particle dusting from the deteriorating handle covering material. 2-Omni Cycles: -Build up unknown particles in the crevices of the pedals on both omni cycles. On 4/24/2025 at 1:20 PM, Director of Environmental Services J stated the therapy gym is deep cleaned once a month. He explained that includes wiping down all the equipment, cleaning the window ledges etc. We went into the gym together to look at the unsanitary state of the Omni Cycles and Nu Steps. When asked exactly what his staff are tasked with cleaning during a deep clean of the machines he stated they would wipe down the machine. Director J was asked to provide the deep cleaning schedule and check off list for the therapy gym. On 4/24/2025 at 1:40 PM, Housekeeper M was interviewed regarding cleaning of the therapy gym. The housekeeper explained the gym is constantly in use, so typically they will sweep the floors, change the trash, clean the bathroom, replenish paper products, and wipe down surfaces. Housekeeper M stated the deep clean must occur after hours. On 4/24/2025 at 2:00 PM, Director J provided the monthly cleaning schedule that indicated the therapy gym was last deep cleaned on 4/1/2025. There were no specific deep cleaning tasks to be performed, so it is unknown exactly what takes place during the therapy gym deep clean. It can be noted that the debris/particle buildup is unlikely to have occurred in three weeks from when it was last cleaned to observation. A discussion was held with the director regarding the cleanliness of the equipment, especially given the amount the resident use. Director J expressed understanding of the concern.

Based on observation, interview and record review the facility failed to ensure that the clinical staff posting was completed and available for review for multiple days from October 2024- April 2025, resulting in the inability of residents and visitors to know what clinical staff were working on those days. Findings Include: FACILITY Sufficient and Competent Nurse Staffing On 4/24/2025 at 9:17 AM, the Administrator was asked where the posted nurse staffing was located. She said the document was on the wall near the entry to the facility. Upon review of the posted document it said Tuesday, 4/24/2025. The Administrator, viewed the document; discussed with her the dated was correct but the day was wrong. It was not Tuesday; It was Thursday. She said the staff member N responsible for completing the document would correct it. The Administrator said the posted staffing documents were to be posted daily. Requested to review the prior year's posted staffing. The Administrator said Staff N would provide the binder with the documents. The posted nurse staffing binder was reviewed. The posted staffing document was used to identify how many RN's (Registered Nurses), LPN's (Licensed Practical Nurses) and CNA's (Certified Nursing Assistants) were staffed each day on each shift. The document identified how many hours were worked for an RN, LPN and CNA and listed Total Hours per shift) and included the Date and Resident Census (number of residents in the building on that day). The document was required to show how many residents were in the facility on a particular day and how many qualified nursing staff were present to care for them; any visitors or residents would then be able to see it after it was posted. During the review, it was identified there were approximately 60 days of posted staffing sheets that were missing from October 2024 - April 2025. On 4/25/2025 at 9:45 AM, the Administrator was interviewed about the posted staffing documents and said Staff N who was completing the daily posted staffing documents was no longer responsible for ensuring their completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00146446. Based on interview and record review, the facility failed to ensure that a complete nursing assessment was done after a condition change (a fall at the facility on 7/2/24) for one resident (Resident #101) of 3 residents reviewed for assessing/monitoring after a change in condition (a decline in therapy due to increased pain), resulting in incomplete nursing and physician documentation, and delayed hospitalization with a CT (Computed Tomography). Findings Include: Resident #101: Review of the Face Sheet, Nurse Practitioner and Nursing and Physician note's dated 7/1/24 through 7/12/24, emergency room and Hospital notes dated 7/12/24 through 7/14/24, care plans dated 6/24, and MDS (nursing assessment tool) dated 7/24, revealed Resident #101 was 67 years-old, alert and able to make his own medical decisions, admitted (last admission) to the facility on 6/27/24, after a fall at home with several fractures and post surgical repair of spine. The resident was a fall risk and required assistance with transfers at the facility. The resident's diagnosis included, chronic stage 5 end stage kidney disease and on Hemodialysis, heart disease, stroke, diabetes, morbid obesity, high blood pressure, T-11 and T-12 fracture with routine healing, spinal fusion, major depression and anxiety. Review of the residents facility Pain Care Plan dated 6/27/24, stated report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. Notify physician if pain frequency/intensity is worsening or if current analgesia regimen has become ineffective. Review of the facility Accident/Incident Report dated 7/2/24, revealed Resident #101 got up from his bed by himself and fell next to his bed. The facility documented no injuries at the time. Due to complaint's of pain in the hip area, the facility had an x-ray done on 7/3/24. Review of the facility's X-ray report dated 7/3/24, stated Multiple views of the left hip and pelvis show normal alignment without acute fractures or dislocations. Hospital Notes: Review of the hospital emergency room notes dated 7/12/24, stated Presented to the ED (emergency department) for evaluation after a fall 1 week ago, complain of left hip pain, left chest pain, the patient (Resident #101) is status post T9-L1 fusion, C6-7 fusion on June 3, 2024 (back spinal surgery); currently wearing TLSO (a abdominal hard brace), LT (left) hip x-ray, LT femur x-ray were negative for any acute abnormalities, CT cervical spine, lumbar spine without contrast, CT chest for any acute abnormalities, CT cervical spine (neck area), thoracic spine (chest area), lumbar spine without contrast, CT chest abdomen and pelvis with contrast ordered; reported comminuted, mildly displaced fracture of the left inferior and superior pubic rami. Nondisplaced left sacral fracture, small left pelvic abductor and adductor hematoma (bruise like), small bilateral pleural effusion with compressive atelectasis of lower lobe (lower lung). The resident had multiple fractures and pneumonia. Review of the facility nursing note's dated 7/2/24 through 7/12/24, revealed pain medication was given and stated, pain relieved with pain medication. No complete pain assessment (per facility policy) after the resident fell (change in condition) was documented. During a phone interview done on 8/26/24 at 10:15 a.m., Physician, MD D stated I talked to patient (Resident #101); the x-ray (done on 7/3/24) came back negative. I don't know if his previous falls at home fractured his pelvis; he had a knee and back brace on. The x-ray may not of been able to pick up the fractures in pelvis. X-ray can miss fractures. During an interview done on 8/26/24 at 11:51 a.m., Occupational Therapist/OT F stated He (Physician D) came in the gym because the (Family Member of Resident #101) wanted another x-ray done (after the x-ray done on 7/3/24). He wanted to know why she was asking for that. I told him of his increased pain. Review of the physician notes dated 7/4/24 through 712/24, revealed no documentation from Physician D regarding an increase of pain in left lip area and a change in condition, nor of what OT F had informed him of. During an interview done on 8/26/24 at 10:29 a.m., with Director of Rehab Services, OTA E stated His fall was on 7/2/24 at 4:45 a.m. A couple of days later we did an x-ray hip and pelvis (No acute fx or dislocation of left hip pelvis). Therapy informed me that (Family Member of Resident #101) would transfer him in his room; to bathroom to bed and to chair, she called for EMS for transport (Family Member called the ambulance herself for a transfer to the hospital due to increased pain). After he fell on 7/2/24, his pain assessment dated [DATE], said pain over last 5 days was 7 (using 0 to 10 pain scale). He had therapy on 7/2/24 (day he fell), bed mobility, transfer with mod assistance, bike for 15 minutes. His pain level for this PT secession was not documented. On 7/4/24, OT (Occupational Therapist F) saw him. (OT F's) response was that the pt (Resident #101) increased pain to lower left extremity, nursing aware, due to decline required increased assist with daily needs and Hoyer for transfer. Attempt from sit to stand with complaints of significant pain with nursing and IDT (Interdisciplinary Team) aware, OT with decision to seize standing until IDT can further assess Hoyer (mechanical lift) to be used for transfers. During an interview done on 8/26/24 at 11:51 a.m., Occupational Therapist/OT F On 7/4 (7/4/24), I said (to Resident #101), lets get up for therapy, when he went to sit up he acted like he was having increased difficulty, he was having increased pain, moderate to max pain; then I put his brace on and once we sat him up the brace pain did not subside. It usually does. I laid him back down and I told the nurse (unable to recall nurse and did not document incident) his pain seems to be worse. I then went and got a PTA (Physical Therapy Assistant) and asked her if she thought he was different (I don't see him regularly). She and I stood him up and at that point he couldn't bear weight because of his legs and his pain; he was complaining of pain. They (the facility transport man) wanted to know how to transfer him to dialysis. Then I put Hoyer for transfer. If we say a max of 2, it means a Hoyer for staff. On 7/4/24, he was made a Hoyer by OT due to decline in therapy. Review of the facility resident's nursing notes dated 7/4/24, had no complete nursing pain assessment per the facility Pain policy. Also there was no documentation of OT F informing nursing of increased pain and decline in ability to participate in therapy secession. Review of the facility nursing Pain Interview assessment dated [DATE] (the day of the fall), revealed the last page (verbal descriptor scale, indicators of pain and frequency of indicator of pain) was not filled out. It was documented on the pain assessment that the resident did have pain in the last 5 days, on occasion and it interfered with day-to-day activities. Review of the facility Pain Level Summary dated 6/27/24 through 7/12/24, revealed from 7/2/24 (day of fall) through 7/12/24, the resident had x 8 #5's, x 5 #6's, x 5 #7's, and x 1 #8 pain levels documented (using a 0 to 10 pain scale). Review of the facility electronic medication administration sheets dated July, 2024, revealed the resident received Gabapentin 300 mg daily (for pain), no documentation of indicators for pain (crying, gasping, moaning), facial expressions, body movements/postures or frequency of pain. Review of the facility Pain Assessment policy dated 1/24, stated Pain management is a multidisciplinary care process that includes: Assessing the potential for pain, addressing the underlying causes of the pain, developing and implementing approaches to pain management, conduct a comprehensive pain assessment whenever there is a significant change in condition, and when there is onset of new or worsening of existing pain. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain. During the comprehensive pain assessment gather the following information: Intensity, descriptors, pattern, location and radiation, frequency, timing and duration, impact and factors that exacerbate the pain.

Based on interview and record review, the facility failed to review and revise care plans with resident changes to ensure interventions necessary for care and services were provided for one resident (Resident #45) reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #45 Activities of Daily Living On 4/15/24 at 12:04 PM, during a tour of the facility a Confidential Resident stated, Resident #45, Never bathes/showers and it makes the room smell. The Confidential Person said they couldn't bring visitors in because of that. On 4/15/2024 at 12:15 PM, Resident #45 was observed lying in bed, awake with soiled clothes with brown stains. The resident appeared disheveled, his hair unwashed and the bed linens were soiled with brown stains. There were papers all over the bed. The resident did not readily answer questions. On 4/16/2024 at 4:20 PM, during an interview with Certified Nurse Aide R about Resident #45, she said she was familiar with this resident, and had taken care of him in the past. Upon entering the resident's room, he was observed in bed, awake and alert. He appeared to have shaved his face, his hair looked cleaner, and he changed his clothes; his bedding was clean. The Nurse Aide said he often didn't want to have help with care. The resident didn't answer any questions about his care but smiled when complemented on how well he looked. Upon review of the staff assignment book that listed the daily showers, Resident #45 was listed to have a shower on 2nd shift that day. On 4/16/2024 at 4:30 PM, during an interview with Certified Nurse Aide Q, she said she was assigned to Resident #45. When asked about the residents lack of bathing and changing his clothes, she said he didn't like to go to the main shower room and stated, He does better in his room if you set him up with the supplies to perform his own care. On 4/16/24 at 4:36 PM, Social Worker N was interviewed about Resident #45, she said the resident previously lived alone and she wasn't sure how well he was doing with providing care for himself. The Social Worker stated, He refuses; I don't think he has ever had his hair washed. He will clean up at times, privately in the bathroom with basin and water. He will usually go a week at a time; at his home he did not have running water. She said his neighbors would call and complain. The Social Worker said Resident #45 went to the facility salon for a haircut and wash and he did well. She said it took constant communication, and encouragement. On 4/17/24 at 9:30 AM, during an interview with the Assistant Director of Nursing/ADON related to Resident #45's lack of hygiene, she said the resident said water is evil. It is my right to not take a shower. She said he would refuse to change clothing, but will wash up with set up, but doesn't thoroughly wash. He refuses. Reviewed with the ADON that the resident appeared to like praise when he washed and changed his clothes and the staff said he really liked having his hair washed and cut in the salon. She confirmed he had gone to the salon, but it wasn't regularly. Reviewed with the ADON that Resident #45's hygiene habits could be a hardship for his roommate. A review of the Care Plan for Resident #45 revealed the following: ADL (activities of daily living) Self-care deficit as evidenced by generalized weakness related to physical limitations. Patient exhibits poor personal hygiene . Patient refusing showers and stated he does not shower or take a bath. Patient stated that water is evil and he does not like water. Continues to refuse all attempts to provide showers, date initiated 8/18/2020 and revised 9/6/2020 with Interventions: Assist to bathe/shower as needed as the patient will allow. Patient refusing showers and refuses to be shaved, date initiated 8/18/2020 and revised 3/17/2023; I prefer to have facial hair. I will request assistance from staff if I wish to shave, date initiated 9/25/2023; Needs strong encouragement for personal hygiene, date initiated 7/14/2023; Patient's preference is not to have staff provide personal care. Patient will not allow staff to assist him with shaving, bathing or changing his clothes. Patient will not take a shower, date initiated 5/3/2023 and revised 5/16/2023. Resistive/noncompliant with are Patient flatly refuses to take a bath or shower. Patient stated that water is evil and does not get near water related to: Belief that treatment is not needed. Patient will not allow staff to assist with daily care. Patient will wear the same clothes for days and not allow staff to change his clothes. Patient refuses to be shaved the majority of the time. Patient does not allow staff to clean his room, date initiated 10/15/2021 and revised 8/29/2023 with Interventions: Allow for flexibility in ADL routine to accommodate mood, preferences, and customary routine, date initiated 10/15/2021; If resists care, leave (if safe to do so) and return later, date initiated 10/15/2021. The interventions on Resident #45's care plans were generic and at times contradicted each other. The staff described specifically how the resident would perform care and hygiene, in the bathroom with set up, but this was not mentioned on the care plans. He also liked going to the salon, but there was no plan for this. Repeatedly the care plans indicated the resident did not like water, but there was no mention of alternative interventions to water, such as waterless bathing and hair washing products. The resident did not allow for his room to be cleaned, but he had a roommate. The Care plans did not provide guidance to promote the resident's hygiene needs. A review of the facility policy titled, Care plans, Comprehensive Person-Centered, dated reviewed 3/23 provided, A comprehensive, person-centered are plan that includes measurable objectives and timetables, to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan: . builds on the resident's strengths and reflects currently recognized standards of practice for problem areas and conditions . The interdisciplinary team reviews and updates the care plan . when the desired outcome is not met .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that medications were administered per the physician's order for two residents (Resident #53 and Residednt #273) resulting in multiple medication administrations not being documented in the Electronic Health Record (EHR)(Resident #53) and a lidocaine patch not being removed prior to administering another patch(Resident #273) with potential for adverse reactions and skin irritation. Findings include: Resident #53 (R#53): On 04/15/24 at 01:00 PM, R#53''s facesheet was reviewed and revealed that they are [AGE] years old and admitted to the facility on [DATE]. Pertinent diagnoses on admission include discitis, endocarditis, osteomyelitis, alzheimers, hypertension, hyperlipidemia and methicillin resistant staphylococcus aureus (MRSA). On 04/15/24 at 01:03PM, record review revealed a physician's order for Daptomycin(antibiotic) 500mg intravenously (IV) one time a day for endocarditis until 04/24/24. On 04/15/24 at 01:06 PM, record review of R#53's medication administration record's (MAR) from March 2024 and April 2024 revealed two (2) administrations for daptomycin (an antibiotic) on 03/30/24 and 04/03/24 not being signed out on the MAR. No documentation of refusal or a reason for not administering the medication is noted. On 04/16/24 at 01:10 PM, record review of the MAR from March 2024 revealed administrations of donepezil(treats dementia of the alzheimers type), mirtazapine and atorvastatin(treats hyperlipidemia) on 03/31/24 not being signed out on the MAR. No documentation of refusal or reason for not administering the medications is noted. On 04/16/24 at 01:15 PM, record review of the MAR from April 2024 revealed administrations of atorvastatin, donepezil, mirtazapine and senna on 04/02/24 not being signed out on the MAR. Administrations of amlodipine(treats hypertension), calcitonin and losartan(treats hypertension) on 04/03/24 were not signed out on the MAR. No documentation of refusal or reason for not administering the medications is noted. On 04/16/24 at 01:27 PM, the Director of Nursing (DON) was interviewed and was asked how they monitor the MAR for residents to ensure completion and that medications are being signed out and administered? The DON states that they review the MAR to look for omissions at their morning meeting, if there are any omissions they are corrected by calling the staff in to correct them. The DON was asked about the omissions on 03/30/24, 03/31/24, 04/02/24 and 04/03/24 and she stated that she doesn't know why they were not signed out but she will look into it. On 04/16/24, the policy titled Medication Administration was reviewed and revealed: 21. If a drug is withheld, refused, or given at a time other than the scheduled, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one. 23. As required or indicated for a medication, the individual administering the medication records in the residents medical record: the date and time the medication was administered, the dosage, the route of administration, the injection site (if applicable), any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed and the signature and title of the person administering the drug. Resident #237: A review of Resident #237's medical record revealed an admission into the facility on 4/6/24 with diagnoses that included stroke, kidney disease and heart disease. A review of the Resident's orders revealed an order for Lidocaine Pain Relief 4% patch, apply to back topically one time a day for pain, with Supply Directions: Apply 1 patch topically to back every morning (on in the morning, off at bedtime). On 4/17/24 at 8:25 AM, during the medication administration task for the survey an observation was made of Nurse F giving medication to Resident #273. The Nurse assembled the medications for Resident #273 that included a Lidocaine patch 4%. The Nurse was asked about the order and reported the patch was to be on for 12 hours and scheduled to be removed in the evening about 9:00 PM. The Nurse administered the oral medications to the Resident. The Lidocaine patch was to go on the Resident's lower back. The Nurse exposed the Resident's lower back and the Lidocaine patch from the previous day remained on the Resident's lower back. The Nurse removed the old patch, cleaned the skin and applied the new patch. When asked if the old patch should have been removed, the Nurse indicated it should have been removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that proper communication/documentation of Hospice services were provided to one resident (Resident #37) of two residents reviewed for Hospice services, resulting in the lack of receipt of progress notes/assessments to resident medical record with ineffective communication and collaboration of services between the facility and hospice service, lack of residents and staff aware of hospice schedule and the potential for unmet care needs. Findings include: Resident #37: A review of Resident #37 medical record revealed an admission into the facility on 9/11/19 and readmission on [DATE] with diagnoses that included chronic obstructive pulmonary disease, depression, anxiety and dependence on supplemental oxygen. A review of the Resident's MDS revealed a BIMS score of 14/15 that indicated intact cognition and the Resident was independent with self-care. On 4/15/23 at 12:43 PM, Resident #37 was observed sitting on her bed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked if she received hospice services while at the facility. The Resident indicated she was under hospice care and stated, My time is coming. The Resident indicated she had a pastor, a nurse that comes and one to give me a bed bath. When asked what days they came, the Resident was unsure. When asked if she had a calendar to refer to, the Resident indicated she was not given a calendar. On 4/17/24 at 10:19 AM, Resident #37's hospice binder was reviewed. The contents of the binder included a paper that listed the hospice schedule: Nursing Fridays, Aide-Tuesday and one Wednesday a month, SW (Social Worker)-One Friday a month. There was a calendar, titled, Planned Hospice Visits for Current Certification, with visits listed for the month of January. There were no recent calendars. The Hospice admission consent was signed on 10/13/24. The Hospice Staff Collaboration Log document listed visits of hospice staff that came. Multiple nurse documentation of visits revealed Collaboration with the Nurse documentation of Other-Explain: Assessment. There was no documentation of the assessments. Upon review of the electronic medical record, there was a lack of documentation of the hospice nursing assessments. On 4/17/24 at 10:30 AM, an interview was conducted with the Director of Nursing (DON). Resident #37's hospice binder was reviewed with the DON and a lack of documentation in the medical record. When asked about a calendar, the DON indicated there should be an up-to-date calendar and stated, I can get those today. The DON indicated that the Hospice Nurse meets with the Resident's nurse or herself when they come in for a visit. When asked if the Hospice notes, assessments should be included in the Resident's medical record, the DON indicated yes, assessment and notes and all documentation should be copied and put in the binder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure timely care and services to maintain dignity for 13 residents (#30, #14, #18, #34, #51, #7, #37, #9,#67, #275, #22, #6 ,#69) and a confidential group of residents resulting in long call light response times, delays in fulfilling resident requests, lack of nail care, limited access to the dining room during meal times, lack of personal grooming and call lights being out of reach with the potential for embarrassment, frustration, lack of social interaction and unmet care needs Findings include: R#67 On 04/15/24 at 01:54 PM, resident was observed sitting on the edge of her bed watching TV. R#67 was asked if the staff responds timely to their call light and requests, R#67 stated multiple times during the conversation she has had to wait two or three hours for staff to come back and help her after a request. R#67 stated the staff will take a long time to answer the call light and then take even longer to come back with her request and this happens often. When asked what items she has to wait for, R#67 stated that she usually just requests a cup of ice because it helps cool her down. On 04/16/24 at 02:30 PM, R#67 was asked how the previous night was R#67 stated that it was ok other than having to wait again for a cup of ice. R#67 again stated that it takes the staff a long time, sometimes two or three hours to come back with the cups of ice she requests. Resident #67 again stated this happens a lot to her. On 04/17/24 at 08:39 AM, R#67 was observed sitting up in her wheelchair, styling her own hair, well dressed and looked a bit upset. R#67 was asked how the previous night went and how they were doing today. R#67 stated the previous night was not good, R#67 stated they had to wait a long time again for a request. When asked what her request was, R#67 stated it was one of the night time medications they get and it was given to her late. R#22: On 04/15/24 at 10:45 AM, R#22 was observed laying in bed and appropriately dressed. R#22 was asked if the staff responds timely to call lights and requests, R#22 stated they often have long wait times to get their requests filled. R#22 was asked if it was any specific request that takes too long and they said it really can be anything it just depends on the day. R#22 did not specify any particular shift that the wait times are worse on. R#275 On 04/15/24 at 10:22 AM, R#275 was observed laying in bed watching TV. R#275 was asked if the staff responds timely to call lights and requests, R#275 stated they wait a long time for call lights to get answered, sometimes it takes two to three hours to get a response. R#275 stated they had an upset stomach the previous night and asked for medication to help and it took over an hour for someone to come back and help. Resident #7 A review of Resident #7's medical record revealed the Resident was admitted into the facility on 3/31/15 and readmission on [DATE] with diagnoses that included Parkinson's disease, dementia, anxiety disorder and reduced mobility. A review of the Minimum Data Set (MDS) assessment revealed a Brief interview of Mental Status (BIMS) score of 13/15 that indicated the Resident had intact cognition and the Resident needed substantial/maximal assistance with personal hygiene. On 4/15/24 at 3:06 PM, the Resident was observed in lying in bed. The Resident was interviewed, answered questions and engaged in limited conversation. An observation was made of Resident #7's fingernails that were long. When asked about her fingernails, the Resident indicated that she did not like them that long. When asked about nail care, the Resident indicated that staff had not offered to trim her nails and reported she did not want the polish and all that, but she did want them trimmed. When asked if she refused to have the nails trimmed, the Resident stated, No, I would not refuse if they offered, they have not offered. Resident #9 A review of Resident #9's medical record revealed the Resident was admitted into the facility on [DATE] and readmission on [DATE] with diagnoses that included stroke, hemiplegia and hemiparesis of left side, contracture of left hand, heart disease, mild cognitive impairment, and repeated falls. A review of the Minimum Data Set (MDS) assessment revealed a Brief interview of Mental Status (BIMS) score of 13/15 that indicated the Resident had intact cognition and the Resident was dependent with most activities of self-care. On 4/15/24 at 3:32 PM, Resident #9 was observed sitting in his wheelchair in the hallway outside his room. The Resident was asked questions, answered questions and engaged in limited conversation. An observation was made of Resident #9's left hand with contractures of the fingers curled towards the palm of the hand. The fingernails were observed to be very long. The fingernails on the right hand were observed to be long but not as long as the left hand. The Resident was asked about his fingernails and indicated they were too long wished that someone would trim them. On 4/16/24 at 2:24 PM, an interview was conducted with the Assistant Director of Nursing (ADON) regarding Resident #9's fingernail length. The ADON reported that the Resident would refuse to have his nails cut and that they had care planned for it. An observation was made of Resident #9's nails with the ADON. The nails were long. The ADON asked the Resident if he would let them cut the nails and the Resident responded that he wanted them cut. The ADON indicated that she would have staff trim his nails. Resident #18 A review of Resident #18's medical record revealed an admission into the facility on 9/2/22 and readmission on [DATE] with diagnoses that included heart disease, diabetes, dementia, seizures, cataract in right eye and anatomical narrow angle in the left eye. Review of the most recent MDS revealed a BIMS score of 13/15 that indicated intact cognition and the Resident was dependent on staff for most self-care needs. On 4/16/24 at 9:16 AM, during the initial tour of the facility, an observation was made of Resident #18 lying in bed. The Resident was interviewed, answered questions and engaged in conversation. An observation was made of Resident #18's call light on the floor and not in reach for the Resident. When asked about her call light, the Resident indicated she uses it and stated, Half the time I can't find it and the other half the time they are busy. I have to wait till someone gets to me. When asked if she had to wait more than a half hour, the Resident stated, sometimes, and longer at times. The Resident stated, They be busy and other people be waiting too. An observation was made of Resident #18's long fingernails. When asked if she liked them long, the Resident stated, My nails are too long, they need to be cut. When asked if they offer to trim her nails regularly, the Resident stated, No one offered, and indicated that she was going to go down to activities to get them trimmed but indicated she missed the nail care and restated, They are too long. On 4/16/24 at 9:40 AM, after the Resident interview, the Nurse was located and told Resident #18's call light was on the floor. The Nurse indicated the call light should be clipped to the bed and indicated she will get the call light for the Resident. On 4/16/24 at 2:42 PM, an observation was made with Unit Manager A of Resident #18's fingernails. The Resident voiced to the Unit Manager that they were too long and wanted them trimmed. The Resident's call light was on the floor and the Unit Manager put the call light back in reach for the Resident. The Unit Manager was notified that the call light had been observed on the floor during the initial tour of the facility and was asked if the cord had a clip on it. The Unit Manager asked the Resident if she wanted it on her TV that had an extension arm and the Resident indicated she did not want the call light there. The Unit Manager indicated she would get a clip to secure it to the bed. Resident #30 and #34 On 4/15/24 at 12:21 PM, an observation was made of Resident #30 propelling himself in the wheelchair from his room to the hallway. An observation was made in Resident #30 and #34's room of the call light for Resident #30 lying on the floor underneath the bed. Resident #34 was not in the room, but the bed was made. An observation was made of Resident #34's call light not in reach but was found underneath the Resident's bed by the head of the bed. When asked about using the call light, Resident #30 reported he uses it if he needs something but indicated he takes himself to the bathroom. Resident #37 A review of Resident #37 medical record revealed an admission into the facility on 9/11/19 and readmission on [DATE] with diagnoses that included chronic obstructive pulmonary disease, depression, anxiety and dependence on supplemental oxygen. A review of the Resident's MDS revealed a BIMS score of 14/15 that indicated intact cognition and the Resident was independent with self-care. On 4/15/23 at 12:43 PM, Resident #37 was observed sitting on her bed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked if she had a call light in reach and indicated she did and stated, I have a call light, its' getting them to answer it. When asked how long it takes them to answer, the Resident reported over a half an hour, or longer at times and stated, They don't like me, and they don't like to answer my call light. Resident #51 A review of Resident #51's medical record revealed an admission into the facility on 4/25/22 and readmission on [DATE] with diagnoses that included dementia, depression, and heart disease. A review of the Resident's MDS revealed a BIMS score of 9/15 that indicated moderately impaired cognition and the Resident needed substantial/maximal assistance with dressing and partial/moderate assistance with personal hygiene. On 4/15/24 at 11:48 AM, an observation was made of Resident #51 laying in bed with the head of the bed elevated. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about her call light, but she did not know where it was. An observation was made of the Resident's call light cord clipped to the roommates TV cord on the other side of the partially pulled privacy curtain. The call light was not in reach for the Resident. The Resident was asked about response time when she used the call light and reported sometimes it was more than a half hour wait for staff to answer. An observation was made of the Resident's fingernails that were long, misshaped, and inconsistent in length with the thumb nails very long. When asked if she like to have long nails the Resident reported not liking the nails that long and stated, They need to be shorter, get stuff under them. When asked if she would let staff trim her nails, the Resident stated, Yes I would let them clip them if they would come in and do it. A review of facility policy titled, Call Light, Use of, revealed, Procedure Purpose: To respond promptly to resident's call for assistance . Procedure Details: .2. Answer call lights in a prompt, calm, courteous manner, .4. When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the light is and show him/her how to use the call light . 7. Place call light on the bed or preferred location stated by the resident prior to leaving the room. A review of facility policy titled, Fingernails/Toenails, Care of, revealed, Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . General Guidelines: 1. Nail care includes regular cleaning and regular trimming/filing. 2. Proper nail care can aid in the prevention of skin problems around the nail bed . 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . FACILITY Resident Council A review of the Resident Council Meeting Minutes for October 2023 - March 2024 revealed the following: Call light answering times too long: October 2023/reviewed for September 2023, March 2024. Residents receiving medications late; Residents not receiving care from the staff during the night- March 2024. Resident food preferences are not being honored; cold food when delivered to their room March 2024. On 4/15/24 at 9:56 AM, during a tour of the facility a Confidential Resident was observed to have their call light clipped to the bed sheet high up near their left shoulder. The length of the cord was short from the clip to the button and the resident couldn't reach it. The resident stated, They won't give it to me. They said I rely on it too much. On 4/16/24 at 2:03 PM during a meeting with a Confidential Group of Residents, they voiced concerns of waiting 1-3 hours for their call lights to be answered. They said it happened on all three shifts and sometimes it got better and then worse. They said they had discussed this with the facility administration, but sometimes on the weekend it was Terrible and some residents stated, They get there when they get there. On 4/16/2024 at 2:30 PM, during a meeting with a Confidential Group of Residents about their meals, they said some residents didn't always receive the food they ordered. Many residents said it was more difficult to receive the food they ordered when they ate in their room. They said it was better when they ate in the dining room. The residents also said if you did not arrive to the dining room in time, the staff would shut the doors and say you are too late and you have to eat in your room. The residents were very upset about this and said this occurred during the lunch and dinner meals, as the dining room was closed for breakfast. On 4/17/24 at 1:34 PM, during an interview with Dietary Director L, she said breakfast was served on trays to the resident's room from 7:00 AM to 8:00 AM; Lunch began at 11:15 AM in the dining room. She said the cook was in the dining room for 15-20 minutes and then the [NAME] and dietary aides returned to the kitchen to begin preparing trays on the hall; dinner was at 5:00 PM in the dining room with the cook and dietary aide in the dining room for 15- 20 minutes. The Dietary Director said the cook then came back to kitchen for tray line on the hall with trays delivered to the hall starting with the 600, 500 halls , then 400 hall, 300 hall, 200/100 halls. She said the dining room was not open for breakfast and all residents had to eat in their rooms, except one long term resident insisted on eating in the dining room and was allowed to eat in there. She said if the resident wasn't allowed to eat in the dining room, he would pound on the doors until he was served. The Dietary Director L was asked if there was a limited amount of time that residents could eat in the dining and she said, the cooks were only in the dining room for a short amount of time (15-20 minutes) for lunch and dinner to serve the meal and then they returned to the kitchen. When asked if residents were being told they could not eat in the dining room after that time, that they had to eat in their rooms, she said some staff told the residents their trays would be sent to their rooms, and they would not be served in the dining room. On 4/17/2024 at 2:10 PM, during an interview with Dietary [NAME] M he said he worked the day shift at the facility for the breakfast and lunch meals. The [NAME] M was asked about serving the resident's meals in the dining room and he said once he returned to the kitchen after 10-20 minutes in the dining room, he did not serve any more meals in the dining room. He said the residents were told their trays were going to their room. Resident #6 Activities of Daily Living Resident #6 (R6) on 04/15/24 02:20 PM, was observed lying on his bed with his wife visiting on the bedside. R6 was observed wearing a white T-shirt that appeared one size larger on him and a gray jogging pants that was too short and too tight for his size. When asked if he felt comfortable, he did not answer. R6 wife explained that R6 is very hard of hearing and may not have heard the question. R6 was observed with beard growth all over his face. The hair growth stood out because it was gray in color, on the R6's jaw, chin, upper lip, lower lip, cheeks and neck. Meanwhile, R6 wife was holding on to a shaving cream and razor. When asked, R6 wife revealed that she and her daughter had been taking turns shaving R6 beard and was not sure if the facility does it or them. She indicated that it seems that they were not doing it so they assumed that it is her and her daughter's responsibility. Resident's family had indicated that they have been shaving the residents all this time since admission. They have been bringing their own supplies (shaver and shaving cream) because he always have hair growth when they visit and R6 did not like that. R6's wife reported that they had been doing it because the staff did not do it. R6 was [AGE] years old, admitted to the facility on [DATE] with a primary diagnosis of Chronic Systolic Heart Failure in addition to other diagnoses. alert with a Brief Interview of Mental Status BIMS score of 03/15 dated 3/15/24. A score of 0-7 points suggests severe cognitive impairment. R6 Minimum Data Set (MDS) assessment dated [DATE] revealed, limited assist x 1 person for hygiene and limited assist x 1 for ambulation. Other skilled services include safety management. A review of R6 Electronic Medical Record done on 3/15/24 at 4:00 PM, revealed that both R6 [NAME] and Care Plan were consistent requiring one person assistance with Activities of Daily Living ADL's especially with showers, grooming (which included hair and nail care, and shaving) and toileting. On 4/15/24 at 2:25 PM, The Director of Nursing (DON) and surveyor entered R6 room and found the resident with shaving cream on his face and wife was shaving his beard with the razor. The DON explained to the wife that the staff will do the shaving for R6 moving forward. The DON was asked at @ 2:30 PM 4/15/24 and explained to the surveyor that staff do that and it is not the family's responsibility. Resident #69 Activities of Daily Living On 04/15/24 at 02:22 PM, Resident #69 (R69) was observed lying in bed with a neck brace and left arm and wrist brace and left lower leg brace. R69 was alert and oriented and answered question appropriately. R69 expressed issues with the long waits for call light response, his teeth consistently not brushed and shaving not done on a daily basis. R69 revealed he required totally dependent on staff with Activities of Daily Living due to the recent Motor Vehicle Accident and suffered from multiple fractures and had to wear the splints. R69 had expressed to get a shave because it bothers him. R69 was observed to have a hair growth of approximately less than a centimeter on the jaw, chin, upper lip, lower lip, cheeks and neck. He stated, It would be nice to get a shave. My beard is getting long. It bothers me. On 4/16/24 at 10:00 AM, a review of R69's Electronic Medical Record (EMR) revealed R69 was 61 y/o with a primary diagnosis of Traumatic Subarachnoid Hemorrhage without loss of consciousness. R69 was admitted to the facility Post-Motor Vehicle Accident MVA on 3/21/2024. R69 was his own responsible party with a Brief Interview of Mental Status BIMS Score of 14/15 (date assessed 3/28/24), which means R69 is cognitively intact. R69's Minimum Data Set (MDS) assessment dated [DATE], revealed that R69 depended on staff to perform his Activities of Daily Living (ADL's), especially with feeding, personal hygiene, bed mobility, and transfers. A review of the MDS dated [DATE], revealed that ADL's explained Personal hygiene as: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). R69 Care Plan was reviewed on 4/16/24 at 9:15 AM. It revealed: ADL Self care deficit. The goals specified were the following: > Will be clean, dressed and well groomed daily to promote dignity and psychosocial wellbeing. (Date initiated: 3/21/24) >Will not develop any complications related to decreased mobility. (Date initiated: 3/21/24) On 3/16/24 at 4:00 PM, R69 was observed with shaved, clean face. R69 stated, It felt good after they shaved me. I needed it.

Based on interview and record review, the facility failed to ensure that residents received their mail on Saturdays, resulting in residents not being able to exercise their right to receive mail and access communication. Findings Include: FACILITY On 4/16/24 at 2:30 PM, during an interview with a Confidential Group of Residents, when asked if the residents received Mail on Saturdays, the residents stated, The Mail doesn't run on Saturday. The Mail lady has weekends off. During further discussion, the residents said they did not receive mail on Saturday but did receive mail during the week. On 4/17/24 at 2:32 PM, the Activity Director I was interviewed related to resident mail delivery on Saturday, she said the post office was to deliver it to the front desk receptionist and the receptionist was to put it in the activities mailbox and then the activities aide who works on the weekend delivered it. The Activity Director I said she had worked on the weekend for the last several weeks and didn't recall if there was mail in the Activities mailbox. The Activities Director showed the room with the mailboxes and identified where the Activities mailbox was. It was located on the top of the mailboxes. On 4/17/2024 at 2:40 PM, Activities Aide K was interviewed about delivering the resident's mail to them on Saturday; she said she had delivered mail during the week but didn't remember the last time mail was delivered on the weekend. On 4/17/2024 at 2:50 PM, the Front desk Receptionist J was interviewed about the Mail delivery to the residents and she said sometime between 12:00 PM and 3:00 PM on Monday-Saturday, the post office delivered the mail to the front business office (sometimes it was later). She said although the business office door was locked, the receptionist had to open it with a key for delivery. When asked if the Mail was being delivered on Saturday, she said she was unsure if it was actually being delivered. She said if there was mail, the receptionist would sort the mail and place the resident's mail in the Activities mailbox. She said she supervised the other receptionists and would contact them to see if they were following the process. On 4/17/2024 at 3:30 PM, interviewed the Administrator about the mail. She explained the process for delivering the mail via the Receptionist at the front desk. Reviewed with the Administrator, the staff did not know if the residents were receiving mail on Saturday. A review of the facility policy titled, Mail and Electronic Communication, dated 4/2023 provided, Residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail . Mail and packages will be delivered to the resident within twenty-four hours of delivery on premises or to the facility's post office box (including Saturday deliveries) . A review of the Rights of Residents in Michigan Nursing Facilities, dated 2022 revealed, As a resident of a Michigan nursing facility, you have extensive rights guaranteed under federal and state law. As a basic premise, all residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . You have the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for you .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1.) Resident rooms were clean and in good repair and free of chipped paint and broken tiles; 2) Resident lift equipment was clean; and 3.) Wash basins were properly stored and labeled, affecting room numbers #101, 103, 104, 105, 203, 204, 209, and 211, and residents using the sit-to-stand lift, resulting in an unsanitary environment, potential spread of infection, and dissatisfaction with living conditions. Finding include: On 4/15/24 at 11:43 AM, an observation was made of a Sit-to-Stand mechanical lift in the 100-unit hallway. An observation was made of whitish/yellowish debris on the pads where the lower leg rest against when the mechanical lift was in use. An observation was made of the base, where the Resident's feet would be placed, of dirt and debris. On 4/15/24 at 11:57 AM, an observation was made during the initial tour of the facility, of the bathroom between room [ROOM NUMBER] and 103, with two Residents in each room that shared the bathroom. An observation was made of two basins stacked together and on the floor underneath the sink with a bed pan in a bag on the floor. The basins and the bedpan did not have visible identifying information as to whom the basins and bedpan belonged to. On 4/15/24 at 1:00 PM, an observation was made during the initial tour of the facility of room [ROOM NUMBER]-1's dresser drawers with two drawers that overlapped. The CNA in the room attempted to open the bottom drawer but the second drawer opened not allowing the contents to be accessible. On 4/16/24 at 9:24 AM, an observation was made of room [ROOM NUMBER]-1 of the Resident laying in bed with the breakfast tray on the overbed table. When asked the Resident said she was done eating. An observation was made of a soiled brief on the floor, two wipes on the floor with one that had bowel movement on it, a piece of the brief, and two washcloths on the floor. On 4/16/24 at 9:28 AM, an interview was conducted with CNA E regarding the debris on the floor in room [ROOM NUMBER]-1. The CNA indicated that she had not been in the room to provide care to the Resident. An observation was made with the CNA of the debris on the floor and reported that had been left from the nightshift and indicated that should not be left on the floor. The CNA indicated she had been in the room earlier but had been on the other side of the bed and it was not visible from that side. On 4/16/24 at 9:32 AM, an observation was made with the Director of Nursing (DON) of room [ROOM NUMBER]-1 with the debris on the floor. The DON indicated that staff were to pick up items and throw them away when care was provided and stated, They should not be left on the floor, The DON was not aware that it was from the nightshift and reported that she will deal with that. On 4/16/24 at 9:40 AM, an observation was made of a Sit-to-Stand in the 100 Unit hallway that was a different mechanical lift then observed on 4/15/24. An observation was made of whitish debris on the pads where the Resident's leg would rest against when the lift was in operation. On 4/16/24 at 2:42 PM, an interview was conducted with the Unit Manager A of the Sit-to-Stand mechanical lift in the 100 Unit hallway. An observation was made of the lift that was observed on 4/15/24 that had the same debris on the base as seen on 4/15/24. The lift had a cream-colored debris on the pads that the Resident legs would be positioned against when the lift was in use. The Sit-to-Stand mechanical lift in the 200 Unit hallway was observed with the Unit Manager with whitish substance on the leg pads. The Unit Manager got a glove and wiped at the leg pads and smeared and indicated it was possibly lotion. The Unit Manager indicated that she would make sure they are cleaned. An observation was made with the Unit Manager of basins stacked together with a bedpan on top of the basins. The Unit Manager indicated that the basins should be labeled with resident initials or room number, and they should not be stored on the floor of the bathroom. There was no identifying information on the wash basins or bedpan and the Unit Manager threw the items out. FACILITY Environment On 4/15/2024 at 10:00 AM, during a tour of the facility bathroom for the 205 and 207 rooms, two blue wash basins were lying beside each other on the floor under the sink. In one blue basin was a bed pan unlabeled. There were two residents in both the 205 and 207 rooms, with all sharing the bathroom. It was unclear which basin belonged to which resident or who the bedpan belonged to, or if they had been used. All were contaminated from sitting on the floor. On 4/15/2024 at 10:45 AM, during a tour of the facility in rooms 208 the floor was observed to have chipped floor tile and scrapes on the walls. On 4/15/2024 at 11:13 AM, during a tour of the facility, the bathroom that was shared by the residents in the 204 and 206 rooms, was observed to be very soiled and unkempt. There were two blue wash basins on the floor of the bathroom and a piece of plumbing pipe was laying in one of the basins. On 4/17/2024 at 11:10 AM, during a review of the facility Infection Prevention and Control program, spoke with Infection Preventionist H and requested to speak with the Maintenance Director. He said the Maintenance Director had resigned that week and someone else was filling in. Prior to exit on 4/17/2024 at 5:30 PM, the interim Maintenance Director was not interviewed about the identified issues in need of repair. A review of the document titled, My Rights as a Resident of a Nursing Home, via the Michigan Long Term Care Ombudsman Program provided, . My Right to Dignity: I have the right to- Live in a clean and safe place .

Based on observation, interview and record review, the facility failed to properly dispose of wasted medications and secure treatment carts that contained prescription treatment medications and medical supplies, resulting in the potential for drug diversion and ingestion of medicated substances. Findings include: On 4/16/24 at 2:42 PM, an observation was made with Unit Manager, Nurse A during a review of concerns in the 100 Hall Unit and 200 Hall Unit. While approaching the 200 Hall Unit with Nurse A an observation was made of the treatment cart in the 200 Hall, unattended by a Nurse. The cart had a drawer that was partially open. Upon observation of the cart, the drawer was able to be pulled open with skin and wound treatments in the drawer. The Unit Manager indicated that the cart should be locked. Upon locking the cart, it was found to be locked but that the drawer was not pushed in all the way, leaving access to that drawer. The Unit Manager closed the drawer and made sure it was then secure. On 4/17/24 at 7:53 AM, an observation was made during medication administration task of the survey of a treatment cart in the 400 Hall unit that had a drawer partially open. Nurse G was asked about the open drawer in the treatment cart and stated, It should be locked. The drawer had supplies for wound treatments. On 4/17/24 at 8:15 AM, an observation was made during the medication administration task of the survey of Nurse F doing a medication administration for a Resident. As this surveyor came up to Nurse F with medications in a medication cup. The Nurse was asked for observation during medication administration. The Nurse indicated that she was OK with the observation. The Nurse had medication prepared for a Resident and reported she had dropped a medication, threw the medication, which was a large white pill, into the garbage on the side of the medication cart. The Nurse went to pass the medications to a Resident. Upon return, the Nurse was observed to prepare the medication for another Resident. The Nurse dropped a Tums tablet (antacid medication) on the medication cart. The Nurse indicated she had dropped the medication, would discard it, threw the medication into the side garbage on the medication cart and retrieved another tablet for the Resident. The Nurse pushed the cart in the hallway to the Resident's room where she was going to be giving the medication. The medication cart remained in the hallway while the Nurse went to the Resident in bed two, who had a curtain pulled. The medication cart was out of sight of the Nurse. Upon returning to the cart, a Resident in a wheelchair was next to the cart on the side of the garbage that was positioned low on the cart. The garbage did not have lid positioned over the garbage leaving it accessible to the Resident in the wheelchair. Upon realization that the Nurse had discarded two medications into the garbage, the Nurse was informed of the medication in the garbage and asked what the facility policy was on disposal of medication. The Nurse reported that they do not belong in the garbage. When asked what the other medication was that had been discarded in the garbage, the Nurse indicated it was Metformin (an antidiabetic medication to control high blood sugar often used in patients with diabetes). The Nurse did not remove the garbage from the medication cart. The Nurse proceeded to prep medication for the next Resident. One of the medications was not available in the medication cart and the Nurse left the cart in the hallway to retrieve medication from the back-up medications. The Nurse left the hallway and was not seen. The Resident remained in the hallway propelling herself in the wheelchair. Upon the return of the Nurse, the surveyor informed the Nurse that the garbage where the medications had been discarded remained on the cart. The garbage did not have a lid positioned over the contents of the garbage. The Nurse then removed the garbage from the side of the medication cart. On 4/17/24 at 1:47 PM, an interview was conducted with the Director of Nursing (DON) regarding medication storage and disposal of medication. The DON indicated that the Nurse should not be throwing the medication in the garbage. A review of facility policy titled, Discarding and Destroying Medications, revealed, Policy Statement: Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances . 2. Non-controlled and Schedule V (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications . A review of facility policy titled, Medication Administration, revealed, .19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to resident or others passing by .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that ongoing surveillance of infectious illnesses for employees was maintained, documented, analyzed and reported, resulting in the potential for a lack of guidance to ensure compliance with infection control standards of practice and exposure to infectious organisms, which could lead to an unidentified outbreak. Findings Include: FACILITY Infection Control On 4/17/24 at 10:20 AM, during a review of the Infection Prevention and Control Program with Infection Preventionist/IP H, he was asked about surveillance for employee illnesses. The IP said the facility had an employee call in log, that identified staff call-ins from work. He said during the morning Interdisciplinary Team Meeting, he would look at the employee call in logs. The IP was asked if he collected the data and analyzed for similar infections during the week or month. He said he looked at the information but did not write anything down. The IP did not have any written data to compare with resident infections occurring at the same time, monthly, quarterly, yearly or any additional timeframe that might be needed. The IP did collect ongoing data for employee Covid-19 infections, but not for any other employee illnesses/infections. The IP was asked if he reported Infection Surveillance data at the Infection Control Committee meetings and he said the data was reported at the monthly QAPI meetings, but he said he did not report employee illness information. A review of the Facility assessment dated [DATE] revealed, Evaluation of Infection Prevention and Control Program, provided . Track employee and resident infections. Reports monthly on infection control information at our monthly QAPI meetings . Upon review of the monthly Infection surveillance line listings for August 2023 to March 2024, there was no surveillance identified for employee illnesses. The resident infection surveillance listed a variety of skin/wound, urinary, gastrointestinal, ophthalmic, respiratory including a positive urine antigen specimen for Legionella that was being followed by the local health department with monthly water testing and included resident testing in August 2023, infections with multi-drug resistant organisms/MDRO's, including Clostridium difficile. A review of the Monthly Infection summary reports for August 2023 to March 2024 also identified resident infection surveillance including 8 respiratory infections of unknown origin in August 2023, but there was no mention of employee illnesses in any of the reports, except each month the IP wrote Employee illnesses were tracked and considered for possible transmission. There was no additional information. IP H was asked about this during the Infection Prevention and Control program review on 4/17/2024 at 10:45 AM and he said he hadn't written anything down. He was not monitoring, analyzing or reporting infection surveillance for employees. A review of the facility policy titled, Infection Prevention and Control Program, dated reviewed and revised on 3.23, provided An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. The program is based on accepted national infection prevention and control standards . The elements of the infection prevention and control program consist of . prevention of infection, and employee health and safety . Surveillance: Process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of IPCP effectiveness . The information obtained from infection control surveillance activities is compared with that from other facilities and with acknowledged standards . Data gathered during surveillance is used to oversee infections and spot trends . Monitoring Employee Health and Safety: The facility has established policies and procedures regarding infection control among employees, contractors, vendors, visitors and volunteers .

Based on observation, interview and record review, the facility 1.) Failed to ensure that food products were properly labeled with an Opened and/or Use by date and dispose of expired food items; 2.) Failed to monitor/document temperatures of a refrigerated unit; 3.) Failed to properly wash and dry cookware/bakeware/food containers before stacking/storage; and 4.) Failed to maintain sanitary cooking equipment, resulting in the potential contamination of food, bacterial harborage and the increased potential for food borne illness. This deficient practice had the potential to affect all residents who consume food prepared in the kitchen with a census of 73. Findings include: Initial tour of the Kitchen: On 4/15/24 at 9:27 AM, an initial tour of the facility kitchen was conducted with Dietary Manager L. The following observations were made: -Two knives were found in the knife holder that had debris on them. The Dietary Manager was asked if the items were ready for use and the Dietary Manager indicated they were. -Muffin tins ready for use were found to be oily, had baked on oil residue and one with food debris on them. -Metal trays stacked and ready for use, had multiple trays that were wet and one with whitish droplets on them. [NAME] Q was asked about stacking the items wet and indicated they were not aware the items needed to be dried prior to stacking. The Dietary Manager indicated they needed to be dry before stacking. -Venting system over the cook area with debris. -Four of five non-stick pans with the coating coming off the cook area of the pans. -Multiple wet metal pans that would hold food, stacked together wet. -Refrigerated section in the kitchen area, that had an open date that was hard to read of 4/13. There was not a use by date. When asked, the Dietary Manager indicated there should be an open date and a use by date. -Milk in the refrigerator opened and partially used, not labeled with an open date or use by date. -Juice in plastic containers without a date it was stored in the containers or a use by date. -Mustard with a received by date of 8/8/23, not labeled with an open date or use by date. -Meat slicer with a bag over top. The Dietary Manager indicated it was ready to use. The slicer had meat debris on the cutting area and oily residue were the meat would rest after being sliced. -Robot Coupe used to puree food, stored with the top on and wet inside. -Coffee containers, ready to use. One container had coffee inside and another had paper debris inside. -Hot water pitcher, stored wet with the lid on. -Coffee machine, dirty inside the machine and the bagged coffee did not have an open date. When asked about dating the opened coffee bag, the Dietary Manager stated, Yes, they should date it even though we go through it so fast. -Juice machine dirty and sticky inside the door and underneath. The juice that was hooked up to the juice machine were not dated with an open date. When queried, the Dietary Manager indicated staff should be dating when it was opened. -Instant coffee container with an expiration date of 3/21/24. -English muffins on the bread rack had moisture inside the bag. The Dietary Manager indicated they were pulled from the freezer. The Dietary Manager was unsure when the item was pulled from the freezer and indicated it should have a use by date on the package. -Personal staff items of a drink in a Styrofoam cup and a jacket in the tray prep area. The Dietary Manager indicated the items should not be stored there. -Plastic trays that are used to serve food to the units had some trays that were stacked and wet. -In the cupboard area a mixer had food debris on the cord and cocoa powder with an expiration date of 3/24. There was not an opened date on the container. -In the walk in refrigerator, a tray of cups of pineapple were on a shelf that were not well covered and exposed to the circulating air. The Dietary Manager indicated they should be covering them. -An open bucket of pickles that did not have a receive by date and was not labeled with a open or use by date. The Dietary Manager indicated they had recently received the pickles. -Two ice cream containers, opened on 6/6/23 and was not labeled with a use by date. The Dietary Manager reported she was unsure how long they were good once opened but indicated she thought it was three months but discarded the containers. A review of the kitchenette on the 500-hall unit was reviewed for food storage with Dietary Manager L. An observation was made of open ketchup in the cupboard area that did not have an open date or in a refrigerated area and syrup that did not indicate who the items belonged to or when they were opened. Thickened coffee container with an expiration date of 4/14/22. The refrigerator temperature logs for the Dairy cooler were reviewed with Dietary Manager L. The logs had an area for an AM temperature and PM temperature recording. The temperature log showed multiple entries, six from April 1st to 14th, of temperatures not recorded but had a dash for the time, temperature and initials. The March log had three areas that were left blank and six areas that were left with dashes. The Dietary Manager indicated they had a staff that put the dashes when the temperatures were within range and reported they should be filling it in with the temperatures. A review of facility policy titled, Food Service Sanitization, revealed, Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: .2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions . A review of facility policy titled, Refrigerators and Freezers, revealed, Policy Statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation: .3. Monthly tracking sheets will include time, temperature, initials, and action taken . 4. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening . 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators and freezers are not expired or past perish dates .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure policies and procedures were in place for advance care planning for two residents (Resident #48 and Resident #380) of three residents reviewed, resulting in a lack of timely and comprehensive assessment, completion, and documentation of advance care planning for residents, the likelihood for lack of understanding of advance directives, resident goals and wishes for proxy decision makers and care decisions not being known, and undesired healthcare decisions and decision makers. Findings include: Resident #48: On 4/5/23 at 12:35 PM, Resident #48 was observed sitting in a wheelchair in their room and an interview was completed. Resident #48 was pleasantly confused and frequently repeated themselves but able to answer questions. When queried if facility staff had discussed advance care planning with them, including formulation of Advance Directives, Resident #48 revealed they did not recall anyone asking them what or who they wanted to make medical decisions for them if they were no longer able. Record review revealed Resident #48 was most recently admitted to the facility on [DATE] with diagnoses which included dementia, chronic kidney disease, urine retention, sepsis (infection in blood which spreads throughout body), and UTI. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required limited to total assistance to complete ADL's with the exception of eating. Review of the Resident's Electronic Medical Record (EMR) indicated the Resident was a full code. A care plan entitled, Advance directive: FULL CODE (Initiated: 3/23/23) was noted in Resident #48's EMR. The care plan included the intervention, (Witness FF) is decision maker (Initiated and Revised: 3/23/23). Review of scanned documents in Resident #48's EMR revealed a court document entitled, Letters of Conservatorship dated 12/18/18 which named Witness FF as Resident #48's conservator of their estate. The court document detailed Witness FF was granted power to take possession, collect, preserve, manage and dispose of property of the estate . The court document did not grant Witness FF authority to make medical decisions for Resident #48. Review of documentation in Resident #48's EMR included: - 3/28/23 at 11:02 AM: Social Services . SW (Social Work) met with pt (patient). Pt was alert, oriented and able to make needs known . full code . - 3/28/23: Social Services Evaluation . Advance Care Planning . 1. Does the patient/patient's decision maker report that advance care planning has been completed . Yes . What advance care planning has been completed . Other . Family may file for guardianship, pt (patient) has conservator . On 4/6/23 at 1:04 PM, an interview was conducted with Licensed Practical Nurse (LPN) M. When queried regarding the facility policy/procedure related to Advance Directives and Advance Care Planning, LPN M indicated they were unsure. LPN M was then asked if nursing staff assess resident code status upon admission and replied, Yes. LPN M further revealed resident code status is assessed as part of the nursing assessment. When queried how nursing staff assess and determine a resident's code status, LPN M replied, We ask them. When queried if they also ask residents if they have documentation of what medical care they want and/or who they want to make their decisions if they are not able to make decisions, LPN M indicated that is not something nursing staff addresses. LPN M was then queried how they determine what a Resident's code status is if they are confused and do not have a legal decision documentation, LPN M stated, Look at what they came in as from the hospital. An interview was completed with facility Social Services Staff C on 4/6/23 at 2:00 PM. When queried regarding Resident #48's cognitive status, Staff C stated, (Resident #48's) BIMS was 15 but they are confused at times and repeats themselves. Staff C was then queried regarding Resident #48's advance care planning and stated, (Resident #48) has a conservator. When asked if Resident #48's Conservator was solely related to their estate and not medical decisions, Staff C reviewed the document in Resident #48's EMR and confirmed. Staff C was then asked if Resident #48 had an Advance Directive in place such a durable power of attorney for health care/guardian and revealed they did not know. When queried if they had discussed Advance Care planning for medical decisions with Resident #48, Staff C stated, Usually in our notes. I have not talked to (Resident #48) about it yet. When queried regarding documentation in their assessment indicating family may file for guardianship including the relationship of the family member and if they had discussed the process with the family member, Staff C was unable to provide a response. Staff C proceeded to review their assessment and progress note documentation in Resident #48's EMR and stated, I have not discussed that with (Resident #48). When queried if they discussed the Resident's resuscitation and code status with them, Staff C indicated they review resident code status in the EMR to ensure it has been addressed. Staff C was then asked if they address code status with residents who are documented as being a full code, Staff C stated, No. That is more with the doctor and nursing. Resident #380: Record review revealed Resident #380 was most recently admitted to the facility on [DATE] with diagnoses which included heart failure, Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, and Covid-19. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete all ADL's with the exception of eating. Review of Resident #380's EMR revealed the Resident was full code. No advance care planning documentation was noted in the EMR. Review of Resident #380's EMR included the following: - 3/21/23: Admission/re-admission Evaluation . Advance Directive(s)/Advance Care Planning . Full Code (checked) . - 3/30/23: Social Services Evaluation . Advance Care Planning . Does the patient/patient's decision maker report that advance care planning has been completed (Blank) . Social Services Evaluation Summary/Plan . SW met with pt . Pt's code status is full code . Review of Resident #380's care plans included a care plan entitled, Advance directive: FULL CODE (Initiated: 3/23/23). The care plan included the intervention, (Resident #380) is own decision maker (Initiated: 3/23/23) No documentation pertaining to advance care planning and/or advance directives were present in Resident #380's EMR. An interview was completed with facility Social Services Staff C on 4/6/23 at 2:08 PM. When queried regarding Resident #380's advance care planning, Staff C stated, (Resident #380) doesn't have a DPOA (Durable Power of Attorney) of anything. Staff C was then asked if they had discussed advanced care planning with the Resident, Staff C stated, I have not had those conversations. An interview was conducted with Unit Manager Registered Nurse (RN) H on 4/7/23 at 8:22 AM. When queried regarding facility process related to nursing assessment of resident code status, RN H replied, During admission assessment address code status. RN H continued, Does not go any further related to POA or decision maker. When asked who addresses if Resident POA or decision maker status, RN H stated, Information usually obtained during admission process. When asked who discusses advance care planning for residents who do not have advance directive in place when they are admitted , RN H revealed facility social services. On 4/12/23 at 8:30 AM, an interview was conducted with the facility Administrator. When queried regarding the facility process/procedure related to advance care planning, the Administrator revealed facility Social Services Staff address advance care planning and advance directives in their assessment. When queried regarding Staff C statements related to Resident #48 and 380 and lack of evaluation and lack of evaluation and assistance with completion of advance care planning, the Administrator confirmed the concern and indicated they would discuss with social service staff. A policy/procedure related to advance care planning was requested at this time. Review of facility policy/procedure entitled, Advance Directives (Reviewed 3/23) revealed, 1. Upon admission, the resident will e provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate and advance directive . 8. If the resident indicates that he or she had not established advance directives, the facility staff will offer assistance in establishing advice directives . Review of facility policy/procedure entitled, Social Services (Reviewed 1/23) revealed, Our facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being . The policy did not address advance care planning. A policy/procedure related to advance care planning was not received by the conclusion of the survey.

Based on interview,and record review, the facility failed to update/revise the care plan in a timely manner for one resident (Resident #58) of 21 sampled residents' urinary care plans, resulting in the likelihood of missed care and services not being care planned and the likelihood of unmet care needs. Findings include: Record review of the facility 'Care Plans, Comprehensive Person-Centered, Timing and Revision' policy dated 3/13/2023, revealed the purpose of a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: (#13) Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. (14.) The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. Resident #58: Observation on 04/04/23 at 12:29 PM of Resident #58 lying in bed, per resident the catheter was removed a week or more ago, no catheter observed in use. Resident #58 acknowledged that she had a urinary tract infection and had received pills for it. Record review on 04/06/23 at 12:35 PM of Resident #58's electronic medical Record review of lab for Urinary Analysis with Culture & Sensitivity dated 4/3/2023 noted 'polymorbic specimen, no predominant morphotype, Please resubmit'. The lab results did note leukocytes Esterase large amounts and Protein. In an interview and record review on 04/07/23 at 07:47 AM with Registered nurse/Infection preventionist (RN/ICP) B revealed Resident #58 was admitted in January 26 2023, came with candida with diflucan treatment. Record review of the infection control line listing revealed Resident #58 did not have any infection the month of February. Record review of the infection control line listing revealed Resident #58 did have Corona virus (COVID-19) infection the month of March. On April 3, 2023, Resident #58 was diagnosed with a facility acquired in-house urinary tract infection (UTI). There was no organism identified in the urine specimen per RN/ICP B stated that the physician started a Cipro antibiotic empirically, for polymicrobic specimen. Record review of Resident #58's physician orders revealed antibiotic of Cipro 250 mg oral for one week. RN/ICP B is also the Staff educator. The surveyor asked when was the last peri care/catheter in-service with hands on demonstration was when? RN/ICP B could not give a date and presented no documentation of education. RN/ICP B stated that Resident #58 has dementia and may be doing her own peri care and we may need to step in and take care of that for her. RN?ICP B stated that he did not know why Resident #58 got an in-house acquired UTI. RN/ICP stated that he did not have a specific organism to treat, but the doctor started antibiotic. Record review on 04/12/23 at 9:21 AM of Resident #58's urinary retention care plan started 3/21/2023 related to impaired mobility and physical limitations revealed interventions to assist with toileting and to provide incontinence care as needed. There was no revisions/updates of interventions for monitoring of antibiotic therapy/use started on 4/3/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00129407. Based observation, interview, record review, the facility failed to get one resident (Resident #131) transported to the correct address for a cardiac appointment, resulting in the likelihood for a delay in care and prolonged illness. Findings include: Record review of the facility 'Change in a Resident's Condition or Status' Policy, dated 3/2023, revealed that the facility shall promptly notify the resident, attending physician, and representative of changes in a resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc ). (1.) The nurse will notify the resident's attending (2.) A significant change of condition is a major decline or improvement in the resident's status. Resident #131: Record review of Resident #131's closed medical record progress note dated 6/28/2021 at 4:48PM by Social Worker C, noted that there was an appointment for 6/30/2021 at 10:40 AM and that the resident needed a ride to the appointment. Record review of Resident C's progress note dated 6/29/2021 at 5:24 PM written by Social Worker C noted that the appointment transport was set up for 10 AM on 6/30/2021. Nursing progress not dated 6/30/2021 at 1:42 PM revealed that resident went to appointment today, leave of absence between 10 AM - 11:20 AM and they stated that she was at the wrong location. She should have been in [NAME]. The cardiologist's office made the resident another appointment for 7/19/2021 at 2:20 PM. In an interview on 04/06/23 at 1:55 PM, the facility's Appointment Scheduler CC shared that she was also the unit secretary and appointment scheduler. Record review of the facility's electronic calendar for June 30, 2022, noted a cardiology appointment for Resident #131. Staff CC stated that there are few locations for them, and that she did not know why the address doesn't print off on the calendar.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement procedures and planned interventions for pressure ulcer (wounds cause by pressure) prevention for two residents (Resident #182 and Resident #380) of two residents reviewed, resulting in a lack of turning and repositioning for a resident with pressure ulcers, a lack of monitoring and assessment of alternating air mattress functions, uncontrolled pain, and the likelihood for pressure ulcer development/worsening, ongoing and untreated pain, and a decline in overall health. Findings include: Resident #182: On 4/4/23 at 3:14 PM, Resident #182 was observed in their room. The Resident was in bed, positioned on their back with their knees slightly bent and heels positioned directly on the mattress. Resident #182 replied occasionally when asked questions but was confused. Record review revealed Resident #182 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis (MS) and Urinary Tract Infection. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required assistance of two+ staff to complete Activities of Daily (ADL's). The MDS did not detail the Resident's pressure ulcer risk and/or status. Review of Resident #182's Admission/re-admission Evaluation dated 3/28/23 at 1:08 PM detailed, Clinical Evaluation Integumentary (Skin) . Current skin integrity issues . Dry peeling skin to entire abdomen area . Chest: Areas of dry peeling skin . Bilateral inner thighs multiple scars and areas of skin color alterations. [areas deep brown- to light brown in color] . Patient admitted with pressure wounds to left knee, left medial thigh, left medial ankle, right foot-sole, right heel, right buttocks, and left buttocks .Multiple areas of discoloration to back area. Review of Resident #182's care plans revealed multiple care plans related to pressure ulcers. The care plans were entitled: - Patient admitted with stage 2 (partial thickness tissue loss pressure ulcer with exposed dermis) pressure wound to left buttocks. Wound measures 3.5 cm (centimeters) x 2.0 cm. No depth to the wound. Red tissue noted to wound bed surface. No drainage . (Initiated and Revised: 3/28/23) - Patient admitted with Stage 2 pressure wound to left knee. Wound measures 6.8 cm x 4.5 cm. No depth to the wound. Red tissue to wound bed surface. No drainage . (Initiated and Revised: 3/28/23) - Patient admitted with stage 2 pressure wound to left medial inner thigh. Wound measures 7.9 cm x 9.5 cm. No depth to the wound. Red tissue noted to wound bed surface. Surrounding tissue dry peeling skin noted (Initiated and Revised: 3/28/23) - Patient admitted with stage 2 pressure wound to right buttocks. Wound measures 1.6 cm x 1.2 cm. No depth or drainage . (Initiated and Revised: 3/28/23) - Patient admitted with stage 2 pressure wound to sole of right foot. Wound measures 6.0 cm x 4.8 cm. No depth . Wound bed red tissue noted. No drainage . (Initiated and Revised: 3/28/23) - Patient admitted with stage 3 (full thickness loss with exposed fat) pressure wound to left medial outer ankle. Wound measures 1.0 cm x 1.4 cm. Wound bed 30 percent brown slough and 70 percent red tissue. No depth to the wound. No drainage . (Initiated and Revised: 3/28/23) - Patient admitted with unstageable (pressure ulcer with unknown depth) pressure wound to right heel. Wound bed covered with brown/ purple tissue. No depth to the wound. Wound measures 2.2 cm x 1.5 cm. No drainage . (Initiated and Revised: 3/28/23) All care plans included identical interventions which included: - Administer analgesics as needed (Initiated: 3/28/23) - Administer treatment per physician orders (Initiated: 3/28/23) - Friction reducing transfer surface (Initiated: 3/28/23) - Incontinence management (Initiated: 3/28/23) - Pain evaluation prior to treatment (Initiated: 3/28/23) - Pressure redistributing support surface (Initiated: 3/28/23) - Repositioning during ADL's (Initiated: 3/28/23) Review of documentation in Resident #182's Electronic Medical Record (EMR) revealed the following: - 3/28/23 at 3:30 PM: Nursing/Clinical . admitted [DATE] . from [NAME] hospital. Patient's family called EMS due to exacerbation of MS. Patient reported increased weakness to lower legs with intermittent sharp pain. Patient also stated decreased ability to care for self. Patient admitted with exacerbation of MS started on high doses of steroids. Patient diagnosed with UTI (Urinary Tract Infection) . Patient alert talking with staff. Skin assessment completed at this time. Chest area dry peeling skin. Abdomen layers of dry peeling skin. Multiple scars to inner thigh areas. Back scars and dry skin. Buttocks areas of dry peeling skin multiple scars to buttocks area. Left knee stage 2 pressure wound. Wound measures 6.8 cm x 4.5 cm. No depth to the wound. Red tissue noted to wound bed surface. No drainage from the wound. Left medial inner thigh stage 2 pressure wound. Wound measures 7.9 cm x 9.5 cm. No depth to the wound. Red tissue noted to wound bed surface. No drainage from the wound. Dry peeling skin to surrounding tissue with multiple scars. Left medial outer ankle stage 3 pressure wound. Wound measures 1.0 cm x 1.4 cm. No depth to the wound. Wound bed 30 percent brown slough and 70 percent red tissue. No drainage from the wound. Right sole of foot stage 2 pressure wound. Wound measures 6.0 cm x 4.8 cm. No depth . Red tissue noted to wound bed surface. No drainage . Right heel unstageable pressure wound. Wound measures 2.2 cm x 1.5 cm. Wound bed brown/purple tissue. No drainage from the wound. Right buttocks stage 2 pressure wound. Wound measures 1.6 cm x 1.2 cm. No depth to the wound. No drainage . Red tissue noted to wound bed. Dry peeling skin noted to right buttocks. Left buttocks stage 2 pressure wound. Wound measures 3.5 cm x 2.0 cm. No depth . Red tissue noted to wound bed surface. No drainage from the wound. Surrounding tissue dry peeling skin. Treatments completed to wounds as ordered. Patient dependent on staff for all personal care. Patient alert able to express her needs to staff. Staff will provide frequent position changes q (every) shift. Pressure relieving mattress on bed to promote comfort and to enhance wound healing. Protective wound care provided by staff as needed. Staff will assist the patient with bed mobility and transfers. Patient requires max. assistance with turning and repositioning. Patient is incontinent of bowel and bladder. Staff will provide incontinence care as needed . - 4/1/23 at 5:11 PM: Nursing/Clinical . Resident c/o (complain of) LLE (Left Lower Extremity) painful muscle spasms. Notified (Doctor) via telephone and received order to start Baclofen (muscle relaxer) . - 4/3/23 at 3:53 AM: Nursing/Clinical .Pt c/o LLE pain x 1 . - 4/4/23 at 11:11 AM: Skilled Nursing . denies pain when asked and does not exhibit signs of pain except moaning at times but given mentation . and wounds MD gave order to schedule Tylenol . On 4/6/23 at 10:39 AM, an observation occurred of Resident #182 in their room. The Resident was in their bed, positioned on their back with the call light was observed on the floor. The Resident was talking to themselves upon entering the room. The TV was off and there was no radio or other noise in the room. The room walls were devoid of color and there were no decorations and/or signs of activities present. When asked questions, Resident #182 made eye contact but did not provide a meaningful response to the question asked. An interview was conducted with Licensed Practical Nurse (LPN) M on 4/6/23 at 10:46 AM. When queried regarding Resident #182's cognitive status, LPN M stated, I don't think (Resident #182) knows what's going on. When asked how much assistance Resident #182 required for ADL care, LPN M revealed the Resident was completely dependent upon staff. At 11:27 AM on 4/6/23, Resident #182 was observed laying in bed in the same position as previously observed. On 4/6/23 at 12:36 PM, Resident #182 was observed in their room. The Resident was in bed, positioned in the same position as prior observation. At 12:43 PM on 4/6/23, An interview was conducted with LPN M. When asked if Resident #182 was able to turn/reposition themselves, LPN M stated, (Resident #182) does not move themselves at all. When queried regarding the frequency of repositioning for dependent residents, per facility policy/procedure, LPN M indicated Residents should be turned every two hours. On 4/6/23 at 1:28 PM, Resident #182 was observed in their room in bed. The Resident remained in the same position on their back. An interview was completed with Certified Nursing Assistant (CNA) N on 4/6/23 at 1:38 PM. When queried, CNA N revealed they were Resident #182's assigned CNA. CNA N was asked how often they reposition the Resident and replied, Well, (Resident #182) resists. CNA N was queried what they mean by resist, CNA N revealed the Resident had grabbed at them before and indicated they did not try. CNA N was asked when the Resident was repositioned and stated, Around noon. CNA N was asked if they had repositioned the Resident before noon and revealed they had not. When queried why the Resident had been in the same position since 10:39 AM if they had repositioned them at noon, CNA N replied, Just repositioned the pillow under their leg. CNA N was asked if moving the pillow under the Resident's leg was adequate repositioning for pressure ulcer prevention and to relieve pressure from the Resident's multiple pressure ulcers, CNA N indicated it was not. At 3:34 PM on 4/6/23, Resident #182 was observed in bed, positioned in the same position as previously observed. Family Member Witness P was sitting in a chair next to the Resident. An interview was completed at this time. When queried how long they had been at the facility, Witness P they had been there over an hour. Witness P was queried if staff had come into the room to reposition the Resident while they were there. Witness P revealed that no staff had requested and/or attempted to reposition the Resident. A wound care treatment observation for Resident #182 was completed on 4/7/23 at 8:40 AM with Registered Nurse (RN) Q and Wound Care RN A. Prior to beginning the treatment, neither staff member assessed the Resident's pain. During the wound care treatment, Resident #182 displayed non-verbal signs/symptoms of pain including facial grimacing, reaching out, and clenching their hand into a fist. Resident #182 yelled, Ow, ow, ow . multiple times throughout the treatment. As Resident #182 was yelling out, this Surveyor asked the Resident if they were having pain and Resident #192 replied, My legs. The Resident did not provide a numerical rating for their pain. An interview was conducted with RN Q at 4/7/23 at 9:24 AM following the wound care treatment. When queried if Resident #182 displayed signs and symptoms of pain during the wound care treatment, RN Q replied, Yes. When queried regarding Resident #182's pain management, RN Q stated, (Resident #182) has Tylenol scheduled. When queried if the Resident had other pain management interventions, either pharmacological or non-pharmacological, RN Q indicated there were no other interventions in place. When asked if the Tylenol was effective, RN Q confirmed it was not and stated, I will call the doctor. RN Q was then asked what Resident #182's alternating air mattress settings were supposed to be and replied, I don't know. Further review of Resident #182's care plans revealed a care plan entitled, Pain (Coccyx, hips, bilateral lower ext's [extremities]) evidenced by pt assessment/history related to multiple pressure points/ulcers, MS, generalized aches and pains. Pt has a pain goal of (blank) . (Initiated and Revised: 4/4/23). The care plan included the interventions: - Report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc (Initiated: 3/28/23) - Administer pain medication per physician orders (Initiated: 3/28/23) - Encourage/Assist to reposition frequently to position of comfort (Initiated: 3/28/23) - Notify physician if pain frequency/ intensity is worsening or if current analgesia regimen has become ineffective (Initiated: 3/28/23) Review of Resident #182's Health Care Provider (HCP) orders and Medication Administration Record (MAR) revealed the following orders: - Tylenol 500 milligrams (mg) four times a day for pain (Start Date: 4/4/23) - Baclofen 5 mg two times a day for muscle spasm (Start date: 4/4/23) - Tylenol 625 mg every six hours as needed for pain (Start Date: 3/28/23) Review of pain documentation in the MAR for April 2023 revealed Resident #182 experienced pain daily from ranging from one to seven out of 10 with 10 being the worst. Resident #380: On 4/5/23 at 12:05 PM, Resident #380 was observed in their room in bed, positioned on their back. An alternating air mattress was present on the Resident's bed. The Resident was wearing a hospital gown and was unshaven with and unkept appearance. An interview was completed at this time. When asked if they had any wounds, Resident #380 shook their head to indicate no. When asked the reason they had an alternating air mattress on their bed, Resident #380 revealed they were unsure. Record review revealed Resident #380 was most recently admitted to the facility on [DATE] with diagnoses which included heart failure, Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, and Covid-19. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete all ADL's with the exception of eating. The MDS further revealed the Resident was at risk for pressure ulcer development. Review of Resident #380's care plans revealed a care plan entitled, Patient admitted with thick dry discolored skin to bilateral elbow areas. Skin intact to both areas (Initiated and Revised: 3/22/23). The care plan included the interventions: - Encourage and assist as needed to turn and reposition; use assistive devices as needed (Initiated: 3/22/23) - Pressure reducing surface on bed/wheelchair (Initiated: 3/22/23; Revised: 4/3/23) - Use pillows and/or positioning devices as needed (Initiated: 3/22/23) A second care plan entitled, Patient admitted with brown vascular discoloration to bilateral feet. Dry skin noted to both feet (Initiated and Revised: 3/22/23) was also noted in Resident #380's EMR. This care plan included the interventions: - Pressure reducing surface on bed/wheelchair (Initiated: 3/22/23; Revised: 4/3/23) - Elevate heels as able (Initiated: 3/22/23) Review of Resident #380's EMR revealed the following progress notes: - 3/22/23 at 10:36 AM: Nursing/Clinical . patient admitted [DATE] . from hospital. Patient treated at the hospital for COPD exacerbation . Skin audit completed at this time. Left upper arm bruise. Left outer elbow region resolved abrasion. Skin intact pink in color. Area does not require treatment left open to air. Left elbow thick dry skin . Right elbow thick dry discolored skin . [NAME] vascular discoloration noted to right foot. Dry skin to right foot. Right great toenail fungal toenail. Tip of right great toe red in color. Left foot brown vascular discoloration. Buttocks skin intact brown discoloration noted to gluteal fold. Scrotum left side red in color with skin intact . Staff will provide frequent position changes q (every) shift. Preventive skin care provided by staff as needed. Genesys 3 pressure relieving mattress (alternating air mattress) on bed . On 4/7/23 at 8:01 AM, Resident #380 was observed in bed, positioned on their back. The Resident's body appeared sunken into the bed. There were no lights on the alternating air mattress controller and the power switch on the side of the alternating air mattress was in the off position. When asked how long they had been sunk into the mattress, Resident #380 indicated it had been like that since they had moved rooms the previous day. On 4/7/23 at 8:31 AM, an interview and observation of Resident #380's mattress was completed with Certified Nursing Assistant (CNA) O. Upon entering Resident #380's room, CNA O was asked why Resident #380 appeared sunken in the mattress and indicated they did not know. When asked if the alternating air mattress was functioning, CNA O checked the mattress and revealed it was turned off but plugged in. When queried who checks the alternating air mattresses to ensure they are functioning and at the correct settings, CNA O replied, I don't know. CNA O then stated, To be honest, I probably wouldn't have even noticed if you wouldn't have pointed it out to me. CNA O proceeded to turn the power on the alternating air mattress. At 8:37 AM on 4/7/23, an interview was conducted with Registered Nurse (RN) Q. When queried regarding facility policy/procedure related to monitoring alternating air mattresses, RN Q replied, I do. When asked if they ensure the settings are correct and as ordered, RN Q stated, I just check to make sure they are on. RN Q was then asked if they had been in Resident #380's room today, RN Q replied, Yes, to get vital and their blood sugar. When queried if they saw the Resident's mattress, RN Q indicated they had. RN Q was informed the mattress was not on at this time and stated, Oh, that makes sense because third shift said (Resident #380) was sunk in the bed. When queried what Resident #380's alternating air mattress was supposed to be set at, RN Q replied, I don't know. An interview was completed with the facility Administrator and Director of Nursing (DON) on 4/12/23 at 8:15 AM. When queried regarding facility policy/procedure regarding alternating air mattress monitoring and settings, the DON indicated nursing staff monitor the mattresses but did not provide further explanation. When queried how often Residents who have or are at risk for pressure ulcers and dependent upon care should be repositioned, the DON indicated Residents should be repositioned frequently. When asked if they should be repositioned every two hours at a minimum, a response was not provided. When queried regarding Resident #182's pain management, an explanation was not provided. The DON and Administrator were told about observations of Resident #182 not being repositioned but did not provide an explanation. Review of facility provided policy/procedure entitled, Pain Assessment and Management (Reviewed 1/22) revealed, The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . 'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals . Recognizing Pain . 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. 2. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc.; c. Changes in gait, skin color and vital signs; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Limitations in his or her level of activity due to the presence of pain; f. Guarding, rubbing or favoring a particular part of the body; g. Difficulty eating or loss of appetite; h. Insomnia; and i. Evidence of depression, anxiety, fear or hopelessness . Identifying the Causes of Pain . b. Skin/Wound Conditions: (1) Pressure, venous . h. Infection . Implementing Pain Management Strategies: 1. Non-pharmacological interventions may be appropriate alone or in conjunction with medications . Review of facility policy/procedure entitled, Skin Management Guidelines . (Revised 1/2023) revealed, The purpose of this procedure is 1) to identify residents at risk for developing alterations in skin including pressure ulcer/injury risk factors, and 2) to identify specific interventions to assist with prevention and management of skin alterations . Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors . A facility policy/procedure related to alternating air mattress use and monitoring was requested from the facility Administrator on 4/6/23 at 4:37 PM, 4/7/23 at 10:02 AM, and 4/11/23 at 10:05 AM but not received by the conclusion of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to 1) Ensure that a resident who enters the facility without an indwelling catheter is not catheterized and 2) Provide indwelling urinary catheter care, per standards of practice, to prevent Urinary Tract Infections (UTI) for three residents (Resident #48, Resident #58 and Resident #182) of four residents reviewed, resulting in lack of the care and management of an indwelling urinary catheter for Resident #48 and Resident #58, Resident #58 developing a UTI, and Resident #182 being catheterized without appropriate indications and the likelihood for infection and decline in overall health status. Findings include: Resident #182: On 4/4/23 at 3:14 PM, Resident #182 was observed in their room. The Resident was in bed, positioned on their back with their knees slightly bent and heels positioned directly on the mattress. An indwelling urinary catheter drainage bag was observed on the right side of the Resident's bed. The urinary catheter drainage bag had a dignity flap to conceal the urine in the drainage bag but no barriers to prevent contamination. The urine in the catheter drainage tubing was orange with red-colored blood noted. Resident #182 was confused and occasionally answered questions. On 4/6/23 at 10:43 AM, an observation of Resident #182 was completed. The Resident was in bed, laying on their back. An indwelling urinary catheter was present on the left side of the bed. The urine in the drainage bag was orange in color. An interview was completed at this time. Resident #182 was pleasantly confused and responded to questions. Resident #182 then began repeating themselves with non-sensible and disorganized. Record review revealed that Resident #182 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis (MS) and UTI. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood, required two+ assistance to complete Activities of Daily (ADL), and did not have an indwelling urinary catheter. Review of Resident #182's active Health Care Provider (HCP) orders in the Electronic Medical Record (EMR) revealed the order, 16 Fr (French- size) Foley (indwelling urinary) catheter with 10 cc (cubic centimeters) balloon for urinary retention. Change PRN (as needed) for pain, occlusion, infection every shift for monitoring (Ordered: 4/3/23). There was no order in the EMR for catheter care. Discontinued HCP orders in Resident #182's EMR included: - Bladder Scan every shift for 3 Days (Ordered: 4/1/23; Discontinued: 4/3/23) - UA (urinalysis) with C&S (culture and sensitivity) one time only for 1 Day (Ordered: 4/3/23) - Place Foley catheter one time only for 1 Day (Ordered: 4/3/23) Review of Resident #182's HCR-Admission/re-admission Evaluation dated 3/28/23 revealed, Clinical Evaluation Renal/Urinary . Urinary Characteristics . Continence . Unable to Determine . Indwelling catheter: No . Review of progress note documentation in Resident #182's EMR revealed the following: - 3/29/23 at 3:30 PM: Nursing/Clinical . admitted [DATE] . from hospital . admitted with exacerbation of MS started on high doses of steroids. Patient diagnosed with UTI treated with IV (intravenous) ABT (antibiotics) . Left knee stage 2 pressure wound (wound caused by pressure with partial-thickness loss of skin and exposed dermis [second layer of skin]) . Left medial inner thigh stage 2 pressure wound . Left medial outer ankle stage 3 pressure wound (wound caused by pressure with full thickness tissue loss) . Right heel unstageable pressure wound (full thickness skin and tissue loss) . Right buttocks stage 2 pressure wound . No depth to the wound . Left buttocks stage 2 pressure wound . No depth to wound . Patient requires max. assistance with turning and repositioning. Patient is incontinent of bowel and bladder. Staff will provide incontinence care as needed . - 3/29/23 at 3:40 PM: Physician/Practitioner Progress Note . I saw for face-to-face evaluation with the help of nurse . has multiple wounds . (Spouse) was present inquiring about (Resident's) status but later on (Resident #182) told me that (spouse) is not involved with care and we do not need to talk to (Spouse) which I conveyed to the unit manager . (Resident #182) is a retired nurse . Based on the review of the hospital records (Resident #182) was admitted for unable to care for self with incontinence of bladder and bowel and . had decreased oral intake . Denies any neurogenic bladder due to MS but admits to chronic incontinence . Urinary bladder is not distended and there is no palpable tenderness in the hypogastric area (lower abdomen) . - 3/30/23 at 12:25 PM: Physician/Practitioner Progress Note . I reviewed the wound care evaluation and care plan . Infection denies any specific symptoms . Today (Resident) denies any bladder or bowel symptoms but will continue to provide the care to keep dry and will consider doing the bladder scan to see if (Resident) is retaining and may require a catheter or not . Assessment .We will monitor for any possibility of a neurogenic bladder . - 4/1/23 at 11:31 AM: Nursing/Clinical . Resident is alert with increased confusion. Resident is slower to respond and cannot recall events that have happen on this shift Doctor notified . - 4/1/23 at 2:33 PM: Physician/Practitioner Progress Note . I was notified . about change in the mental status by nurse . does remain incontinent of bladder and surprisingly has no diagnosis of neurogenic bladder which is very common in multiple sclerosis and therefore I requested nurse to start doing the bladder scan (measure amount of residual urine remaining in bladder following urination) every shift and if there is any significant residual, we will consider placing a Foley (indwelling urinary) catheter . No clinical evidence of infection but will monitor for neurogenic bladder and UTI . I will order for bladder scan to be done at every shift and if necessary, put a straight (catheter which is inserted to drain urine from the bladder) urinary catheter . - 4/2/23 at 5:34 AM: Nursing/Clinical . At 2300 (11:00 PM), Pt (patient) noted to be A&O x 4 (Alert and Orientated to person, place, time, and orientation) with some confusion . confused about what facility in . bladder scan- 86 mls (milliliters) - 4/2/23 12:49 PM: Nursing/Clinical . Total care for all ADL's including meals. Appetite good. Notified (Physician) of resident having some hallucinations . seeming decline in abilities to feed self. (Physician) acknowledged awareness and ordered psych evaluation. - 4/3/23 at 12:50 PM: Physician/Practitioner Progress Note . confused today and was acting weird . (Spouse) was present . it appears that (spouse) will have to apply for guardianship . we explained to (spouse) that we do not know the reason for altered behavior and if this was related to MS is a possibility but we have psych evaluation requested. I told (family) that there was no signs of infection in the wounds but since has urinary incontinence and possibly neurogenic bladder we may have to consider a Foley's catheter to prevent any superficial ulcers on the gluteal area getting worse since . unable to reposition self . - 4/4/23 at 11:59 AM: Physician/Practitioner Progress Note . I saw her for follow-up . alert and . able to answer my questions . I asked (Resident #182) if ever received any antidepressant medications before and said no so at this point we will wait for psych evaluation . mood was better than yesterday and was more smiling and happy and the lab results show has slight leukocytosis (elevated white blood cells indicative of infection) of 12.2 thousand and urinalysis is consistent with a UTI so I will start on Pyridium (medication used to treat the symptoms of UTI including pain, burning, and feelings of frequency) 100 mg (milligrams) twice daily for 3 days. (Resident #182) ended up having a placement of a catheter . which will protect from being incontinent helping wound healing . will wait for the culture report to see if would need specific antibiotic . spoke with wound care nurse and tells me that (Resident #182's) wounds are clean . Assessment . Change in mental status . Urinary tract infection . Placement of Foley's catheter for neurogenic bladder with chronic incontinence and lower extremity and gluteal wounds . - 4/5/23 at 10:05 AM: Physician/Practitioner Progress Note . urine culture report is still pending . - 4/6/23 at 1:20 AM: Nursing/Clinical . (Resident #182) alert to self only, confusion noted . Foley catheter intact, patent and draining clear, orange-tinted urine to collection device . continues taking Pyridium 100mg BID (twice a day) for 3 days for UTI . Review of Resident #182's diagnostic testing results revealed a urinalysis was completed on 4/3/22. The UA report detailed the sample was collected on 4/3/23 and the results were received on 4/4/23 at 4:01 AM. The UA results revealed a culture was pending due to abnormal results including the presence of white blood cells, red blood cells, bacteria, epithelial cells (may indicate contamination), and trichomonas (protozoan parasite). Review of Resident #182's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2023 included documentation of Bladder Scan every shift for 3 Days (Start 4/1/23; Discontinued: 4/3/23). Detailed review revealed documentation of the following residual urine: - 4/1/23 at 2:00 PM: 60 cc residual urine - 4/1/23 at 10:00 PM: 86 cc residual urine - 4/2/23 at 6:00 AM: 89 cc residual urine - 4/2/23 at 2:00 PM: 93 cc residual urine - 4/2/23 at 10:00 PM: 64 cc residual urine There was no residual urine documentation on 4/3/23. Review of Resident #182's care plans revealed a care plan entitled, Use of indwelling urinary catheter needed due to Disease process (MS, Neurogenic bladder, retention) (Initiated and Revised: 4/3/23). The care plan included the interventions: - Catheter Care (Initiated: 4/3/23) - Change catheter per physician order (Initiated: 4/3/23) - Change urinary collection bag as needed (Initiated: 4/3/23) - Evaluate as needed for possible removal of catheter and bladder retraining or toileting plan (Initiated: 4/3/23) - Maintain drainage bag below bladder level (Initiated: 4/3/23) - Report to physician signs of UTI such as blood, cloudy urine, fever, increased restlessness, lethargy, c/o pain/burning, acute change in mental status, functional decline in ADL's (Initiated and Revised: 4/3/23) - Secure catheter with securement device (Initiated: 4/3/23) - Report any changes in amount and color, or odor of urine (Initiated: 4/3/23) Review of Task documentation in Resident #182's EMR did not include any tasks pertaining to indwelling urinary catheter care. On 4/6/23 at 12:36 PM, Resident #182 was observed in their room. The Resident was in bed, positioned on their back in bed. Their indwelling urinary catheter drainage bag was on the left side of the bed and the was resting on the visibly dirty overbed table and the floor. An interview was conducted with Licensed Practical Nurse (LPN) M on 4/6/23 at 12:37 PM. When queried the reason Resident #182 had an indwelling urinary catheter inserted at the facility, LPN M stated, A couple days after (Resident #182) got here the doctor thought they have a neurogenic bladder and wanted them bladder scanned. When asked if the catheter was inserted due to urinary retention, LPN M indicated it was. LPN M was then queried regarding the facility policy/procedure related to bladder scanning and if the bladder scan is completed post void, LPN M replied, It just kind of depends. It is usually whenever, usually try after meals. Documentation of bladder scan residual on Resident #182's MAR/TAR was reviewed with LPN M at this time. When asked about the timing of the bladder scan documentation, LPN M indicated it would have been completing following the Resident voiding. LPN M was then asked how much Resident #182 had voided prior to the bladder scan being completed, LPN M revealed the output amount was not documented due to Resident #182's incontinence. When queried if the facility obtained brief weights to determine urinary output for incontinent residents, LPN M replied, No, we don't do that. LPN M was then queried regarding facility policy/procedure pertaining to residual urine measurements and urinary catheterization. LPN M stated the residual is normally over 300 (cc) when a urinary catheter is inserted. When queried regarding Resident #182's UA results revealed the presence of trichomonas, LPN M indicated they were unaware of the result and stated, I thought they were waiting for it (results). When queried regarding the received date on the UA results being 4/4/23 at 4:01 AM and lack of treatment, LPN M confirmed the Resident was only receiving Pyridium which would not treat the trichomonas. On 4/6/23 at 3:47 PM, an observation of Resident #182 occurred in their room. The Resident was in bed, positioned on their back with their catheter positioned on the left side of the bed. A significant amount of a thick appearing, white colored substance was noted throughout the tubing. On 4/7/23 at 8:11 AM, an interview was conducted with Unit Manager Registered Nurse (RN) H. When queried if urinary catheter drainage bags should be touching the floor and/or the visibly soiled base of the overbed table, RN H specified that urinary catheter drainage bags should never touch the floor. RN H was then asked the rationale for Resident #182's indwelling urinary catheter placement. After reviewing progress note documentation in Resident #182's EMR, RN H revealed the catheter was inserted due to neuropathic bladder and urinary retention related to MS diagnosis. When queried if all Resident's with MS have neurogenic bladder, RN H replied no. When asked if Resident #182 had a diagnosis of a neurogenic bladder, RN H stated, No. Unit Manager RN H was then asked to review Resident #182's bladder scan residual urine documentation. When queried if the amount of residual suggested urinary retention and subsequent need for catheter insertion, RN H stated, No. When asked if insertion of indwelling catheter was appropriate, RN H replied, No. RN H then indicated they would speak to the Physician regarding catheter removal. When queried if Resident #182's Stage II pressure wounds on their buttocks were the rationale for the catheter insertion, RN H revealed the pressure wounds on Resident #182's buttocks did not necessitate urinary catheterization for healing. RN H was then queried the reason the indwelling urinary catheter was inserted, when there was no documentation of urinary retention, the Resident did not have a diagnosis of neurogenic bladder, and it was not necessary to promote pressure injury healing. Unit Manager RN H confirmed there was no valid medical justification for the catheter and indicated nursing staff were not in agreement but had followed the physician order. When asked to speak to the physician who ordered Resident #182's catheter insertion, RN H disclosed the physician was off work and unable to be reached. RN H was then queried regarding the UA results showing trichomonas in Resident #182's urine and stated, Doctor did not order anything for that. When asked why it was not addressed, RN H was unable to provide an explanation but stated they would review with the Medical Director. Resident #48: On 4/5/23 at 12:35 PM, Resident #48 was observed sitting in a wheelchair in their room. A urinary catheter drainage bag was present under their wheelchair and touching the floor. The urinary catheter drainage bag had a dignity flap to conceal the urine in the drainage bag but no barriers to prevent contamination. An interview was completed at this time. When queried regarding their catheter, Resident #48 revealed they had the catheter prior to entering the facility. Resident #48 stated, I want to have a supra pubic (surgically created connection from the skin to the bladder to allow drainage of urine) put in. When queried if they had seen nephrology regarding suprapubic catheter insertion, Resident #48 revealed they saw a nephrologist at the hospital but had not received any follow-up since being admitted to the facility. Record review revealed that Resident #48 was most recently admitted to the facility on [DATE] with diagnoses which included dementia, chronic kidney disease, urine retention, sepsis (infection in blood which spreads throughout body), and UTI. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required limited to total assistance to complete ADL's with the exception of eating. The MDS further revealed the Resident had an indwelling catheter. Review of Resident #48's care plans revealed a care plan entitled, Use of indwelling urinary catheter needed due to urinary retention - pt (patient) has chronic urinary catheter (Initiated and Revised: 3/22/23). The care plan included the interventions: - Catheter Care (Initiated: 3/22/23) - Change catheter per physician order (Initiated: 3/22/23) - Change urinary collection bag as needed (Initiated: 3/22/23) - Evaluate as needed for possible removal of catheter and bladder retraining or toileting plan (Initiated: 3/22/23) - Maintain drainage bag below bladder level (Initiated: 3/22/23) - Report to physician signs of UTI such as blood, cloudy urine, fever, increased restlessness, lethargy, c/o (complaints of) pain/burning, acute change in mental status, functional decline in ADL's (Initiated: 3/22/23) - Secure catheter with securement device (Initiated: 3/22/23) - Report any changes in amount and color, or odor of urine (Initiated: 3/22/23) Review of Resident #48's progress note documentation in the EMR included: - 3/22/23 at 9:46 PM: Admit/Readmit . Patient transported via EMS to room . admitted after found down in home due to a fall while experiencing acute renal failure and sepsis with e coli bacteremia (bacteria). Pt has a hx (history) of . Chronic urinary retention w/ Foley, UTI . A/O x 4 . - 3/23/23 at 10:28 AM: Nursing/Clinical . patient admitted [DATE] from hospital . Patient went to the ER after being found on the floor . Patient had reportedly been on the floor for days . UA positive for UTI. Patient admitted for sepsis. Patient has chronic catheter due to chronic retention. Patient had pneumonia . Indwelling catheter patent with yellow urine connected to bedside collection . - 3/24/23 at 7:57 PM: Physician/Practitioner Progress Note . History and physical: Chief complaint debility post hospitalization rehab . admitted to the hospital . initially treated for with IV antibiotics IV fluids . urinary retention . nephrology . saw (Resident #48 in hospital) . Foley catheter in place . Assessment and plan: Acute renal failure secondary to urinary retention fall in patient was down for a period of time dehydration urinary retention sepsis syndrome patient finished antibiotics . maintain Foley catheter for now repeat labs in the coming days . On 4/6/23 at 4:01 PM, an observation occurred of Activity Director W pushing Resident #48 in their wheelchair quickly down the hallway, towards the main hall in the facility. The Resident's urinary catheter drainage bag was under the wheelchair and had a dignity flap but no barrier to prevent contamination. The drainage bag and tubing were observed dragging on the floor as the wheelchair was pushed by Activity Director W. This Surveyor caught up with Activity Director W and Resident #48 as they rounded the corner of the hallway. Activity Director W continued to push the Resident #48's wheelchair and stopped by the Internet café. When queried if they were aware the catheter drainage bag and tubing were dragging on the floor, Activity Director W stated, I don't know what to do about that. Activity Director W proceeded to turn the wheelchair around, without addressing the urinary catheter drainage bag and/or tubing and pushed Resident #48 back towards their room with their urinary catheter drainage bag and tubing still dragging on the ground. Activity Director W proceeded to push the Resident past their room to the nurses' station prior to pushing the Resident back to their room. An interview was conducted with Unit Manager Registered Nurse (RN) H on 4/7/23 at 7:40 AM. When queried if catheter tubing and drainage bags should be touching and/or dragging on the floor, RN H stated, No. When asked about observations of Resident #48's catheter, RN H revealed they were aware. No further explanation was provided. Review of facility infection control line listing data for March 2023 revealed Resident #48 was receiving Cefpodoxime (antibiotic medication) 200 mg (milligrams) PO (oral) daily from 3/23/23 to 3/30/23 for a UTI. Review of facility provided policy/procedure entitled, Catheter Care, Urinary (Reviewed 1/22) revealed, Purpose . prevent catheter-associated urinary tract infections . General Guidelines: 1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. 2. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered . Infection Control . Be sure the catheter tubing and drainage bag are kept off the floor . Resident #58: Observation on 04/04/23 at 12:29 PM of Resident #58 lying in bed. Per resident the catheter was removed a week or more ago, no catheter observed in use. Resident #58 acknowledged that she had a urinary tract infection and had received pills for it. Record review of Resident #58's physician's orders for the month of April 2023 revealed on 4/4/2023 Ciprofloxacin 250mg oral tablet every 12 hours for UTI (Urinary Tract Infection). Record review on 04/06/23 at 12:35 PM of Resident #58's Electronic Medical Record review of lab for Urinary Analysis with Culture & Sensitivity, dated 4/3/2023, noted polymorbic specimen, no predominant morphotype, please resubmit. The lab results did note leukocytes Esterase large amounts and Protein. In an observation on 04/06/23 at 2:26 PM, Resident #58 was in her room self-ambulating from the bathroom to the bed. An interview and record review on 04/07/23 at 07:47 AM with Registered Nurse/Infection Control Preventionist (RN/ICP) B revealed that Resident #58 was admitted on [DATE], came with candida with Diflucan treatment. Record review of the infection control line listing revealed Resident #58 did not have any infection the month of February. Record review of the infection control line listing revealed Resident #58 did have Coronavirus (COVID-19) infection the month of March. On April 3, 2023, Resident #58 was diagnosed with a facility-acquired in-house urinary tract infection (UTI). There was no organism identified in the urine specimen and RN/ICP B stated that the physician started a Cipro antibiotic empirically, for polymicrobic specimen. Record review of Resident #58's physician's orders revealed antibiotic of Cipro 250mg oral for one week. RN/ICP B is also the Staff educator. The surveyor asked when was the last peri care/catheter in-service with hands on demonstration occurred. RN/ICP B could not give a date and presented no documentation of education. RN/ICP B stated that Resident #58 has dementia and may be doing her own peri care and we may need to step in and take care of that for her. RN/ ICP B stated that he did not know why Resident #58 got an in-house acquired UTI. RN/ICP stated that he did not have a specific organism to treat, but the doctor started an antibiotic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures and ensure the availability of emergency supplies and the provision of tracheostomy (surgically created opening in the neck to the trachea to allow the passage of air) care, per professional standards of practice, for one resident (Resident #10) of one resident reviewed. This deficient practice resulted in a lack of assessment, accurate documentation, comprehensive orders, emergency equipment at the bedside, routine tracheostomy care, Resident #10's tracheostomy being visibly soiled, the tracheostomy inner cannula not being changed since admission to the facility, and the likelihood for infection, decline in overall health, airway complications, and respiratory compromise. Findings include: During the survey entrance conference on [DATE] at 9:15 AM, the facility Administrator and Director of Nursing (DON) identified three residents, including Resident #10, who currently had Covid-19 and were in transmission-based isolation precautions. Review of the facility provided CMS - 802 form, dated [DATE], did not delineate that Resident #10 had a tracheostomy, was on transmission-based precautions, and/or had Covid-19. On [DATE] at 11:05 AM, a sign was observed on the outside of Resident #10's room door which specified, Stop, See Nurse Before Entering . The sign did not specify what Personal Protective Equipment (PPE) was required to enter the room. An interview was conducted with Registered Nurse (RN) Q on [DATE] at 11:07 AM. RN Q was asked what the Stop . sign on the door meant and stated, Those are our Covid patients. When asked if the Resident had tested positive for Covid, RN Q replied, Yeah. RN Q was asked what type of isolation precautions were in place for Resident #10, RN Q stated, Airborne. RN Q was then asked what PPE was required to enter the room and replied, N-95 (fit tested, respirator mask which filters up to 95% of particles in the air), (face shield), gown, and gloves. Resident #10: On [DATE] at 11:48 AM, an observation of Resident #10 occurred in their room. The Resident was in bed, positioned on their back with the head of the bed flat. On the overbed table, an opened tracheostomy cleaning kit was present and two visibly soiled tracheostomy cleaning brushes were open and uncovered, sitting directly on the table. Resident #10 was observed to have a tracheostomy. An extra inner tracheostomy cannula, oxygen, suction, and/or emergency equipment were noted in the room. The visible outer cannula of the tracheostomy was observed to be markedly unclean with unknown dark colored substances and the tracheostomy collar holder was also visible soiled. Resident #10 was observed covering their tracheostomy with their finger to enable speaking. The Resident's fingernails were long and jagged with an unknown dark colored substance under them. A speaking valve and/or cap was not present on the Resident's tracheostomy. Resident #10's respirations were audibly moist and congested sounding. When queried regarding care of their tracheostomy, Resident #10 revealed they complete their own tracheostomy care and facility staff do not assist them. When queried regarding the cleaning brushes on their overbed table, Resident #10 revealed they used them to clean their tracheostomy. Resident #10 proceeded to pick up the brush and remove the inner cannula of the tracheostomy to clean their tracheostomy. Resident #10 was asked why they were going to use a soiled brush and indicated there was nothing wrong with using the brush. At 11:52 AM, Certified Nursing Assistant (CNA) DD brought Resident #10's lunch tray into their room and placed the tray on the Resident's overbed table. CNA DD did not provider nor offer Resident #10 hand hygiene and no hand hygiene wipes were present on the Resident's table and/or in the room. After CNA DD exited the room, Resident #10 was queried how they got out of bed and revealed they were unable to get out of bed without staff assistance. When queried where they completed tracheostomy care, Resident #10 revealed they completed care in bed. When asked how they were able to see what they were doing when in bed, Resident #10 did not provide an explanation. When asked how they washed their hands before completing tracheostomy care, Resident #10 revealed they did not have anything to wash their hands with. Resident #10 was then asked about their congested sounding respirations and if they required suctioning for their tracheostomy. The Resident revealed they do not have suction available in the facility. Resident #10 revealed they do not normally need suctioning but did have a lot of mucous and needed their trach suctioned. When queried how often they change the inner cannula of their trach, Resident #10 revealed it had not been changed since they were admitted to the facility. When asked why they had not changed it, Resident #10 stated they didn't have any. When asked, Resident #10 provided permission for this Surveyor to look for extra tracheostomy supplies in their room. The only items related to tracheostomy care present in the room included a new tracheostomy collar holder and an expired tracheostomy cleaning kit. Emergency equipment including an extra inner cannula, suction machine and equipment, ambu-bag, and/or oxygen were not present in the room. Review of Resident #10's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses which included left hip fracture, diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), tracheostomy, and Covid-19. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete Activities of Daily Living (ADL's) with the exception of eating. The MDS further indicated Resident #10 received tracheostomy care prior to and during admission to the facility. On [DATE] at 4:21 PM, an interview was completed with Licensed Practical Nurse (LPN) EE. When queried regarding Resident #10's tracheostomy care, LPN EE indicated they would need to review Resident #10's orders as they float and work in different units throughout the facility. After reviewing Resident #10's EMR, LPN EE stated, I do not see an order for trach care. LPN EE continued, there is an order to encourage trach care daily and PRN (as needed). With further inquiry, LPN EE stated, (Resident #10) does own trach care. When asked if the facility completes assessments for tracheostomy self-care to ensure Resident's are able to complete care, LPN EE replied, I would assume. When queried where the assessment was, LPN EE reviewed Resident #10's Electronic Medical Record (EMR) and revealed they were unable to locate a self-performance assessment for tracheostomy care. LPN EE was then queried what equipment should be Resident #10's room and indicated they were unclear regarding the question. LPN EE was then asked if there should be an extra inner cannula in Resident #10's room for their trach and stated, I think there should be one in their room. When queried regarding Resident #10's inner cannula brand/size, LPN EE reviewed Resident #10's EMR and stated, I do not see that information. Review of Resident #10's Health Care Provider (HCP) Orders revealed the following active orders: - Suction PRN (as needed) . for Maintain patent airway (Ordered: [DATE]) - Encourage Trach care daily and PRN (as needed): For disposable: remove and dispose of inner cannula. Replace with new inner cannula. Pt (patient) is able to perform trach care. As needed for Reduce risk of infection (sic) (Ordered: [DATE]) Review of discontinued orders in Resident #10's EMR included the following: - Trach care daily and PRN: For disposable: remove and dispose of inner cannula. Replace with new inner cannula. as needed for Reduce risk of infection (Ordered: [DATE]; Discontinued: [DATE]) - #6 Shiley (size/brand) disposable tracheal tube cuffless to be changed daily and PRN as needed (Ordered: [DATE]; Discontinued: [DATE]) A self-assessment for tracheostomy care completion was not present in Resident #10's EMR. An interview was completed with Unit Manager Registered Nurse (RN) H on [DATE] at 4:26 PM. When queried regarding Resident #10's tracheostomy care and documentation, RN H indicated care was documented on the Resident's Treatment Administration Record (TAR). When asked if Resident #10 completed their own trach care, RN H stated, Yes. RN H was then asked if the facility completes an assessment to evaluate the Resident's ability to complete tracheostomy care and replied, Should be. When queried where the assessment was located, RN H reviewed Resident #10's EMR and stated, Should be but (Resident #10) said they could do it themselves. When asked what tracheostomy and emergency equipment should be present in the Resident's room, RN H stated, A spare (inner) trach and an ambu bag. RN H was then asked why a spare trach and ambu bag were not present in Resident #10's room and stated, It should be. (Resident #10) got moved (to a different room). RN H indicated the equipment must not have been moved to the Resident's new room. When queried if suction and oxygen equipment should be present in the Resident's room, RN Hdid not provide a direct response but indicated the Resident had not needed their trach suctioned and had not needed supplemental oxygen. RN H was then asked how facility nursing staff know the size/brand of Resident #10's tracheostomy and revealed there should be an order in the EMR. When queried regarding LPN EE not knowing and/or being able to locate the information in Resident #10's EMR, RN H reviewed the Resident's HCP orders and stated, The #6 Shiley order was discontinued. With further inquiry, RN H stated, I updated the orders and didn't put in the right one. The orders were reviewed with RN H at this time. When queried if trach care was supposed to be completed daily and the trach tube changed daily, RN H revealed it was. Review of Resident #10's progress note documentation in the Electronic Medical Record (EMR) detailed: - [DATE] at 9:38 PM: Admit/Readmit . The patient was transported via EMS . admitted for a left hip fracture that was caused from a fall and required surgical intervention . has a endotracheal tube . - [DATE] at 10:13 AM: General Progress Note . admitted [DATE] . from the hospital. Patient went to the ER s/p fall. X-rays showed left hip fracture. Patient requires surgical interventions . Patient able to speak with staff. Patient stated . has had the Trach x 25 years . stated . is able to perform own trach care . Trach site clear of drainage. No congestion noted . Staff will assist the patient with daily care. Patient able to participate with care tasks . - [DATE] at 5:20 PM: Medical Practitioner Note . Late Entry: Medical History . chronic endotracheal tube . - [DATE] at 12:53 PM: General Progress Note . Resident advised nurse that does own trach care. Nurse supplied (Resident) with supplies to do care. Nurse observed while doing care. Trach and necktie in place securely . - [DATE] at 1:44 PM: General Progress Note . Resident preformed own trach care this shift . - [DATE] at 10:54 PM: Physician/Practitioner Progress Note . Patient seen for follow-up is overall doing okay respiratory status stable as trach stable chest bilateral breath sounds (lung assessment findings not documented) . - [DATE] at 5:39 PM: Physician/Practitioner Progress Note . Patient seen for follow-up . exposure to a patient who was roommate tested positive for COVID patient has no symptoms . Exam lungs bilateral breath sounds has trach no wheezing . - [DATE] at 11:13 PM: Physician/Practitioner Progress Note . Patient seen follow-up diagnosed with sore COVID-19 infection . has some cough congestion wheezing has trach patient is on anticoagulation multiple drug interactions he was started on oral treatment . Exam bilateral breath sounds mild expiratory wheeze (abnormal finding indicating airway constriction- location of wheezes not documented) . Resident #10's TAR for March and [DATE] were reviewed. The TAR included the task #6 Shiley disposable tracheal tube cuffless to be changed daily and PRN every day shift for Trach care (Start: [DATE]; Discontinued: [DATE]). The Task was documented as completed by nursing staff 29 out of 35 days. On [DATE] at 8:10 AM, an interview was conducted with the DON. When asked what equipment should be maintained in the room for Resident's who have a tracheostomy and stated, Ambu bag and an extra inner cannula. When queried why the equipment was not in Resident #10's room, Resident #10 replied, Because when (Resident #10) got moved to the Covid unit, it (equipment) didn't get moved with them. The DON was then asked how frequently tracheostomy care should be completed and the inner cannula replaced and replied, (Resident #10) doesn't allow us to do that. When queried if facility nursing staff had trained and/or assessed Resident #10's knowledge and ability to perform tracheostomy care independently, the DON stated, Not that I know of. When asked if an assessment should be completed and documented, the DON indicated there should be an assessment. When queried where the assessment would be completed in the EMR, the DON replied they were not sure where to look. When queried if a Resident with a tracheostomy should have other emergency equipment in their room such including oxygen and suction, the DON did not provide a response. The DON was then asked if Resident #10 had a care plan related to refusals due to their statement that the Resident would not allow staff to complete trach care and/or change the trach inner cannula and revealed they were unsure as RN H completed/updated resident care plans. No further explanation was provided. Review of Resident #10's care plan revealed a care plan entitled, Has/At risk for respiratory impairment related to Pt (patient) has a Shiley 6 endotracheal tube . has had long term that self-cares for. Will assist pt as needed . (Initiated and Revised: [DATE]). The care plan included the interventions: - Encourage deep breathing exercises (Initiated: [DATE]; Revised: [DATE]) - Evaluate lung sounds and VS (Vital Signs) as needed . (Initiated: [DATE]) - Provide assistance with ADL's to conserve energy (Initiated: [DATE]) - Obtain pulse oximetry and report abnormal findings (Initiated: [DATE]) - Suction per physician orders (Initiated: [DATE]) - Report signs of infection or edema (Initiated: [DATE]) - Trach care per protocol (Initiated: [DATE]) An interview was completed with LPN M on [DATE] at 8:45 AM. When queried regarding Resident #10, LPN M revealed they were frequently assigned to provide care to the Resident. LPN M was asked if documentation on Resident #10's TAR indicating the trach tube had been changed daily signified facility nursing staff had completed the task, LPN M stated, No, we just give (Resident #10) the supplies. LPN M was asked what supplies they gave to the Resident and replied, The trach cleaning kit. When queried if a new inner cannula was provided to Resident #10 with the cleaning kit, LPN M replied, No. LPN M was asked why they had documented the task as completed when they did not change the tracheostomy tube and/or complete tracheostomy care, LPN M did not provide an explanation. LPN M was asked how to know when Resident #10's inner cannula was changed last, LPN M stated, We don't. When queried how often the Resident's tracheostomy collar was replaced and the stoma cleaned, LPN M revealed they did not know and there was no way to know from the documentation. On [DATE] at 1:15 PM, an interview was completed with CNA DD and LPN M. When queried regarding the provision of hand hygiene for residents who require assistance to get out of bed and if the facility had sanitizing hand wipes for Residents, LPN M replied, No, we used to. CNA DD then stated, Now, we have to get a washcloth and take it to them. When queried if they had sanitizing hand wipes for residents, LPN M replied, No, we used to. When asked how Resident #10 performed hand hygiene prior to completing tracheostomy care when staff provided supplies but did not assist and the Resident did not have sanitizing wipes, an explanation was not provided. Review of facility policy/procedure entitled, Tracheostomy Care Policy (Reviewed 1/23) detailed, Policy . Licensed clinicians with demonstrated competence may provide tracheostomy care. The goals of tracheostomy care are to maintain the patency of the airway, prevent breakdown of the skin surrounding the site, and prevent infection. Aseptic/sterile technique should be used for permanent inner cannula care. Clean technique may be used for disposable inner cannula care and site care . An emergency trach setup kit should be kept at the bedside of patients with tracheostomies. This kit should contain: Trach Tube of the same size and manufacturer o Ambu-Bag with face mask o Water soluble surgical grade lubricant o Extra neck band (Velcro trach tie) o Emergency oxygen trach mask with tubing connected o Suction catheters oYankauer suction wand o 4 x 4 sterile gauze o Gloves: non-sterile o Hemostats/obturator . General: Tracheostomy site care and/or inner cannula care should be performed at least twice daily and as needed . Cleaning stoma and changing dressing: clean technique . Change the dressing when moist, to prevent skin irritation. Inspect the stoma and surrounding skin for leakage, infection, and drainage . Procedure: 1. Perform hand hygiene . 3. Place patient in a comfortable position on back with a small blanket or towel roll under shoulders to extend the neck and allow easier visualization and trach care. 4. Establish a clean field. 5. Open Q-tips, trach gauze and regular gauze. 6. Pour sterile water or saline into cup or open prefilled cup. 7. [NAME] clean gloves. 8. Remove dressing if present. 9. Remove gloves and perform hand hygiene. 10. [NAME] new clean gloves. 11. Clean the skin around the trach tube with Q-tips soaked in sterile water. Using a rolling motion, work from the center outward using Q-tip swabs, one for each quarter around the stoma and under the flange of the tube. Do not allow any liquid to get into trach tube or stoma area under the tube. 12. Pat dry with gauze pad or dry Q-tips. 13. Make note of skin condition at stoma site and around the neck. 14. Apply skin barrier/protective ointment (if ordered) in a thin layer at peri-stoma area, using caution that no ointment gets into the stoma itself. 15. Change the Velcro trach ties if needed . Disposable Inner Cannula Care: clean technique . Procedure . 4. Unlock inner cannula, remove and discard. 5. Remove gloves and perform hand hygiene. 6. [NAME] new clean gloves. 7. Open new cannula package and ONLY touch the outer locking mechanism end of the new inner cannula. 8. Replace new inner cannula. 9. Ensure new cannula is locked in trach tube. 10. Replace Velcro trach ties as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #21: During initial tour on 4/42023, Resident #21 explained his dialysis days are Monday, Wednesday and Friday and he returns to the facility about 2:00 PM. When asked if he is provided with lunch upon his return, he stated he is not. He further expressed he did not wish to take lunch with him to dialysis as it is unsanitary. Resident #21 stated he does not receive anything when he returns from dialysis but would enjoy a light snack upon his return to hold him over until dinner. Review was completed of Resident #21's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included, hypertension, renal failure, hemiparesis and hyperlipidemia. Further review was completed of Resident #21's medical records and it revealed the following: Care Plan: Renal insufficiencies related to: chronic renal failure, presence of fistula. No deal to adjust mealtimes dialysis does not interfere with meal times. Patient receives dialysis weekly as ordered . Days of the week: M W F . chair time 10:15 am pick up time 3 hour run time . There was nothing else located in the residents' medical records regarding the facility assessing the residents preferences for receiving a meal or nutritious snack upon his return from dialysis. On 4/4/2023 at 11:38 AM, an interview was conducted with Nurse I regarding Resident #21's dialysis schedule. Nurse I reported he leaves for dialysis about 9:15 AM and does not return until around 2:30 PM. She reported at one point he did receive a tray, but was unsure if he receives one once he returns as Nurse I shift ends as he returns. Nurse I and this writer reviewed Resident #21's physician orders and there was no order for him to offer a meal or snack upon him returning from dialysis. On 4/6/2023 at 12:27 PM, an interview was held with Regional Dietitian V, regarding Resident #21 not being offered or provide with a meal or snack upon his return from dialysis. She reported she would have to discuss with dietary what they are doing upon his return from dialysis. Dietitian V reported Resident #21 receives Nepro in the afternoon which is 420 calories and 19 grams of protein. This writer and Dietitian reviewed Resident #21's care plan and there was nothing listed they indicated staff assessed the residents need for a meal or snack upon his return. We then reviewed the Medication Administration Record (MAR) record for his Nepro administration, and it was not listed on the MAR for March or April 2023. Dietitian V, reviewed his physician orders and while it was listed there it did not pull over onto his MAR. It was unknown if the resident is receiving his Nepro daily as ordered. On 4/6/2023 at 2:10 PM, an interview was conducted with Dietary Manager D regarding Resident #21 being offered a meal upon his return from dialysis. He explained there is not a current process in place for meals or snacks once dialysis residents return (if a mealtime is missed). Manager D stated they will complete a ledger in the kitchen with all dialysis resident's food preferences, dialysis days and times they return. He stated the nurses are also able to contact the dietary department to request items for the resident upon their return. On 4/11/2023 at 4:00 PM, a review was completed of the facility policy entitled, Dialysis/Hemodialysis Program, revised 1/2023. The policy stated, .Do not hold breakfast prior to dialysis. If resident will be gone during mealtime obtain ordered meal and sent with resident . Based on observation, interview and record review, the facility failed to ensure that a meal or nutritious snack was offered upon return from dialysis treatments for one resident (Resident #21) and failed to ensure that medication administration times were adjusted to coordinate care when one resident (Resident #30) was out of the facility for dialysis treatments of two residents reviewed for dialysis, resulting in a lack of nutrition following dialysis treatments, feelings of hunger and the potential for weight loss and lethargy for Resident #21 and medications not administered with the potential for exacerbation of diagnoses for Resident #30. Findings include: Resident #30: A review of Resident #30's medical record revealed an admission into the facility on 2/2/23 with diagnoses that included heart attack, diabetes (DM), heart failure, end stage renal disease(ESRD) and dependence on renal dialysis. A review of the Minimum Data Set assessment, dated 2/9/23, revealed a Brief Interview of Mental Status score of 15/15 that indicated intact cognition and the Resident needed extensive assistance with bed mobility, transfers and toilet use and needed limited assistance with dressing and personal hygiene. Further review of the medical record revealed the Resident went out of the facility for dialysis treatments. On 4/4/23 at 1:22 PM, an observation was made of Resident #30 sitting up in her room. The Resident was interviewed, answered questions, and conversed in conversation. The Resident reported that she went out of the facility for dialysis treatments three times a week on Monday, Wednesday, and Friday. The Resident was asked what time she usually went to dialysis and the Resident indicated she left the facility after lunch about 12:30 (PM) and returned to the facility about 6:00 to 6:30 (PM). The Resident indicated that she received her dinner meal when she came back. When asked about not receiving medications that were scheduled during their absence from the facility for dialysis treatments, the Resident indicated that she had missed some medications and sometimes the binder was waiting for her when she returned. A review of Resident #30's Medication Administration Record (MAR) revealed the following medications with scheduled times at 5:00 PM or 6:00 PM: -Humalog KwikPen subcutaneous (SQ) solution (Insulin Lispro). Inject 5 unit SQ before meals for DM (diabetes), with a start date on 2/6/23 and discontinued date on 2/15/23. -Humalog KwikPen subcutaneous (SQ) solution (Insulin Lispro). Inject 7 unit SQ before meals for DM (diabetes), with a start date on 2/15/23 and discontinued date on 3/6/23. -Humalog KwikPen subcutaneous (SQ) solution (Insulin Lispro). Inject per sliding scale: . SQ before meals for DM (diabetes), with a start date on 2/3/23 and discontinued date on 2/4/23. -Humalog KwikPen subcutaneous (SQ) solution (Insulin Lispro). Inject per sliding scale: . SQ before meals for DM (diabetes), with a start date on 2/5/23 and discontinued date on 2/15/23. -Humalog KwikPen subcutaneous (SQ) solution (Insulin Lispro). Inject per sliding scale: . SQ before meals for DM (diabetes), with a start date on 2/15/23 and discontinued date on 3/6/23. -Sevelamer carbonate (medication used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis, called phosphate binders) 800 mg (milligrams). Give 3 tablet by mouth three times a day for ESRD, with a start date on 2/6/23. -Midodrine HCl 5 mg. Give 1 tablet by mouth three times a day for hypotension Hold for sys (systolic blood pressure) greater than 130 with a start date on 2/3/23 and discontinued date on 3/1/23. Further review of the MAR revealed, the insulin Lispro, ordered units and per sliding scale scheduled at 6:00 PM, had not been administer on Wednesday 2/8, Friday 2/10, Monday 2/13, Monday 2/20, Wednesday 2/22, Wednesday 3/1, Wednesday 3/15, Friday 3/17, and Wednesday 3/22. The MAR indicated on these days, the chart code documented was 3 which indicated, Absent from home without meds. The medication Sevelamer carbonate 800 mg was not given on Wednesday 2/8, Friday 2/10, Monday 2/13, Monday 2/20, Wednesday 2/22, Wednesday 3/1, Wednesday 3/15, Friday 3/17. The MAR indicated on these days, the chart code documented was 3 which indicated, Absent from home without meds. The medication Midodrine HCl 5 mg was not given on Wednesday 2/8, Friday 2/10, Monday 2/13, Wednesday 2/15, Friday 2/17, Monday 2/20, Wednesday 2/22. The MAR indicated on these days, the chart code documented was 3 which indicated, Absent from home without meds. The Resident's medical record lacked documentation that the Physician was notified of the medications not administered and there were no orders to hold the medications per physician orders. On 4/6/23 at 10:57 AM, an interview was conducted with the Director of Nursing (DON) regarding coordination of care for Resident #30 with dialysis treatments received outside of the facility. The medications documented as not given on the days the Resident indicated she went to dialysis treatments, Monday, Wednesday, and Friday, was reviewed with the DON. The DON stated, We need to adjust the times for dialysis. The DON indicated that depending on when the Resident returned to the facility, the meal and those medications should be given when the meal was given and stated, If she comes back later (then the scheduled times of medication) they should still be giving the medication and doing the accucheck (blood glucose monitoring that is performed to dose the sliding scale insulin). A review of facility policy titled, Dialysis/Hemodialysis Program, reviewed 1/2023, revealed, Policy: To ensure the proper assessment and care of residents receiving hemodialysis . The policy did not include directive on medications ordered/scheduled when the Resident was out of the facility for dialysis treatments. A review of facility policy titled, Medication and Treatment Administration Guidelines, revealed, General: .Medications are administered in accordance with standards of practice and state specific and federal guidelines . Documentation: .Medications not administered according to physician orders are reported to the attending physician and documented in the clinical record including the name and dose of the medication and reason .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2: Based on observation, interview and record review, the facility failed to maintain storage in a sanitary manner of nebulizer and mask equipment for the delivery of inhalation medication for two residents (Resident #39 and Resident #51) of five residents reviewed for oxygen and respiratory care, resulting in the potential for respiratory infection and illness. Findings include: Resident #39: A review of Resident #39's medical record revealed an admission into the facility on 9/11/19 and re-admission on [DATE] with diagnoses that included chronic obstructive pulmonary disease, anxiety disorder, chronic respiratory failure, dependence on supplemental oxygen. A review of the Minimum Data Set (MDS) assessment revealed the Resident had intact cognition was independent with activities of daily living and needed set up assistance with eating. A review of Resident #39's Medication Administration Record for April 1st to 7th 2023 revealed the Resident had an order for Ipratropium-Albuterol Solution 0.5-2.5 mg/3ml, 1 vial inhale orally every 4 hours as needed for SOB (shortness of breath). The inhalation medication was documented as given on 4/1/23 at 8:22 AM; 4/2/22 at 9:29 AM and 7:56 PM; 4/3/23 at 7:00 AM, 12:37 PM, and 6:15 PM; 4/5/23 at 12:05 PM; and 4/6/23 at 4:04 PM. On 4/4/23 at 10:28 AM, during the initial tour of the facility, Resident #39's room was observed. The Resident was not in the room at the time. An observation was made of Resident #39's nebulizer equipment inside a bag and was closed at the top of the bag by the string closure. The nebulizer equipment was assembled together and was wet inside the medication chamber. The nebulizer equipment was not allowed to air dry. On 4/4/23 at 1:01 PM, an interview was conducted with Resident #39. The Resident answered questions and conversed in conversation. An observation was made of the Resident's nebulizer equipment inside a bag and was closed at the top of the bag. The nebulizer equipment was assembled together and was wet inside the medication chamber. The Resident was asked about respiratory treatments and reported she took the breathing treatments as needed with some days not at all and other days 3 or 4 times in a day. When asked about respiratory infections, the Resident indicated no recent illness. When asked about the nebulizer in the bag wet, the Resident reported that staff don't always leave it in the bag wet. On 4/6/23 at 1:30 PM, an observation was made with Nurse R of Resident #39's nebulizer equipment stored inside a bag with the top closed. The nebulizer equipment was assembled, and the medication chamber was wet inside. The Nurse was questioned about facility policy for storage and indicated that the nebulizer should not be stored inside the bag until it was dry. The Nurse cleaned the nebulizer and set it on paper towel to air dry. The Nurse indicated that it was an infection control issue to be left in the bag wet without the equipment time to dry after a treatment. When asked when the Resident had the last breathing treatment, the Nurse was unsure. Resident #51: A review of Resident #51's medical record revealed an admission into the facility on 9/8/21 and re-admission on [DATE] with diagnoses that included stroke, gastrostomy, subarachnoid hemorrhage, seizures, encephalopathy, and pneumonia. A review of the Resident's MDS, dated [DATE] revealed the Resident had severely impaired cognition and needed extensive assistance with two persons physical assist with bed mobility, dressing, and toilet use. A review of Resident #51's Medication Administration Record revealed the Resident had an order for Albuterol Sulfate Nebulization Solution 2.5 mg/3 ml, one dose inhale orally via nebulizer every 6 hours and as needed for Pneumonia, and Ipratropium Bromide Inhalation Solution 0.02%, one dose inhale orally every 6 hours for Pneumonia. Both medications had a start date on 3/10/23 and were scheduled at 5:00 AM, 11:00 AM, 5:00 PM and 11:00 PM. On 4/4/23 at 10:55 AM, an observation was made during the initial tour of the facility of Resident #51 sleeping in bed. An observation was made of a mask and nebulizer apparatus assembled together and stored in a bag with the top of the bag partially closed. The nebulizer equipment was observed to have liquid in the medication chamber. On 4/5/23 at 1:04 PM, an interview was conducted with Resident #51. The Resident was lying in bed, answered most questions and conversed with conversation on a limited basis. The Resident was asked about breathing treatments, and the Resident indicated he received breathing treatments every day. The Resident was asked if he had any respiratory infections and the Resident indicated he had pneumonia but was unsure when he had been sick with pneumonia. An observation was made of the nebulizer equipment and mask were assembled together and were stored inside a bag with moisture in the medication chamber of the nebulizer. On 4/6/23 at 1:05 PM, an observation was made of Nurse R administering a bolus tube feeding to Resident #51. After completion, the Nurse was asked about the facility policy of storage of the nebulizer equipment after breathing treatments are given. An observation was made with Nurse R of Resident #51's oxygen mask and nebulizer equipment stored in a bag with the medication chamber wet inside. The equipment was assembled together that did not allow the equipment to air dry. The Nurse indicated that the nebulizer should not be stored in the bag until the equipment was dry. The Nurse cleansed the equipment and laid the disassembled equipment on a paper towel on the Resident's nightstand. A review of the facility policy titled, Nebulizer Process, not dated, revealed, .Process: .10. Following medication administration, rinse equipment with water and place on paper towel to completely air dry in resident's room. Then wash hands. Once completely dried place in storage bag . This Citation has two Deficient Practice Statements (DPS), Deficient Practice Statement #1: Based on observation, interview and record review, the facility failed to institute, implement and operationalize a comprehensive infection control program including appropriate Infection Control practices and Transmission-Based Isolation Precautions, in accordance with the Centers for Disease Control and Prevention (CDC) recommendations for all 73 residents residing in the facility. This deficient practice resulted in the lack meaningful and accurate process and outcome surveillance, inaccurate analysis, lack of easily accessible hand sanitizer, lack of Personal Protective Equipment (PPE) use by staff during high community levels of Covid-19 transmission, lack of appropriate PPE use for Covid-19 positive Residents, and the likelihood for spread of infection and decline in overall health. Findings include: An observation of the 600 hall of the facility occurred on 4/5/23 beginning at 11:00 AM. No staff were present in the hallway. Two plastic, three drawer carts were noted next to opposing resident room doors in the hall. The cart, on the left side of the hall was outside of Resident #10's room door. The cart contained N-95 respirator style masks (respirator mask which filters up to 95% of particles in the air), face shields, gowns, and gloves. There was no hand sanitizer and/or disposable wipes in the cart. No hand sanitizer dispensers were present in the hallway. A faded, red colored sign was present on Resident #10's room door. The print on the sign was very faint, as though the ink in the printer was almost gone, but specified, Stop, see nurse before entering . The sign did not specify what PPE was required to enter the room. Resident #379 and Resident #380's room was directly across the hall with a PPE cart beside the door. The same signage indicating to Stop, see nurse before entering was also present on their room door. A tour of this PPE cart revealed the cart contained the same items, N-95 style masks, face shields, gowns and gloves but no hand sanitizer and/or disposable wipes of any kind. An interview was conducted with Registered Nurse (RN) Q on 4/5/23 at 11:07 AM. RN Q was asked what the Stop . sign on the door meant and stated, Those are our Covid patients. When asked if the Resident had tested positive for Covid, RN Q replied, Yeah. RN Q was asked what type of isolation precautions were in place for Resident #10, RN Q stated, Airborne. RN Q was then asked what PPE was required to enter the room and replied, N-95, (face) shield, gown, and gloves. When asked about the room opposite Resident #10's in the hallway, RN Q revealed Resident #'s 379 and 380 were in that room and both were Covid positive. When queried regarding staffing for the residents who had Covid-19, RN Q stated, I am the only nurse down here on the 500 and 600 halls. RN Q was then asked about Certified Nursing Assistant (CNA) staffing and stated, There is only one (CNA DD). At 11:12 AM on 4/5/23, Resident #379 was observed exiting their room, without a mask and no staff assistance. The Resident was walking and pushing a wheelchair. The Resident entered the hallway and stood before walking towards the end of the hallway. At 11:16 AM on 4/5/23, RN Q was approached and asked if Resident #379 was supposed to be ambulated without assistance outside of their room and without a mask. RN Q replied they were not. RN Q was told Resident #379 was ambulating in the hall and proceeded to walk down the hall towards the Resident. RN Q was only wearing a mask when they approached Resident #379. RN Q began speaking to Resident #379 and touched their arm to guide them back to their room. RN Q entered Resident #379's room without donning PPE and assisted the Resident to sit. RN Q then exited the room but did doff their mask and don a new one and did not perform hand hygiene. On 4/5/23 at 11:48 AM, PPE was donned to complete an observation and interview with Resident #10. Hand sanitizer was not available to complete hand hygiene prior to donning PPE. Upon entering the room, a garbage can was observed directly to the left of the door. Visibly worn face shields (head strap stretched and shield soiled with fingerprints) were sitting on the top of the garbage can lid. At 11:52 AM, Certified Nursing Assistant (CNA) DD brought Resident #10's lunch tray into their room and placed the tray on the Resident's overbed table. CNA DD was wearing PPE upon entering the room. When CNA DD exited the room, they removed their face shield, gown, and gloves. CNA DD then opened the door and reached back in to obtain hand sanitizer. CNA DD did not remove and/or change their mask. Upon exiting the room, gown and gloves were removed, placed in the garbage, and hand hygiene performed. No face masks were observed in the garbage can. After exiting the room, there was no place to doff and dispose of the used face shield, N 95, and perform hand hygiene. On 4/5/23 at 11:57 AM, a visitor was observed entering Resident #379 and Resident #380's room without donning additional PPE. The visitor was wearing a procedural mask. RN Q was sitting at the nurses' station and had acknowledged the visitor prior to them entering the room. RN Q did not inform the visitor of the Resident's Covid positive status and/or Transmission-Based Isolation precautions prior to the visitor entering the room. At 11:58 AM on 4/5/23, an interview was completed with RN Q. When queried regarding observation of the visitor entering Resident #379 and Resident #380's room without donning additional PPE, RN Q stated, Well, (Resident #379) is being discharged . When queried if Resident #379 was still in Transmission Based precautions due to testing positive for Covid-19, RN Q replied, Yes. When asked if Resident #379's roommate (Resident #380) was also Covid positive, RN Q revealed they were. RN Q was then queried regarding the facility policy/procedure related to visitors for Residents who have Covid-19, and stated, Well, we encourage them. When asked when they educated the visitor and encouraged them, RN Q did not respond. When queried why they did not don PPE when they assisted Resident #379 back into their room and why they did not change their mask/perform hand hygiene, RN Q reiterated the Resident was being discharged . Review of facility provided policy/procedure entitled, Covid-19 PPE Usage Guide (Dated 10/18/22) revealed, Community Transmission Rate . High . Employee . N 95: During aerosol generating procedures or treatments; During care of patients with Suspected or Confirmed Covid-19 . Procedure Mask: When in areas where patient encounters can occur . Eye Protection: When in areas where patient encounters can occur . Outbreak . Employee . N 95: During all patient encounters in specific areas that are higher risk of Covid-19 Transmission . Eye Protection: During all patient encounters in specific area that are higher risk of Covid-19 Transmission . Review revealed the facility was at a High level for Covid-19 Community Transmission. An interview and review of facility infection control program and data was completed with Infection Control RN B on 4/12/23 at 9:49 AM. RN B was queried regarding the Covid positive Residents in the facility and indicated the facility had a recent outbreak. When queried the first step to donning PPE, RN B indicated hand hygiene should be performed. When asked why there was no hand sanitizer available in the 600 hallway and/or outside of the Covid-19 positive resident rooms, RN B revealed there used to be wall mounted alcohol-based hand sanitizer dispensers in the halls but that the facility had taken them down because they were getting knocked off the wall by food carts. When asked why hand sanitizer was not present on the top of the PPE carts, RN B indicated there should be. RN B was then asked if N-95 masks should be removed and disposed of after providing care to a Covid positive Resident and indicated they should. When asked, RN B confirmed hand hygiene should be completed following removal of the N-95 and prior to doffing a new mask. RN B was queried where the masks should be doffed and disposed, and hand hygiene performed but did not provide a response. When asked if they should be removed after exited the room, RN B revealed they understood the concern. When queried regarding observation of staff and visitors not wearing PPE, doffing appropriately, and performing hand hygiene, RN B disclosed they had previously identified concerns of staff not doffing their masks after providing care to Covid-19 positive Residents. When queried how staff and visitors know what type of precautions the Resident has in place and what PPE is required to enter the room when it is not posted in a conspicuous location outside of the room, RN B indicated they were following the facility policy/procedure. Facility resident Infection Tracking Log for Survey documentation was reviewed with RN B at this time beginning with March 2023. Review reviewed 49 total infections during the month. The infections included: - Eight community acquired, and 41 Healthcare Acquired (HAI-facility) acquired infections - 32 resident Covid-19 infections (all HAI) - 2 respiratory infections - Seven urinary infections - Eight skin/wound No carry over infections from the prior month were included in the tracking. When queried regarding the first Resident who exhibited signs and symptoms and tested positive for Covid-19, RN B replied, (Unsampled Resident #1) was the first. Per the line listing, the Resident's symptoms included, Cough, sore throat, congestion which began on 3/5/23. RN B was asked if the Resident had a roommate and if they tracked that as part of their infection surveillance and revealed they did not track it but could look it up. Review of the Unsampled Resident #1's census documentation revealed the Resident was placed in Transmission-based isolation precautions on 3/1/23 due to exposure. When queried regarding what exposure the documentation was referring to, RN B reviewed the Resident's medical records and stated, (Resident #68) was their roommate. They were sent out (to hospital) on 2/28/23. RN B revealed they were notified by the hospital that Resident #68 had tested positive for Covid-19. Review of the Infection Tracking Logs for February and March 2023 did not indicate Resident #68 was positive for Covid-19. When asked when the Resident returned to the facility, RN B revealed they had to review the medical record. After reviewing the medical record, RN B stated, Returned on 3/10/23. When asked if the Resident returned with signs/symptoms of Covid-19 and if they were placed in isolation precautions, RN B had to review the Resident's Electronic Medical Record (EMR). After review, RN B stated, (Resident #68) was on isolation for one day then moved. When asked why Resident #68 was not included in their infection logs for tracking, RN B indicated they had not put them on the log because they had not tested positive at the facility. When queried if facility staff had also tested positive for Covid-19, RN B replied, There were five staff that were related. When asked were they maintained documentation of staff illness including Covid-19, RN B revealed both Resident and Staff members with Covid -19 are tracked on the County LTC Covid Surveillance Line List. The County LTC Covid Surveillance Line List for March 2023 indicated 29 facility Residents and six facility staff tested positive for Covid-19. When queried regarding the discrepancy in the numbers of Residents who had tested positive for Covid-19, RN B revealed they would need to review line by line to provide an explanation. When asked if they had identified the source of the outbreak, RN B replied, It went from room [ROOM NUMBER] to 505 then 507 before it made a jump to the 300/400 halls. The Infection Tracking Log for Survey provided did not detail if the Resident was moved rooms when placed in isolation and/or if they had a roommate. Resident #55 was included on the Infection Tracking Log for Survey as having Covid-19. The log detailed, Date: 3/6/23 . HAI . Signs/Symptoms: Cough, congestion . Isolation/Type: Airborne . Additional Notes: isolation, pt (patient) sent to ER 3/7 . The log did not indicate the date Resident #55 was placed on isolation precautions, if they were moved rooms, and/or if they had a roommate. Review of the information on the County LTC Covid Surveillance Line List form for Resident #55 detailed the Resident's signs and symptoms of Covid-19 included congestion and that their symptoms began on 3/4/23. When queried the date that Resident #55 was placed in isolation precautions related to Covid-19, RN B reviewed the Resident's EMR and stated, 3/6/23. When asked why the Resident was not placed in isolation precautions sooner, RN B reviewed Resident #55's EMR and stated, Doctor got a chest x-ray and started on Tessalon Pearls (prescription cough relieve medication) on 3/4/23. When asked if the Resident had a roommate, RN B indicated they believed they did but the EMR was converted on 3/1/23 and the census data was not correct. When asked why they did not include that information as part of their tracking, RN B did not provide an explanation. When asked why the information and dates on the tracking documentation forms did not match, RN B revealed the symptom onset set was incorrect. Further review and comparison of the forms revealed multiple discrepancies between the sign/symptom onset date. When asked how they are informed of signs/symptoms of potential infections, RN B indicated they are verbally informed by staff, and it is discussed in the facility morning meeting. When queried how they determine the date for their line listing of symptom onset, RN B revealed they look back in the Resident's medical record when they are made aware of the infection. When asked where they track infections which do not require antibiotic/antiviral treatment, RN B reiterated it is through verbal communication. No infections not necessitating treatment, with the exception of Covid-19, were included on the infection tracking/line listing documentation. When queried how they determine which infections to count/include on the line listing, RN B replied, New or worsening which required new treatment. When asked if staff are consistently assigned to the same units, RN B revealed the facility attempted but most staff worked in all units. When asked how they addressed carry over infections from the previous months, RN B revealed they did not carry over infections from the previous month. Upon request, RN B provided their March 2023 - QA Meeting - Infection Prevention monthly summary document. The form detailed there were 49 total infections tracked which included 9 community acquired and 40 center acquired. When queried regarding the discrepancy in the number of infections, RN B confirmed and indicated they had made a mistake. Review of the Infection Tracking Log for Survey documentation for February 2023 revealed one Resident tested positive on 2/3/23. The tracking form did not detail if the Resident was moved rooms, had a roommate, and/or when isolation precautions were initiated. Review of the line listing and monthly summary documentation revealed multiple discrepancies and inaccuracies. When queried regarding the Community Covid-19 Transmission rate, RN B replied, High. The policy/procedure entitled; Covid-19 PPE Usage Guide was reviewed with RN B at this time. When asked if the policy/procedure specified staff should be wearing eye protection during patient encounters, RN B replied, Yes. When asked if staff were wearing eye protection, RN B stated, No. RN B was then asked about process surveillance completion including infection rounds, RN B revealed they did. When asked if completed rounds on all shifts and weekends, RN B revealed rounds are completed during the week on day shift. When asked if that was providing and accurate and well-rounded representation of practices in the facility, RN B confirmed it did not. When queried regarding the facility having eight Urinary Tract Infections (UTI) in January and February and seven in March 2023, RN B revealed they were aware. When queried if they had identified a root cause and/or completed education to prevent infections, RN B revealed they had not but would. No further explanation was provided. Review of facility provided policy/procedure entitled, Coronavirus Disease (Covid-19) - Using Personal Protective Equipment (Revised September 2022) detailed, . 2. If community transmission is high, staff will use NIOSH approved particulate respirators with N 95 filters or higher used for: a. All aerosol-generating procedures; and b. Other situations where additional risk factors for transmission are present, such as (1) the resident is unable to use source control and the are is poorly ventilated; or (2) health care- associated SARS-CoV-2 transmission is identified and universal respirator use by staff working in affected areas in not already in place . 4. When caring for a resident with suspected or confirmed SARS-CoV-2 infection: a. Personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection adhere to standard precautions and use a . N 95 . gown, gloves, and eye protection . b. Respirator: (1) An N 95 . is donned before entry into resident room . (2) Disposable respirators are removed and discarded after exiting the resident's room or care area and closing the door . (3) Hand hygiene is performed after removing the respirator . c. Eye Protection . (2) Eye protection is removed after leaving the resident room or care area . A policy/procedure related to infection control surveillance, tracking, and program were requested during the entrance conference on 4/4/23 but not received by the conclusion of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a comfortable and homelike environment for six residents' rooms on the 200 Hall, resulting in six rooms having numerous skid-like markings on the heat registers and deep gouges in the walls. Findings Include: During initial tour of the 200 Hallway on 4/4/2023, room [ROOM NUMBER]-1 was observed to have a trapeze attached to the bed. Behind the headboard were large gouges in the wall with a white, dust like, substance that was visible inside of the deep gouges. Certified Nursing Assistant (CNA) K was asked how the gouges occurred and it was reported its from the back portion of the trapeze digging into the wall. The bottom of the heat register had numerous black scratches/streaks on it in varying lengths and widths. Continuing with initial tour of the facility there were five other resident rooms observed to have many black streaks on their heart registers. 210-2: Deep gouges in the wall behind the headboard 206: Heat register with varying sizes/widths of black skid like markings 204: Heat register with varying sizes/widths of black skid like markings 205: Heat register with varying sizes/widths of black skid like markings 202: Heat register with varying sizes/widths of black skid like markings On 4/7/2023 at 8:25 AM, a tour of the 200 unit was completed with Maintenance Director L, of the six resident rooms with heat register skid marks and gashes in the wall. 211-1 was observed with Director L and he explained the gashes behind the bed are from trapeze being too close to the wall. He explained when staff move the bed up/down the base of the trapeze is digging in the plaster walls. 210-2: Director L, reported the marking are from the trapeze, that was previously attached to the bed. Rooms 202, 204, 205 and 206 were also observed with Director L, and he explained the black markings on the heart registers are from resident wheelchairs sliding against it. There are wood pieces going across the heat register and that is the portion resident wheelchairs hit against.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8: A review of Resident #8 medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included stroke, spastic hemiplegia affecting left dominant side, contracture of left hand, mild cognitive impairment, contracture of left knee, muscle weakness, reduced mobility, and need for assistance with personal care. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 13/15 that indicated intact cognition and needed extensive assistance with bed mobility, dressing, toilet use and personal hygiene. On 4/4/23 at 10:11 AM, an interview was conducted with Resident #8 who answered questions and conversed in conversation. The Resident was observed to be lying in bed with a gown on. The Resident was observed to have a full beard and mustache. When asked about his facial hair, the Resident indicated he has not had a shave and reported his beard was longer than he likes to keep it. Fingernails were long, chipped, and dirty underneath. When asked about bathing, the Resident stated, I get a bed bath here. They don't have any time to take me down there (for a shower), and indicated he would prefer to have a shower. The Resident stated, They don't ask they just do the bed bath. A review of Resident #8's task list revealed a task for Shower/Bed Bath- Mon/Thu on days and PRN (as needed). A review of the last 30 days revealed multiple bed baths given but no showers given. A review of Resident #8's care plan revealed a focus for ADL self care deficit as evidenced by generalized weakness related to disease process CVA (stroke) with left sided weakness physical limitations, leg contractures . Patient is dependent on staff for all aspects of personal care . A goal of Will receive assistance necessary to meet ADL needs. Interventions that included Assist to bathe/shower as needed; Assist with daily hygiene, grooming, dressing, oral care and eating as needed. The care plan lacked Resident preference or staff directive in the care plan for bathing activities. On 4/6/23 at 3:36 PM, an interview was conducted with Unit Manager, Nurse H regarding Resident #8's bed baths and activity level. The Unit Manager indicated that the Resident would get up once in a while and gets up and watches TV. The Unit Manager was asked about the frequent bed baths given and the Unit Manager stated, sometimes when they are in bed like that, they will clean them up that frequently. The facility document of Resident #8's shower sheets had been requested and not received. When asked why there were no shower sheets, the Unit Manager indicated that staff does not always fill out a shower sheets, and stated, Its paper and we are phasing out of doing papers. When reviewed with the Unit Manager that the policy indicated shower sheets to be filled out, the Unit Manager reported that they were phasing out of the paper and as long as they are charting it in the medical record, they did not fill in the shower sheets. On 4/6/23 at 3:43 PM, an observation was made of Resident #8 lying in bed and not dressed in clothes. The Resident was asked if he had received a bed bath, the Resident indicated he did not and stated, I want to get up in the shower, I don't always want a bed bath. The Resident was asked if he got up out of bed and stated, Yes, I get up but the person that gets me up wasn't here today or yesterday, so I didn't get up. I wanted to get up in my wheelchair, but she wasn't here. On 4/7/23 at 10:39 AM, an interview was conducted with Unit Manager, Nurse A regarding Resident #8's bathing preferences. When asked about the Resident's preference for shaving, the Unit Manager indicated the resident was resistant to shaving. The Unit Manager was asked about the Resident's refusals and after review of the Resident's medical record revealed a lack of documentation of refusals for showers or shaving. A review of the Resident's care plan revealed a lack of care planning for refusing shaving and showers and the length of beard was not documented for the Resident's preferences. The Unit Manager indicated that staff were to give the option for shower or bed bath, but indicated the staff was not documenting if he was refusing or not. The Unit Manager indicated that facility policy was to ask up to three times, try to accommodate their needs, tell the nurse after three refusals, if they flatly refuse, don't harass the patient, the Nurse would encourage them to accept the shower. When asked if they should document the refusals, the Unit Manager stated, They are supposed to document, but you know. Resident #26: A review of Resident #26's medical record revealed an admission into the facility on 4/11/16 and readmission on [DATE] with diagnoses that included depression, dementia, psychotic disorder with delusions, adjustment disorder, Alzheimer's disease, anxiety disorder, and diabetes. A review of the MDS, dated [DATE], revealed the Resident needed supervision with personal hygiene and toilet use and needed physical help with part of bathing activity. On 4/4/23 at 10:08 AM, an observation was made of Resident #26 dressed and in her wheelchair. The Resident was asked questions but was non-interviewable and did not converse in conversation. The Resident was observed in the morning to be sitting up in her wheelchair and propelling herself through the hall and sitting by the Nurse passing medication to Residents. A review of Resident #26's care plan revealed a focus for ADL Self care deficit: Patient has multiple medical problems that include the following . mood disorder with episodes of increased confusion and agitation . Patient has facial hair to her chin does not want it removed. Patient had episodes of resistant behaviors and will yell and scream at staff. Patient moans constantly and saying-OH OH over and over. Goal Will receive assistance necessary to meet ADL needs. Interventions included Assist to bathe/shower as needed; Assist with daily hygiene, grooming, dressing, oral care and eating as needed. The care plan lacked the Resident's preference to shower or bed bath and plan for refusals of shower activity. The [NAME] revealed Shower/Bed Bath-Wed/Sat on Evenings and PRN. The [NAME] lacked staff directive for Resident's preference for a shower or bed bath. A review of Resident #26's Task for Shower/Bed Bath- Wed/Sat on Evenings and PRN, revealed a shower given on 3/9/23 and 4/5/23 and multiple bed baths given. A review of the task for bathing and progress notes lacked documentation of shower refusals. On 4/12/23 at 10:35 AM an interview was conducted with the Director of Nursing (DON) regarding Resident #26's preference for a shower or bed bath. It was reviewed with the DON of the Resident up in her wheelchair and propelling herself and a review of two showers given in the last 30 days from the reviewed task list for bathing. The DON was asked what the Resident's preference was and the DON indicated that staff were to ask if she wants a shower but if she refuses then they give her a bed bath. The DON was asked about documentation of refusals of showers. The DON indicated there was no documentation of refusals and stated, If they don't take a shower then they take a bed bath. We don't document the refusals. Resident #30: A review of Resident #30's medical record revealed an admission into the facility on 2/2/23 with diagnoses that included heart attack, diabetes (DM), heart failure, end stage renal disease(ESRD) and dependence on renal dialysis. A review of the Minimum Data Set assessment, dated 2/9/23, revealed a Brief Interview of Mental Status score of 15/15 that indicated intact cognition and the Resident needed extensive assistance with bed mobility, transfers and toilet use and needed limited assistance with dressing and personal hygiene. Further review of the medical record revealed the Resident went out of the facility for dialysis treatments. On 4/4/23 at 1:22 PM, an observation was made of Resident #30 sitting up in her room. The Resident was interviewed, answered questions, and conversed in conversation. The Resident reported that she went out of the facility for dialysis treatments three times a week on Monday, Wednesday, and Friday. The Resident was asked what time she usually went to dialysis and the Resident indicated she left the facility after lunch about 12:30 (PM) and returned to the facility about 6:00 to 6:30 (PM). The Resident indicated that she received her dinner meal when she came back. When asked about not receiving medications that were scheduled during their absence from the facility for dialysis treatments, the Resident indicated that she had missed some medications and sometimes the binder was waiting for her when she returned. A review of the Resident's care plan revealed a lack of care planning for dialysis treatments. On 4/6/23 at 12:57 PM, an interview was conducted with Unit Manager, Nurse H regarding Resident #30 going out for dialysis treatments and the Resident's care plan. The care plan was reviewed by the Unit Manager and indicated there was not a care plan for dialysis. The Unit Manager was asked if there should be a care plan. The Unit Manager stated, She did not have a care plan for dialysis, she does now. Based, observed, Interview, and record review, the facility failed to ensure the development of comprehensive care plans and interventions for six residents (Resident #8, Resident #26, Resident #30, Resident #38, Resident #68, and Resident #71), resulting in the likelihood for a lack of care and prolonged illness. Findings include: Record review of the facility 'Care Plans, Comprehensive Person-Centered, Timing and Revision' policy dated 3/13/2023, revealed the purpose of a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Record review of facility 'Bath-Shower' policy dated 3/13/2023, revealed the procedure of giving a bath/shower and to record in PCC (Point Click Care) POC (Plan of Care). Care Plan documentation guidelines: list the amount of assistance the resident needs with bathing and any resident preferences, precautions, special soap, or lotion to be used, etc. Record review of the facility 'Station A Shower Schedule' undated, revealed resident in 308-2 is to have showers on Tuesday & Friday. Resident in room [ROOM NUMBER]-2 was to have showers on Wednesday & Saturday. Resident in room [ROOM NUMBER]-1 was to have showers on Monday & Thursday. Resident #38: Observation on 04/04/23 at 12:20 PM of Resident #38 residing in room [ROOM NUMBER]-2 observed in bed, has a long white beard and food in beard. The Resident #38 was noted to be lying in bed with the blankets off, observed in hospital style gown with a peg tube protruding from abdomen, resident appeared to have full white beard and messy white hair, unkept in appearance. Record review of Resident #38's Minimum Data Set (MDS) significant change dated 2/2/2023, revealed an elderly male medical diagnosis of coronary artery disease, heart failure, hypertension, renal insufficiency, viral hepatitis, thyroid disorder and dementia. Cognitive assessment with Brief Interview of Mental Status (BIMS) score of 0 out of 15, severe cognitive impairment. Section G: Functional Status revealed the resident needed extensive assist of two plus persons physical assist with bed mobility and transfers. Bathing was assessed at total dependence on staff with one person assist. Record review of Resident #38's Bathing task for 30 days in the electronic record revealed: Question #1- How resident takes full body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing back and hair)? On dates: 3/13/2023, 3/14/2023. 3/15/2023, Total support, skip 6 days to 3/21/2023 physical help, 3/24/2023, 3/28/2023, skipped 8 days, 4/6/2023 total support. Question #2- Bath support provided? On dates: 3/13/2023, 3/14/2023. 3/15/2023, skip 6 days to 3/21/2023, 3/24/2023, 3/28/2023 one-person physical assist, skipped 8 days, 4/6/2023 two-person physical assist. Question #3- Was a shower, bed bath or tub bath completed? On dates: 3/13/2023, 3/14/2023. 3/15/2023, skip 6 days to 3/21/2023, 3/24/2023, 3/28/2023, skipped 8 days, 4/6/2023 were all bed baths. Record review of Resident #38's care plans pages 1- 19, revealed on page 3, ADL (activity of Daily Living) Self-care deficit related to disease process of ischemic cardiomyopathy, congestive heart failure. Intervention dated 1/12/2023 on the care plan revealed assist to bathe/shower as needed. No days or shift was identified for when staff are to perform task. Record review of Resident #38's [NAME] (Nursing assistant task guide) did not mention a bed bath/shower to be performed. Resident #68: Observation on 04/04/23 01:17 PM of Resident #68 in the resident's room revealed an elderly female lying in bed. Record review of Resident #68's Minimum Data Set (MDS) dated [DATE], revealed an elderly female with medical diagnosis of anemia, coronary artery disease, heart failure, hypertension, gastro esophageal reflux disease, urinary tract infection, cerebral vascular accident, and non-Alzheimer's dementia. Cognitive assessment of Brief Interview of Mental Status (BIMS) score of 99, unable to complete/severe cognitive impairment. Section G: Functional Status revealed the resident needed extensive assist of two plus persons physical assist with bed mobility. Resident #68 transfers were total dependence with two plus person's physical assist. Bathing was assessed at physical help in part of bathing on staff with one person assist. Record review of Resident #68's Bathing task for 30 days in the electronic record revealed: Question #1- How resident takes full body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing back and hair)? On dates: 3/10/2023, 3/12/2023, 3/13/2023 activity did not occur, 3/13/2023 afternoon independent, 3/14/2023, 3/15/2023 total dependence, 3/19/2023, 3/20/2023 activity did not occur, 3/22/2023, 3/24/2023 total dependence, 3/27/2023 physical help with part of bathing activity, 3/29/2023 total dependence, 4/5/2023 physical help with part of bathing activity. Question #2- Bath support provided? on dates: 3/10/2023, 3/12/2023, 3/13/2023 activity did not occur, 3/13/2023 afternoon no set up or help from staff, 3/14/2023, 3/15/2023 one-person physical assist 3/19/2023, 3/20/2023 activity did not occur, 3/22/2023, 3/24/2023, 3/27/2023, 3/28/2023 one-person physical assist 4/5/2023 two plus person physical assist. Question #3- Was a shower, bed bath or tub bath completed? On dates: 3/10/2023, 3/12/2023 bed bath, 3/13/2023 activity did not occur, 3/13/2023 afternoon shower, 3/14/2023, 3/15/2023 bed bath, 3/19/2023, 3/20/2023 not applicable, 3/22/2023 bed bath, 3/24/2023 resident refused, 3/27/2023 bed bath, 3/28/2023 be bath 4/5/2023 bed bath. Record review of Resident #68's care plans pages 1- 20, revealed on page 3, ADL (activity of Daily Living) Self-care deficit related to disease process of ischemic cardiomyopathy chronic heart failure. Intervention dated 2/26/2023 on the care plan revealed assist to bathe/shower as needed. No days or shift was identified for when staff are to perform task. Record review of Resident #68's 'MDS [NAME] Report' (Nursing assistant task guide) print date 4/6/2023 noted medical diagnosis of congestive heart failure, hypoxic and hypercapnia, atherosclerotic heart disease. The bath or bathing schedule area on the form were left blank. Resident #71: Record review of Resident #71's Minimum Data Set (MDS) dated [DATE], revealed an elderly male with medical diagnosis of anemia, atrial fibrillation, hypertension, gastro esophageal reflux disease, hip fracture, depression, and bipolar. Cognitive assessment of Brief Interview of Mental Status (BIMS) score of 14 of 15, cognitive intact. Section G: Functional Status revealed the resident needed extensive assist of one person's physical assist with bed mobility and transfers. Bathing was assessed at physical help in part of bathing on staff with one person assist. Record review of Resident #71's Bathing task for 30 days in the electronic record revealed: Question #1- How resident takes full body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing back and hair)? On dates: 3/15/2023 independently, 3/19/2023 activity did not occur, 3/20/2023 day shift activity did not occur, 3/20/2023 afternoon shift independently, 3/21/2023 activity did not occur, 3/28/2023 independently. Question #2- Bath support provided? On dates: 3/15/2023 no set up or help needed, 3/19/2023 activity did not occur, 3/20/2023 day shift activity did not occur, 3/20/2023 afternoon shift no set up or help needed, 3/21/2023 activity did not occur, 3/28/2023 no set up or help needed. Question #3- Was a shower, bed bath or tub bath completed? On dates: 3/15/2023 bed bath given, 3/19/2023 activity did not occur, 3/20/2023 day shift activity did not occur, 3/20/2023 afternoon shift bed bath given, 3/21/2023 activity did not occur, 3/28/2023 bed bath given. Record review of Resident #71's 'MDS [NAME] Report' (Nursing assistant task guide) print date 4/6/2023 noted medical diagnosis of orthopedic after care, esophagitis, anemia, and diverticulosis. The bath or bathing schedule area on the form were left blank. Record review of Resident #71's care plans pages 1- 11 revealed all pages, that there was no ADL (activity of Daily Living). There were Interventions about showers or bed baths. No days or shift was identified for when staff are to perform task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Number MI00131766 Based on observation, interview and record review, the facility failed to ensure that Activities of Daily Living (ADL) care was provided to four residents (Resident #48, Resident #182, Resident #376, and Resident #380) of four residents reviewed, resulting in a lack of bathing, hygiene, and oral care, resident verbalizations of embarrassment, and the likelihood for psychosocial distress. Findings include: Resident #48: On 4/5/23 at 12:35 PM, Resident #48 was observed sitting in a wheelchair in their room. Obvious, thick, dark colored facial hair was observed above the Resident's top lip. An interview was completed at this time. Resident #48 was queried regarding if the dark facial hair bothered them, Resident #48 stated, Well, yes. Resident #48 then revealed they had asked a friend to bring them a razor to remove it because it was embarrassing. When asked about assistance from facility staff to remove the hair, Resident #48 stated, They haven't offered. When queried, Resident #48 revealed they required assistance from staff to complete ADL care. Record review revealed Resident #48 was most recently admitted to the facility on [DATE] with diagnoses which included dementia, chronic kidney disease, urine retention, sepsis (infection in blood which spreads throughout body), and UTI. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required limited to total assistance to complete ADL's with the exception of eating. Review of Resident #48's care plans revealed a care plan entitled, ADL Self-care deficit as evidenced by pt (patient) assessment/history related to disease process . (Initiated: 3/22/23). The care plan included the interventions: - Assist to bathe/shower as needed (Initiated: 3/22/23) - Assist with daily hygiene, grooming, dressing, oral care and eating as needed (Initiated: 3/22/23) - Break ADL tasks into sub-task for easier patient performance (Initiated: 3/22/23) Review of Resident #48's progress note documentation in the EMR revealed a progress note dated 3/23/23 at 10:28 AM which detailed, Nursing/Clinical . patient admitted [DATE] from hospital . Patient went to the ER after being found on the floor . Patient had reportedly been on the floor for days . Staff will assist the patient with daily personal care . On 4/6/23 at 11:30 AM, Resident #48 was observed in their room. The facial hair remained. When queried, Resident #48 revealed their friend was unable to visit easily to bring a razor. An interview was completed with Certified Nursing Assistant (CNA) O on 4/6/23 at 3:24 PM. When queried if they had noticed Resident #48's facial hair, CNA O replied, Um hum and indicated they did. When asked if the hair was very dark and noticeable, CNA O confirmed it was. CNA O was then queried regarding facility procedure related to facial hair on female Residents and replied, We ask and shave it. When queried if they had offered to shave to Resident #48, CNA O revealed they had not. An interview was completed with CNA HH on 4/6/23 at 3:26 PM. When queried regarding Resident #48, CNA HH revealed they had not seen Resident #48 yet. When queried regarding Resident #48's facial hair, CNA HH indicated they had not noticed the hair but stated, I will offer (shaving) to them today. On 4/7/23 at 7:42 AM, an interview was conducted with Unit Manager Registered Nurse (RN) H. When queried regarding Resident #48's facial hair, RN H revealed they were made aware by staff. RN H stated, They (staff) shaved it and I added it to (Resident #48's) [NAME]. When asked why it had not been completed, RN H was unable to provide an explanation and stated, They (staff) know they are supposed to offer the ladies shaving. Resident #182: On 4/6/23 at 10:39 AM, an observation occurred of Resident #182 in their room. The Resident was in their bed, positioned on their back. Their call light was observed on the floor. A visible build up and coating was observed on Resident #182's teeth. An unopened toothbrush, still in the wrapper, was sitting on the top of the Resident's bedside table. Resident #182 was asked when they had last showered and brushed their teeth but did not a provide meaningful response. An interview was conducted with Licensed Practical Nurse (LPN) M on 4/6/23 at 10:46 AM. When queried regarding Resident #182's cognitive status, LPN M stated, I don't think (Resident #182) knows what's going on. When asked how much assistance Resident #182 required for ADL care, LPN M revealed the Resident was completely dependent upon staff. Record review revealed Resident #182 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis (MS) and Urinary Tract Infection. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required assistance of two+ staff to complete Activities of Daily (ADL's). Review of Resident #182's care plans revealed a care plan entitled, ADL Self-care deficit as evidenced by pt (patient) assessment/history related to disease process . (Initiated and Revised: 3/28/23). The care plan included the interventions: - Assist to bathe/shower as needed (Initiated: 3/28/23) - Assist with daily hygiene, grooming, dressing, oral care and eating as needed (Initiated: 3/28/23) - Break ADL tasks into sub-task for easier patient performance (Initiated: 3/28/23) Review of documentation in Resident #182's EMR revealed the following tasks: - Shower/Bed Bath - No documentation of completed for the previous 30 days - Oral Care Completed - Yes documented six times and Not Applicable was documented 13 times On 4/6/23 at 11:27 AM, Resident #182 was observed in their room. The Resident remained in the same position in bed. Their call light was on the other unoccupied bed in the room and not within reach of the Resident. The toothbrush remained unopened on the Resident's bedside dresser. An interview was completed with Certified Nursing Assistant (CNA) G on 4/6/23 at 1:28 PM. When asked, CNA G indicated they were Resident #182's assigned CNA. CNA G was then asked if they had documented Not Applicable for Resident #182's oral care and confirmed they had. When queried why they documented Not Applicable for oral care completion and how oral care was not applicable, CNA G was unable able to provide a reason. When queried regarding other ADL care for Resident #182 including the level of assistance the Resident requires, CNA G indicated the Resident was able to move their hands and arms but did not elaborate further. CNA G was queried if they had provided ADL care to the Resident and stated, When I direct (Resident #182) to wash their air pits and under their breasts, they resist. So, I don't even try. When asked if they were saying they had not attempted to complete ADL care for Resident #182 because the Resident had previously resisted when they had told them to wash under their arms and their breasts to clarify, CNA G confirmed. When queried regarding facility policy/procedure when ADL is not completed, CNA G questioned, Like let the nurse know? When asked if that was what they were supposed to do when a Resident was resistant and care was not completed, CNA G stated, No. If they refused a shower, I would let (the nurse) know. When asked if they had ever given Resident #182 a shower and/or washed their hair, CNA G replied they had not. CNA G was then asked about observation of Resident #182's call light being on the floor and stated, I went in there and found it on the floor. When queried regarding observation of the Resident's call light being on the other, unoccupied bed in the room, CNA G replied, I don't even know how it got there. When queried how often residents receive new toothbrushes, CNA G indicated toothbrushes are replaced at the same frequency as they are at home. CNA G was then asked about observation of Resident #182's toothbrush being unopened on their bedside dresser table and stated, Last Thursday was unopened. When queried how they assisted Resident #182 to brush their teeth when their toothbrush was unopened, CNA G did not provide a response. When asked if they had assisted the Resident to brush their teeth and/or complete oral care, CNA G revealed they had not. An interview was completed with CNA O on 4/6/23 at 3:23 PM. When queried if Resident #182 was resistant to care and/or refused ADL care completion, CNA O stated, No. When asked why the Resident's toothbrush was unopened, CNA O was unable to provide an explanation. On 4/6/23 at 3:33 PM, Resident #182 was observed in their room in bed. The Resident's toothbrush remained unopened in the same place on the bedside dresser. The visible build up and coating remained present on the Resident's teeth. Resident #376: Review of intake documentation revealed concerns that Resident #376 was not well-cared for at the facility. The intake detailed, (Resident #376) had a rash from their briefs, and their hair was matted from not being bathed or brushed after being at the facility for 10 days. Record review revealed Resident #376 was admitted to the facility on [DATE] and discharged on 9/28/22 with diagnoses which included heart failure, anxiety, depression, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete all ADL's with the exception of eating. Review of Resident #376's care plans included a care plan titled, ADL Self-care deficit as evidenced by pt (patient) assessment/history related to disease process . (Initiated and Revised: 9/10/22). The care plan included the interventions: - ADL Assist: Moderate assist with transfers (Initiated: 9/13/22) - Assist to bathe/shower as needed (Initiated: 9/10/22) - Assist with daily hygiene, grooming, dressing, oral care and eating as needed (Initiated: 9/10/22) - Break ADL tasks into sub-task for easier patient performance (Initiated: 9/10/22) Review of Resident #376's Documentation Survey Report and [NAME] Report for September 2022 revealed there was no task and no documentation that Resident #376 had received a shower and/or bathing activities while they were at the facility. Review of Resident #376's Electronic Medical Record (EMR) revealed one Skilled Nursing note, dated 9/14/22 at 1:49 PM which detailed, Alert, able to make needs known. Consumed 10% meals this shift. Alternatives offered and refused. Refused bed bath and clothing change . An interview was completed with Confidential Witness GG on 4/10/23 at 8:38 AM. When queried regarding Resident #376, Witness GG revealed the Resident had been in the facility approximately two weeks and indicated they went to the facility to visit the Resident on day ten of their stay. Witness GG stated, (Resident #376) had not been bathed. When asked how they knew the Resident had not received a shower or bath, Witness GG replied that Resident #376 smelled. Witness GG continued, They (facility staff) had put two braids in (Resident #376's) hair when they first got there. When asked, Witness GG revealed the braids were french braids. Witness GG continued, When we got there, one braid on the left side was still in and the right was out. The elastic band was matted in (Resident #376's) head. When asked what happened, Witness GG stated, I had to ask them (facility staff) for scissors to cut out the huge matt and the hair tie. I spent 25 minutes trying to get it out and I couldn't. Witness GG revealed they had to cut elastic and the knot out of the Resident's hair. When queried if they had addressed their concerns with facility staff, Witness GG stated, (Resident #376) smelled like urine and their hair was so bad that I snapped at the nurse. When asked what the facility staff member had said, Witness GG replied, They said they tried. Witness GG revealed the staff told them that Resident #376 had refused care. Witness GG was unable to recall the name of the staff they spoke to when asked. When asked if anyone from the facility had contacted them to let them know the Resident had refused care, Witness GG replied, No, if they would have called or told me I would have been there to help them. Witness GG revealed they asked facility staff if Resident #376 had been given a shower and were informed they did not. Witness GG then stated, I even asked them for the stuff to give (Resident #376) a shower and they said they could not because I was not an employee there. When queried if the facility staff assisted the Resident to shower then, Witness GG replied, No. Witness GG then stated, I asked for the Supervisor and all they said was that they had tried. Witness GG continued, (Resident #376) had dementia and needed help. (The Resident) can't remember and needs to be reminded to wash, brush their teeth, and shower. Witness GG revealed they were disturbed and upset because they did not feel the facility staff cared about the ADL care and general well-being of the Resident. Witness GG stated, No one should be left like that with dirty, matted hair and smelling like urine when they are there because they can't remember to take care of themselves. An interview was completed with the facility Administrator and Director of Nursing (DON) on 4/12/23 at 8:15 AM. When queried regarding ADL care documentation for Resident #376, the Administrator stated they were not able to pull up documentation in the EMR from that long ago. Resident #376's September 2022 Documentation Survey Report and [NAME] Report were reviewed with the Administrator and DON at this time. When queried regarding the lack of documentation of bathing and/or showering, including washing their hair, neither the Administrator nor DON were able to provide an explanation. Resident #380: On 4/5/23 at 12:05 PM, Resident #380 was observed in their room in bed, positioned on their back. The Resident was wearing a hospital gown and was unshaven. The Resident had an unkept and unclean appearance with chunks of food and unknown substances on the front of their gown and their bedding. An interview was completed at this time. When queried how they get out of bed, Resident #380 revealed they could not get up without staff assistance. When asked how frequently staff assist them to get out of bed, Resident #380 replied, Only get out of bed with therapy. When asked how they felt about that, Resident #380 stated, I want to get out of bed more. Resident #380 was asked why they did not get out of bed more and indicated staff are busy. When queried how much assistance they require to shower and brush their teeth, Resident #380 replied, I only have teeth on the bottom and opened their mouth. Bottom teeth were observed with noted missing/broken teeth, visible plaque buildup, and edematous appearing gums. When asked if they need assistance to gather the items to brush their teeth, Resident #380 revealed they were not getting help brushing their teeth. Resident #380 was asked when they had last received a shower and revealed they had not received assistance from nursing staff to take a shower. Record review revealed Resident #380 was most recently admitted to the facility on [DATE] with diagnoses which included heart failure, Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, and Covid-19. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete all ADL's with the exception of eating. Review of Resident #380's care plan revealed a care plan entitled, ADL Self-care deficit as evidenced by pt assessment/history related to disease process . (Initiated and Revised: 3/22/23). The care plan included the interventions: - Assist to bathe/shower as needed (Initiated: 3/22/23) - Assist with daily hygiene, grooming, dressing, oral care and eating as needed (Initiated: 3/22/23) - Break ADL tasks into sub-task for easier patient performance (Initiated: 3/22/23) Resident #380 did not have a care plan in place related to refusal of ADL care and/or showering/bathing. Review of Task Documentation in Resident #380's EMR revealed the task, Shower/Bed Bath - Mon/Thu on Days and PRN (as needed). Review of documentation for the prior 30 days revealed no documentation of completion. An interview was completed with CNA HH on 4/6/23 at 3:29 PM. When queried regarding Resident #380 including ADL care and showering, CNA HH stated, (Resident #380) does therapy but then don't want to get up out of the bed. When queried if facility staff had attempted to provide rest periods around the Resident's scheduled therapy, a response was not provided. An interview was completed with Unit Manager RN H on 4/7/23 at 7:46 AM. When queried regarding Resident #380's ADL care and shower documentation, RN H reviewed the Resident's EMR and confirmed there was no documentation of completion. When asked the reason Resident #380 had not received a shower/bathing, RN H stated, I do that PCC (Point Click Care- EMR system) changed and the showers were not popping into the [NAME]. RN H then stated, Now I have to manually do that. It did not show up until yesterday. When asked why it showed in the EMR yesterday, RN H replied, I added to the [NAME] yesterday. When asked if the facility also completed paper shower sheets, RN H indicated they do. When queried if there were any shower sheets for Resident #380, RN H replied they will look. Shower sheets were requested at this time. When queried regarding the expectation for Resident oral care completion, RN H stated, Expectation is to document every shift. Resident #380's oral care documentation was reviewed with RN H at this time. When queried why the documentation did not demonstrate that oral care had been completed per facility expectations, RN H was unable to provide an explanation. No shower sheet documentation for Resident #380 was received by the conclusion of the survey. Review of facility policy/procedure entitled, Activities of Daily Living (ADL's), Supporting (Reviewed 10/2022) revealed, Residents will (be) provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting) . 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate . 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident's response to interventions will be monitored, evaluated and revised as appropriate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to curate a creative, comprehensive, family and community integrated Activity Program that met the needs of their cognitively intact residents for three residents (Resident #15, Resident #49 and Resident #182), resulting in Resident #49's and Resident #15's leisure pursuits being uninspired and repetitive and Resident #182 was denied a radio. This deficient practice caused facility residents to express feelings of frustrations, discontentment, boredom, and unimportance. Findings include: Resident #49: On 4/4/2023 at 12:05 PM, Resident #49 reported she does not have family in the state and would love for someone to read the bible to her a few times a week. She reported not doing much throughout the day. Facility staff who wished to remain anonymous reported the activities program at the facility is subpar for residents that are cognitively intact. They expressed there is not much interest shown in the activities provided at the facility from that group. It was added Resident #49 does not get out the bed much and they have only seen activities go in her room a few times and read to her. On 4/5/2023 at approximately 9:00 AM, a review was completed of Resident #49's records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Lupus, Major Depressive Disorder, Mood Disorder, Legal Blindness and Rheumatoid Arthritis. Resident #49 is able to make her needs knows but required assistance with her Activities of Daily Living (ADL). Further review of Resident #49's records revealed the following: Care Plan: Potential for decreased leisure .prefers room activities .offer activity program directed toward specific interest/need . March 2023 Task List: The task list showed Resident #49 watched television 21 times and was provided with the Chronicle Newspaper 19 times within the month. It can be noted the resident is legally blind and not able to read the Chronicle Newspaper. There were no other substantial activities provided to the resident. Resident #15: On 4/4/2023 at approximately 3:35 PM, Resident #15 expressed she informed staff of her wish to attend Bingo and Penny Auction around 9:00 AM. She reminded the staff of this later in the day and they reported they were unable to locate her wheelchair. Resident #15 expressed frustration as she was excited about the activity and was unsure why staff were unable to locate her wheelchair. On 4/4/2023 at approximately 3:45 PM, this writer asked CNA X if she knew where Resident #15's wheelchair was at. CNA X explained sometimes they are sitting outside of the resident rooms, as the rooms are too small to store them in. She reported she does not know why the aide did not look in the shower room as there are many in there. This writer, CNA X, CNA Y and Nurse R entered the shower room and there were multiple wheelchairs observed with no resident name listed on them. They reported they know which wheelchair belongs to each resident and was able to locate Resident #15's wheelchair. It can be noted the wheelchair was not labeled with Resident #15's name nor were any of the other wheelchairs. On 4/42023 at approximately 4:15 PM, a review was completed of Resident #15's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Chronic Kidney Disease, Diabetes, Dementia, Peripheral Vascular Disease, Heart Disease and Adjustment Disorder. Resident #15 can make her needs known but does require assistance from facility staff for ADL's. Further review was completed of Resident #15's medical records and it revealed the following: Care Plan: Potential for decreased leisure involvement . Encourage participation in group activities of interest such as bingo, crafts, movies and popcorn . March 2023 Task List showed the resident completed the following activities: Television:18 times Chronical Newspaper: 2 times Handheld games: 11 times Phone-media: 1 time Bingo: 1 time Reading: 1 time Visitor: once Music: once Reminisce: once There were no other substantial activities provided to the resident. During the Resident Council meeting on 4/6/2023 at 3:00, residents were asked if they had any concerns regarding the activities provided at the facility. All 7 residents in attendance voiced the activities are monotonous and rarely vary from week to week. They stated they would like to go on outings but have not in a while. They stated they rarely do outside activities since COVID-19 and would like more programs that meet their needs as they sometimes are bored. They reported they enjoyed their activity program prior to COVID-19. On 4/4/2023 at 1:20 PM, an interview was conducted with Activity Director W' regarding the facility's activity program. She reported the new company has provided their program with extra funding to hire another Activity Aide which will aide in being able to deliver better programming. Director W' explained they document under Tasks, and they chart what is applicable to the resident. She reported Resident #49 does not get out bed and they give her the daily chronicle and read it to her. Director W continued they do not have a facility bus to take residents on outings and they have not been anywhere since COVID. She reported she felt as though they could not go in the community because of COVID. A discussion ensued that explained many of the COVID restrictions have been lifted and COVID was not a viable excuse as to why the department does providing enriching outside activities to the residents. Director W' was queried if they collaborate with community agencies or partner with agencies to increase the quality and variety of their activities and she reported they do not. On 4/12/2023 at 10:45 AM, an interview was conducted with the DON (Director of Nursing) and Administrator regarding the quality of their activity program. They expressed the Activity Director has good programming for residents with dementia but does struggle with programming for their cognitively intact residents. They reported the current Activity Director has resigned and a current employee will take over the program in a few weeks. On 4/12/2023 at 11:06 AM, QAPI (Quality Assurance and Performance Plan) was held with the Administrator. It was explained the Activity Director was aware in January 2023 they had the budget for an additional Activity Aide. It was added they struggled with weekend activities as there was only one Activity Aide in the facility. On 4/12/2023 at 10:48 AM, an interview was conducted with Activity Director W regarding programming for cognitively intact residents. She was informed after review of Resident #49 and #15 activity pursuits they only participate in watching television or daily chronicle. Director W stated those residents do not like to get out bed and enjoy television, playing on their phone and the daily chronicle. She added it is difficult to meet the needs of all the residents. Activity Director W was informed the residents expressed the program was monotonous and wanted more outings and creative activities, Director W stated her budget is now bigger to incorporate more outside entertainment. We reviewed the activity calendar, and it was pointed out that with some slight variations most activities are same every Monday thru Sunday. Director W reported if it is something the residents like she will keep it on the schedule. This writer and Director W had a discussion regarding community engagement, utilizing other facility staff and abilities, working with dietary staff, and partnering with community agencies/groups to sponsor an activity. Director W explained she does not partner with other agencies or ask staff to display their talents for resident activities. Director W reported she has resigned from her position and will pass this along to the new Activity Director. Review was completed of the Activity Calendars from January to March 2023, and it revealed the activities were the same from week to week with some minor variations. Most activities are geared toward residents that are not cognitively intact. January 2023: The schedule below was the same every Monday each week with variation in the 1:00 PM and 3:30 PM activity. The 3:30 PM activity is always surrounding a word game. Monday's: 10:30 AM: Exercise 11:00 AM: Daily Questions 1:00 PM: The Year is 1964 1:45 PM: Cooking Club 3:30 PM: Word Web The schedule below was the same every Tuesday each week with variation in the 1:00 PM and 2:00 PM activity: Tuesday's: 10:30 AM Exercise 11:00 AM Daily Questions 1:00 PM Food Council 2:00 PM Penny Auction 3:30 Bingo The schedule below was the same every Thursday each week with variation in the 2:00 PM activity: Thursday's: 10:30 AM: Tube Exercises 11:00 AM: Daily Questions 2:00 PM: National Bird Day 4:00 PM: Arts and Crafts 6:30 PM: Good News Travels The schedule below was the same every Friday of each week: Friday's: 9:30 AM or 10:15 AM: Catholic Mass or Holy Communion Visits 10:30 AM: Quick Tune Up 11:00 AM: Daily Questions 1:30 PM: Music Activity 2:00 PM: Movie & Popcorn The schedule below was the same every Saturday of each week with slight variation: Saturday's: 10:30 AM: Stretching 11:00 AM: Daily Questions 1:00 PM: Just Us/Small Group 2:00 PM: BINGO 3:30 PM: What am I? February 2023: Sunday's: 10:30 AM: Devotions 11:00 AM: Quick Music 1:00 PM: Manicures 2:30 PM: Little [NAME] Party or Super Bowl Party 3:30 PM: Tossing/kicking game Wednesday's: 10:30 AM: Music in Motion 11:00 AM: Daily Questions 1:30 PM: Matinee and Popcorn 4:00 PM: Wi-Fi Games 6:45 PM: Relaxation Thursday's: 10:30 AM: Tube Exercise 11:00 AM: Daily Questions 1:30 PM: Varied 2:00 PM/2:30 PM: Varied 4:00 PM: Arts & Crafts 6:30 PM: Good News Travels March 2023: Monday's: Wednesday's: 10:15 AM: Coffee Chat 10:45 AM: Music in Motion 1:30 PM: Wednesday Matinee 4:00 PM: Wi-Fi Game 6:30 AM: Relaxation Saturdays: 10:30 AM: Stretching 11:00: Trivia/Questions 1:30 AM: Just us/Small Group 2:30 PM: BINGO 3:30 PM: Varied Each weekday activity is the same from week to week with very slight variation and it does not appear that much effort is put forth to curate a program specific to the needs of facility residents. On 4/14/2023 at 3:30 PM, a review was completed of the facility policy entitled, Activity Program, reviewed 1/23. The policy stated, Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident .Our activity program consists of individual, small group and large group activities that are designed to meet the needs and interests of each resident. Activity programs include activities that promote: a. Self-Esteem; b. Comfort; c. Pleasure; d. Education; e. Creativity; f. Success; and g. Independence . Individualized and group activities are provided that: a. Reflect the schedules, choices and rights of the residents; b. Are offered at hours convenient to the residents, including evenings, holidays and weekends; c. Reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents; d. Appeal to men and women as well as those of various age groups residing in the facility; and e. Incorporate family, visitor and resident ideas of desired appropriate activities . Resident #182: On 4/6/23 at 10:39 AM, an observation occurred of Resident #182 in their room. The Resident was in their bed, positioned on their back with the call light was observed on the floor. The Resident was talking to themselves upon entering the room. The TV was off and there was no radio or other noise in the room. The room walls were devoid of color and there were no decorations and/or signs of activities present. When asked questions, Resident #182 made eye contact but did not provide a meaningful response to the question asked. An interview was conducted with Licensed Practical Nurse (LPN) M on 4/6/23 at 10:46 AM. When queried regarding Resident #182's cognitive status, LPN M stated, I don't think (Resident #182) knows what's going on. When asked how much assistance Resident #182 required for ADL care, LPN M revealed the Resident was completely dependent upon staff. When queried regarding activities for the Resident, including their likes and dislikes, LPN M was unable to provide an explanation. Record review revealed Resident #182 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis (MS) and Urinary Tract Infection. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required assistance of two+ staff to complete Activities of Daily (ADL's). Review of Resident #182's care plans the Resident did not have a care plan in place pertaining to activities. Review of Resident #182's progress note documentation in the Electronic Medical Record (EMR) revealed no documentation of Activity assessment and/or completion. On 4/6/23 at 3:33 PM, Resident #182 was observed in bed. Family Member Witness P was sitting in a chair next to the Resident. An interview was completed at this time. When queried, Witness P revealed they were involved in the Resident's care as the Resident did not have any children. When queried regarding the lack of personal items in the room, Witness P revealed they were unsure of what they could bring. When asked what Resident #182 enjoyed, Witness P revealed the Resident had been a pediatric nurse. Per Witness P, Resident #182 enjoyed reading and listening to music. When asked if Resident #182 watched much TV at home, Witness P indicated they had not. With further inquiry regarding the lack of stimulation and activities in the room, Witness P revealed the Activity Lady came in and talked to them. Witness P continued, They asked if we could bring in a radio. When asked, Witness P revealed they were told the facility did not have a radio the Resident could use, not even on a temporary basis, until they were able to purchase and bring one back to the facility. Witness P revealed they did not mind getting a radio and bringing it to the facility for the Resident but would not be able to return immediately. Witness P revealed they were concerned the Resident would have nothing, as they had not since they were admitted , and could not understand how the facility did not have something the Resident could use on a temporary basis. On 4/14/2023 at 3:45 PM, a review was completed of Activity/Recreation Director job description. It stated, .Develops and delivers activity/recreational programming to promote the patients opportunities for engaging in normal life enhancement pursuits .Plans community activities that jointly include the community, staff, families and patients .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper labeling of medications, glucose monitor control solutions, and dispose of expired medication/supplies for three of three medication carts reviewed and one of two medication storage rooms from a total of six medication carts in use and three medication storage rooms, resulting in the potential for a resident to receive medication with decreased efficacy, use of expired supplies and inaccurate blood glucose monitoring. Findings include: On [DATE] at 4:00 PM, an observation was made with Nurse Z during the medication storage task for the 400-hall medication cart. The following observations and interviews were conducted: -Levemir Insulin, opened but did not have a date of when it was opened. Nurse Z indicated that it had been taken out of the refrigerator but was unsure if it had been used. The Nurse indicated that the insulin should be dated. -Lispro Insulin, opened, dated 2/19 as opened. Nurse Z indicated that it was expired past the date of when the medication should be discarded. When asked about facility policy on when opened insulin, how long should the insulin be used, the Nurse stated, four weeks after opened, and indicated the insulin should have been discarded. On [DATE] at 4:10 PM, an observation was made with Nurse Z of the Station A Medication Room. The following observations were made: -Aplisol, tuberculin testing solution, vial is open, not dated, the box has an open date. When asked if the vial needed to be dated, the Nurse was unsure and indicated the vial should probably be dated. -Acetaminophen suppositories 650 mg (milligrams), box of suppositories expired on 1/2023. On [DATE] at 9:55 AM, an observation was made of the 200-hall medication cart with Nurse BB during medication storage and labeling task. The following observations were made: -Humalog insulin, no date on the insulin. Nurse BB indicated she had taken it out of the refrigerator this morning and had not dated it. The Nurse dated the medication with the open date. -Levemir insulin, opened and no date on the insulin of the open date. The Nurse indicated that the insulin should have been dated with an open date. -Evencare G3 Glucose Control Solutions, opened. There was not a date of when the solutions were opened on the bottles or on the box. Nurse BB was asked about the facility policy about the glucose control solutions and indicated she thought the solution was good for three months after opening. -Toothettes, two, with antiseptic oral rinse, had an expiration date on [DATE]. On [DATE] at 8:29 AM, an interview was conducted with the Director of Nursing (DON) regarding concerns observed during the medication storage and labeling task of the survey. The items were reviewed with the DON. The DON indicated that the accucheck (glucose) control solutions needed to be dated and stated, They are good for only 3 months, I know that one as fact. On [DATE] at 12:39 PM, an observation was made of the 500-hall medication cart with Nurse Q during the medication storage and labeling task. The following observations were made: -Large plastic container of disinfecting wipes with an expiration date on 3/2023. -Microkill Bleach Wipes, multiple individual packages, all expired on 3/2023. The Nurse was asked if there were other wipes available that had not expired. The Nurse indicated there were no other available bleach wipes in the medication cart and stated, They should not be in there, that is why I threw them away. A review of facility policy titled, 5.3 Storage and Expiration Dating of Drugs, Biological's, Syringes and Needles, revision on [DATE], revealed, .4. Once any drug or biological package is opened, the Nursing Center should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Center staff should record the date opened on the medication container when the medication has a shortened expiration date once opened . 15. The Nursing Center should destroy or return all discontinued, outdated/expired, or deteriorated drugs or biological's in accordance with Pharmacy return/destruction guidelines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During initial tour residents expressed their dissatisfaction with their dietary department and were aware of the many managerial changes in the kitchen that have affected with overall dining experience. Many expressed staff complete their orders for each meal on a tablet but it's always a surprise when they meal arrives as it does not match what they ordered. They stated the meal ticket is correct but what's on their plate is incorrect. Another resident expressed the facility was out of oatmeal for multiple days and facility staff was kind enough to purchase her oatmeal. An aide was assisting a resident with their lunch tray and saw there were items on the tray the resident would not eat. The aide explained she did not know why they put that on the resident's tray when they will not eat it. The resident confirmed that specific item was known dislike. Facility staff that wished to remain anonymous reported many of the residents will not eat the food provided by the facility due to the inconsistencies in the food quality and following their preferences. During the Resident Council meeting on 4/6/2023 at 3:00, residents were asked if they had any concerns regarding the dietary department. All 7 residents in attendance voiced their concerns regarding their meal service. They expressed the following concerns: - Their meals are normally cold upon arrival and they clarified the staff are passing their trays timely once the cart arrives to the units. - The meal ticket is correct with their meal choices, but the food delivered is incorrect. They reported the inconsistencies in their meal ticket and food received is at least 3 times a week. - They stated most days it is a surprise on what will be provided on their tray. - Once resident expressed, they only ate grilled cheese sandwiches as the other food was not appeasing. On 4/12/2023 at 9:00 AM, an interview was conducted with Dietary Manager D regarding the multiple dietary complaints received during their survey. Manager D expressed he just began at the facility last week and has been taking account of concerns expressed by residents and their families. He is aware of the cold food complaints from a few residents and is still figuring out the root cause of the cold food complaints. He was informed there were multiple complaints over the course of the survey and in resident council. He stated he was not aware of the multiple complaints but will work toward rectifying the residents' dietary concerns. Manager D reported he has been talking to residents and they have informed him they are not receiving the food they order. He explained it appears dietary staff plate the offered meal for that day and are not looking at the resident specific tickets to meet their preferences. Manager D explained they have production sheets that identify how to make the food items, the appropriate portions of food and the number of each ala cart item requested. Manager D reported the are not utilizing the tools available to their department to be successful during meal service. Resident #30: A review of Resident #30's medical record revealed an admission into the facility on 2/2/23 with diagnoses that included heart attack, diabetes (DM), heart failure, end stage renal disease(ESRD) and dependence on renal dialysis. A review of the Minimum Data Set (MDS) assessment, dated 2/9/23, revealed a Brief Interview of Mental Status (BIMS) score of 15/15 that indicated intact cognition and the Resident needed extensive assistance with bed mobility, transfers and toilet use and needed limited assistance with dressing and personal hygiene. Further review of the medical record revealed the Resident went out of the facility for dialysis treatments. On 4/4/23 at 10:49 AM, an interview was conducted with Resident #30. The Resident answered questions and conversed in conversation. The Resident was asked about the facility food. The Resident stated, The food comes cold all the time. When asked if one meal out of the day was better than others, the Resident indicated that cold food served was a problem for all the meals. The Resident was asked if they had any other issues with the food service. The Resident reported not enough food made so if you wanted some extra, there was none available and explained tater tots as an example, you get so many and that's it, if you want a couple extra, you can't get them because they don't cook any extras. The Resident expresses frustration and explained that sometimes you just want a little more. The Resident complained that when their requests are asked, they do not bring the correct items when the tray arrives and stated, You can order and that is great, but I don't know what she is clicking when she takes my order. Sometimes I get things that I never ordered or the tag (items ordered on the paper that comes with the meal) can be right but what I get is not what I asked for. On 4/5/23 at 12:42 PM, an observation was made of Resident #30 in her room and the lunch tray was with the Resident. When asked about the temperature of the food the Resident stated, It is warmer than usual. The meal was meat that the Resident identified as pork but reported she thought they were serving beef. The meat had gravy over top. The Resident voiced frustration with the meal and reported that she did not like gravy and indicated she remembered that she told the person taking the order that she told them no gravy and indicated the dietician was aware the Resident did not like gravy on her food. The Resident refused to eat due to the gravy on the food. A CNA came in and took the tray and indicated she would bring another one. Upon return the next tray had meat with no gravy but there was gravy on the mashed potatoes that spread out to the other foods. The Resident shook her head and indicated she would not take it because again she did not like gravy at all. Resident #36: A review of Resident #36's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included spastic hemiplegia affecting left dominant side, muscle wasting and atrophy, gastro-esophageal reflux disease, diabetes, depression, and chronic obstructive pulmonary disease. A review of the MDS assessment revealed the Resident had a BIMS score of 14/15 that indicated intact cognition and needed extensive assistance with bed mobility, dressing, toilet use and personal hygiene and was independent with eating with setup help only. On 4/5/23 at 11:09 AM, an observation was made of Resident #36 lying in bed. The Resident was interviewed and answered questions and conversed in conversation. The Resident was asked how the facility food was and the Resident indicated that the meals came warm enough most of the time but at times it was not warm enough for her preference. When asked further about food choices, the Resident indicated that staff asked what she wanted and stated, but you don't get it. They can take your order but then you don't get it. Resident #61: A review of Resident #61's medical record revealed an admission into the facility on 6/1/22 with diagnoses that included dementia, seizures, and chronic obstructive pulmonary disease. The medical record revealed the Resident was her own responsible party. A review of the MDS, dated [DATE], revealed a BIMS score of 12/15 that indicated moderately impaired cognition and the Resident was independent with activities of daily living and needed set-up help for eating. On 4/4/23 at 12:35 PM, an interview was conducted with Resident #61. The Resident was asked about issues that needed to be investigated during the survey. The Resident responded with complaints of food being cold when she received the meals. The Resident indicated that there was cold food for many meals and that one was not worse than another. When asked if she ate in the dining area or in her room, the Resident indicated she ate in her room. The Resident indicated that the temperature of the food was not of her preference and that she would like more variety and stated, Lunch was the same for two days in a row. Resident #178: A review of Resident #178's medical record revealed an admission into the facility on 3/28/23 with diagnoses that included idiopathic aseptic necrosis of left femur, heart failure, chronic kidney disease, and muscle wasting and atrophy. A review of the MDS, dated [DATE], revealed a BIMS score of 14/15 that indicated intact cognition and was independent with eating with setup help only. On 4/4/23 at 12:40 PM, an interview was conducted with Resident #178. The Resident answered questions and conversed in conversation. The Resident was asked if there were any concerns related to her care at the facility. The Resident responded that the care was good and that she had no issues or complaints except for the food not being right with what was ordered. The Resident was asked about the concern and the Resident indicated that she got a menu and was able to order but when the meal comes sometimes it was nothing that I ordered, and stated, It is never actually what's been ordered, and reported something was never right when the meal came and gave examples of ordering a drink and something else was on the tray, ordering one piece of bacon and one waffle, but I got 3 pieces of bacon and 2 waffles, or they don't put a fork or spoon with the tray. Based on observation, interview and record review, the facility failed to provide residents preferences for meal choices, failed to provide meals listed on the menu, failed to provide meals as ordered, and failed to keep food warm for six residents (Resident #30, Resident #36, Resident #61, Resident #71, Resident #136, and Resident #178) of 21 residents sampled, and residents who attended the Resident Council meeting held during survey, resulting in residents voicing dissatisfaction with meals, the likelihood of cold meals, and resident frustration and anger. Findings include: Record review of the facility 'Resident Food Preferences' policy dated 3/13/2023, revealed the individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representatives' consents. Policy interpretation and implementation: (3.) Nursing staff will document the resident's food and eating preferences in the care plan . Dining Observation: Resident #71: In an interview on 04/04/23 at 3:16 PM with Resident #71 revealed that the meal portions need to be bigger. Resident #71 stated that he orders a hamburger when asked by staff, and they bring the covered dish and leave, and he take the lid off and it's a grilled cheese sandwich. They come and ask us what we want for our meals and then when the meal comes it is totally not what you ordered or want, and it can be cold. Cold toasted/grilled cheese sandwiches are limp. Observation of the breakfast meal on 4/5/23 at 7:28 AM of 100/300 hallway and 400 revealed that the meal was eggs and ham, juice, oatmeal and coffee. Resident #136: In an observation and interview at bedside on 04/05/23 at 07:59 AM with non-sampled Resident #136 revealed that the resident had requested hard boiled eggs, and received the scrambled eggs he does not like. Every day he requests the hard-boiled eggs, it is on the menu, and he has not received any yet within his stay. The staff tell him they ran out of hard-boiled eggs, and he gets the steam table scrambled eggs he did not request. Observation of meal plates revealed a half slice of ham, a scoop of scrambled eggs, square piece of yellow cake/bread (not listed on the menu tickets) bowl of oatmeal. Observation of the main dining room for breakfast revealed two residents in dining room for meal. Observation and interview on 04/05/23 at 08:04 AM with Resident #28, seated in wheelchair in main dining room revealed that the Resident #28 stated he moved to the facility in 2017, been here awhile. Resident #28 stated that sometimes you don't get what you order, I don't know why. in an interview on 04/05/23 at 08:21 AM with Dietary manager (on job 3 days) D came from another long-term care facility. Dietary manager D just started this job and is getting familiar with the building. The surveyor inquired what was the yellow cake thing on breakfast trays? It was a yellow cake mix with bananas added to it, I am working in my budget, just getting familiar with the place. Record review of the facility 'Week 1' menu dated 4/2/23 through 4/8/23, revealed that on 4/5/23 Slow Roasted Pot Roast, scalloped potatoes, honey glazed carrots, chocolate chip cookie and dinner roll were the menu items for the lunch meal. Observation on 04/05/23 at 11:42 AM the lunch observation in the main dining room revealed only 4 residents present for the meal. the surveyor observed a white color meat with a light-colored gravy over the meat, sliced carrots, scalloped potatoes, cookie and a roll. Observation on 04/05/23 at 11:47 AM of lunch meal tray serves on the 500 hall revealed a white piece of meat with a light-colored gravy over it, did not look like pot roast (beef). The surveyor asked Resident #55 was seated up in wheelchair at bedside with a visitor eating her lunch meal. Resident #55 took a bite of the white colored meat and stated its pork, not beef. Resident #55 stated that this is not pot roast. Observation, and taste by surveyor on 04/05/23 at 11:59 AM of a Sample tray revealed surveyors observed a white meat with light colored gravy, sliced carrots, scalloped potatoes. Dietary Manager D into room brought meal tray ticket which stated Pot Roast he stated that is a beef dish, and this is a pork roast. On 04/05/23 at 12:00 PM a surveyor sampled food items, potatoes and carrots are cool to the taste, meat texture was soft. The surveyor could feel the heat from the plate, but the food itself was not hot. The plate feels warm, but not the food items. Record review of the facility kitchen 'Menu Substitution log' form revealed on 4/5/2023 the planned menu item was Pot Roast, substituted item was Pork Roast. Pot not ordered. In an interview on 04/05/23 at 12:08 PM with the Dietary Manager D discussion of Hard-boiled eggs that the facility does have boiled eggs in the kitchen. The facility bought a bucket of already boiled eggs for breakfast tomorrow. Record review of the Menu Substitution log revealed that the previous dietary manager who placed food order with the food supplier company last Thursday 3/30/2023, ordered pork roast, not Pot Roast (beef). In an interview on 04/12/23 at 08:50 AM with Dietary Manager D revealed that the hard-boiled eggs ordered by residents, the staff are not reading all the tickets with add on and choices. Dietary Manager D also revealed that the Pork roast- was supposed to be pot roast (beef), but the cook just is going against the flow. The surveyor asked about lunch meal on 4/11/2023 running out of pulled pork. Dietary Manager D stated that the facility ran out of the pulled pork yesterday, the cook was using the wrong scoop. The cook has been here 5 years. We must do it by the book. Production sheets that state how much to cook, what size scoops are to be used. In interviews on 04/06/23 at 11:20 AM with Resident #71 and #136 revealed that he and his roommate both received hard boiled eggs this morning as requested. He told the surveyor that you should have been here a few weeks ago and then we could have had them (hard boiled eggs) sooner. Resident #136 stated that it's like getting a mystery meal every day. We laugh at what we get, why ask us if we don't get a choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen, properly air dry mops, and accurately measure sanitizer concentrations, resulting in the potential contamination of equipment, and the potential for improper sanitization of dishware, affecting all residents who consume food from the kitchen. Findings include: On 4/4/23 at 9:37 AM, a dried spill, which appeared to have a fuzzy mold-like film, was observed in the walk-in beverage cooler under the dunnage rack. On 4/4/23 at 9:38 AM, a wet mop head was observed to be in the dietary mop sink, not stored in a position to dry and prevent harborage conditions for pests. According to the 2017 FDA Food Code Section 6-501.16 Drying Mops. After use, mops shall be placed in a position that allows them to air-dry without soiling walls, EQUIPMENT, or supplies. On 4/4/23 at 9:41 AM, used gloves and an employee beverage was observed to be stored on a shelf among clean bowls. At this time, Dietary Manager D removed the items from the shelf. During an interview on 4/4/23 at 9:43 AM, Dietary Manager D stated that they recently bought a new dish machine that uses chemicals as the sanitizing method. When prompted to test the dish machine sanitizer concentration, Dietary Manager D stated that they did not have chlorine test paper strips to determine the concentration of the dish machine. According to the 2017 FDA Food Code Section 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device. Pf On 4/4/23 at 9:45 AM, food and soil debris was observed behind the coffee machine table on the floor/wall juncture. On 4/4/23 at 9:46 AM, food debris was observed on the shelf underneath the steam table. Insulated bowls and disposable lids were stored on the same shelf. Additionally, the utensil storage bins were observed to have food debris. On 4/4/23 at 9:46 AM, two [NAME] ReadyCare thickened liquid cartons were observed to be labeled to expire on 4/3/23. Additionally, one carton of the [NAME] ReadyCare thickened liquid was observed to be open with no expiration date label. The manufacturer's label states to discard product within 7 days of opening. On 4/4/23 at 9:52 AM, food debris accumulation was observed in a pan, on top of the oven, storing cutting boards. According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (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.