**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Numbers: 2575687, 2577971, and 2580349. Based on interview and record review, the facility failed to develop and implement policies and procedures to ensure effective and appropriate communication and documentation for transfer to the hospital and failed to ensure readmission to the facility for one (#701) of three Residents reviewed for discharge rights and planning. Findings include: Review of documentation revealed three separate intakes with allegations pertaining to the facility refusing to readmit Resident #701 back to the facility after being in the hospital. Per the intake information, Resident #701 had a legal Guardian, was a long-term Resident of the facility, and was not provided with a bed-hold policy and/or eviction notice prior to being transferred to the hospital. An interview was completed with Resident #701's Guardian Representative Witness A on 8/12/25 at 10:38 AM. Witness A was queried regarding Resident #701's transfer to the hospital on 7/22/25 and revealed they received a phone call from the facility Administrator the day after Resident #701 had been sent to the hospital. When asked why they were not informed prior to the Resident being transferred, Witness A stated, They often forget to call. It is what it is. Witness A added that the facility did not call their cell phone or their office and did not leave a message. When queried what the Administrator told them when they called, Witness A replied, (The Administrator) said (Resident #701) was petitioned and (the hospital) decided they were not going to keep (Resident #701) and sent them back (to facility) but then (Resident #701) eloped. When queried why Resident #701 was petitioned and sent to the hospital, Witness A responded they were told that (Resident #701) was aggressive and wouldn't get off the elevator. Witness A then stated, I think (Resident #701) had some aggression and I don't know if they were trying to leave or something but it didn't seem like something that was really petition-able but I did not argue with them (facility staff). Witness A revealed the hospital evaluated Resident #701 and determined the Resident did not need inpatient mental health treatment and discharged them back to the facility via a transportation van. Witness A stated, (Resident #701) got mad and out (of the transport van) in the middle of [NAME]. When asked what happened after Resident #701 got out of the back of the van, Witness A stated, (Resident #701) went missing. Witness A continued, They (Administrator) called me to tell me (the Resident) was missing but that it wasn't their fault because they discharged (Resident #701) and that was the (transport companies) fault. Witness A verbalized they were only concerned with finding the Resident and bringing them back to the facility. When queried what happened, Witness A stated, So like 12 hours later, (Resident #701) was found on the side of the road with a crack pipe, passed out. With further inquiry, Witness A stated, The Administrator called me and said they found (Resident #701) and the police wanted them to just take (the Resident) back to the facility. Witness A verbalized they told the Administrator they wanted the Resident to go to the hospital be checked out and that Resident #701 could return to the facility after that. Witness A stated the Administrator responded, We discharged (Resident #701) and Witness A said they told the Administrator, I understand but, in the morning, you can do a readmit and (the Administrator) said we'll get (the Resident) to the hospital to be checked out. Witness A verbalized they did not know what the concern was as the Administrator agreed Resident #701 should be evaluated at the hospital. When asked about the Administrator telling them Resident #701 had been discharged , Witness A responded that they understood that to mean that the Resident was discharged from the computer when they were sent to the hospital and would need to be readmitted which is difficult to do during the night shift. When queried why Resident #701 did not return to the facility, Witness A revealed Resident #701 was evaluated in the Hospital ER and medically cleared to return to the facility but when the hospital called the facility to send the Resident back, the facility informed the hospital they were not taking (Resident #701) back. When queried why the facility would not take Resident #701 back, Witness A revealed they contacted the facility and the facility refused to take (Resident #701) back. Witness A verbalized they told the facility staff they were dumping (Resident #701) and they said that was not what they were doing. Witness A continued, I said (Resident #701) doesn't have a place to do and lives with you guys. Witness A stated they told the facility that not taking Resident #701 back did not seem right. When asked how the facility staff responded, Witness A verbalized the Director of Nursing (DON) told them that the facility discharged (Resident #701) to the hospital and we (guardian) were okay with that. Witness A reiterated they were not notified of the Resident's transfer and specified they were fine with the Resident going to the hospital ER for treatment not as a new placement. Witness A said they told the DON, It wasn't like you discharged (Resident #701) to the emergency room forever. That's not an appropriate discharge. When asked, Witness A revealed Resident #701 ended up being in the hospital for several days without a medical reason to be there because the facility would not readmit them and the hospital had to find a different long-term care facility for the Resident to go. Witness A stated, Now (Resident #701) is down in Detroit and revealed Detroit was far from their home and family as they were from [NAME]. A list of residents who were sent to the hospital and did not return was requested from the facility Administrator and Director of Nursing (DON) on 8/12/25 at 11:00 AM. An interview a review of the list of discharged Residents who did not return to the facility was completed with the Administrator on 8/12/25 at 1:30 PM. When queried regarding the disposition of the transferred Residents on the list, the Administrator stated, I can tell you the only one who we did not take back was (Resident #701) because they were discharged . Record review revealed Resident #701 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease and schizoaffective disorder: bipolar type. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, was independent with ambulation using a wheelchair or walker, and displayed no behaviors. Review of Resident #701's Census documentation detailed the Resident was discharged on 7/22/25 and did not return. However, the MDS assessment dated [DATE] specified discharge with return anticipated. Further review of Resident #701's Electronic Medical Record (EMR) revealed the Resident had a court appointed full legal guardian. Review of progress note documentation in Resident #701's EMR revealed the following: - 7/22/25 at 9:30 AM: Psychiatry Follow up. When this provider arrived to the facility today police were at the facility for this patient and EMS were on their way. The patient was in the process of being PIT (petitioned)/Certed (certified)by the social worker and medical director for a psych eval at (Hospital). Apparently, staff reported the patient was not feeling well this morning and when medical PA (Physician Assistant) arrived at the floor to evaluate. (Resident #701) was on the elevator; when they attempted to redirect (Resident) off the elevator they would not leave. When (Medical PA) asked if (Resident) was feeling weak or lethargic they started to jump around and play box to show was feeling okay however then (Resident #701) stated I will F all of you up. At that point (Resident #701) began to become more aggressive towards staff when they tried to redirect and encourage them to leave the elevator. Apparently, (Resident #701) also made several delusional statements towards staff, such as stating that was a white man. (Resident) is African American. referred to (themselves) as a white police officer and as an RN (Registered Nurse). The patient was in a very delusional and agitated state. This provider met with (Resident #701) on way to the ambulance when the police officer was present to talk with them for a bit and to make sure they stayed calm. (Resident #701) stated had meatballs for dinner last night and it made them very jumpy and could not sleep and has just felt out of sorts since that. After (Resident #701) left via EMS. provider called the charge nurse in the ER . talked at length regarding the medication regimen, patient's noncompliance, patient's past and current delusions. As well as aggression, and aggression being new as patient has a history of delusions however not normally aggressive. Explained that the plan would be to take patient off of Risperdal (atypical antipsychotic medication) . start on paliperidone long-acting injection (Invega - atypical antipsychotic medication) . Later in the afternoon, a social worker. called from the behavioral care team (at hospital) . explained that (Resident #701) had been calm the whole afternoon while in the hospital and (hospital behavioral health services) felt that Rexulti (atypical antipsychotic medication) by mouth would be appropriate for (Resident #701). due to a diagnosis of Alzheimer's, regardless of his schizophrenia. - 7/22/25 at 10:00 AM: Nurses Notes. DON was called to 3rd floor to speak with (Resident #701). Upon arrival, (Resident #701) was on the elevator. stated, ‘I am going home to Oklahoma. I have a house there and I don't belong in this State Run Hospital. has intermittently been refusing mental health medications. Managing PA and Psych NP aware. exhibiting flight of ideas today. Multiple different staff attempted multiple times to redirect and encourage (Resident #701) to leave the elevator. (Resident #701) replied I am never leaving this elevator unless you call the police and arrest me. Physician and PA attempted on 2 separate times to intervene and redirect. Police arrived and were able to successfully get (Resident #701) off the elevator and into the ambulance. He was PIT/Certed per Dr Cherry for psych eval. Sent to (Hospital). -7/22/25 at 6:50 PM: Nurses Notes. Approx 6:50 pm, ambulance service called regarding resident stating res left out of ambulance and started walking. They followed (Resident #701) while on phone with this facility and while waiting for police. They somehow lost resident when police arrived. Police stated there was nothing they could do without resident being petitioned. Meanwhile nursing updating administrator of situation. Resident's family was called and informed. - 7/22/25 at 7:54 PM: Social Services Note. Resident was attempting to leave assigned floor, and when staff and provider attempted to redirect back agitated and swung at the provider. Resident appeared very delusional. When Police arrived, (Resident) told the police was waiting for the police and did not believe that was actually the police. Resident exhibited paranoia. PCP completed Clinical Cert. SW completed Petition for Mental Health Evaluation. Resident was petitioned to (hospital) for psych eval. - 7/23/25: Health Care Provider Note Date of Service: 7/23/25. Follow up. Patient . being seen today for increased behaviors. Patient was upset this AM complaining of an internal chill and is shaking upper torso like. shivering ever since he ate the meatballs for dinner last night. Patient admits to increased agitation and is exit seeking. walking around the unit with a bag packed, stating. is leaving and going home. Patient is arguing with nursing staff this morning and will not get off of the elevator to be redirected. [NAME] police contacted the patient was petitioned out by SW (Social Worker), MD today. Patient willingly went with [NAME] police to [NAME] for further management of symptoms after arguing for extended period of time with staff and police. - 7/29/25 at 8:00 AM: Health Care Provider Encounter. Date of Service: 7/29/25. Visit Type: Others. After being hospitalized with mental illness, patient was being transported back to (facility), via the transportation service, being ran (sic) from the providers after exited from the automobile. guardian was contacted. was later found by the police, then transported back to the hospital. Review of Assessment/Evaluation documentation in Resident #701's EMR revealed the Resident did not have a change in condition, transfer and/or discharge assessment completed prior to being transferred to the hospital ER on [DATE]. A care plan entitled, (Resident #701) has a potential for verbal aggression yelling/screaming and become combative. R/T (Related To): Dx (diagnoses): Schizophrenia, Manic Episode without Psychotic Symptoms, Delusional Disorders, Schizoaffective Disorder, Bipolar Type. observed washing my clothes in my room per my preference. will refuse to shower at times. often say I want to go home and when I am told I have a guardian who makes my decisions, I get agitated and do not like this answer and become argumentative . at times is not able to be redirected. had a verbal altercation with a fellow resident. (Initiated: 10/27/22; Revised: 6/27/25) was active at the time Resident #701 was transferred to the hospital emergency room. The care plan included the interventions:- Anticipate and meet needs (Initiated: 10/27/22; Revised: 1/11/23)- Avoid changes in environment and confrontation (Initiated: 10/27/22)- Document behaviors, and resident response to interventions (Initiated: 10/27/22)- Observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes (Initiated: 10/27/22)- Offer reassurance, support, redirections and diversionary activities as needed (Initiated: 10/27/22)- Provide gentle redirection (Initiated: 10/27/22) A second care plan entitled, (Resident #701) requires 24-hour care/LTC placement at this time related to (diagnosis/condition). (sic) Resident/family/legal decision maker has verbalized acceptance of plan to remain in the facility (Initiated: 12/2/21; Revised: 3/14/22) Review of Resident #701's Documentation Survey Report for July 2025 revealed the only documented behavior demonstrated by the Resident was rejection of care during the day shit on 7/5/25. A review of the scanned documentation section in Resident #701's EMR revealed no documentation that a bed hold policy was provided the Resident and/or guardian. The following was noted in the scanned documentation section of Resident #701's EMR:- Petition for Mental Health Treatment form dated 7/22/25. The Petition form was completed by SW B and specified Resident #701 was experiencing Paranoia, delusions and they were requesting a combination of hospitalization and assisted outpatient treatment.- Report on Examination and Clinical Certificate form completed by Physician C. The form specified Physician C spent 15 minutes with Resident #701 on 7/22/25 beginning at 10:05 AM and determined they required treatment and hospitalization. The Clinical Certificate Facts in Support detailed, Patient has a history of schizophrenia and delusional disorders. Patient is delusional and not in touch with reality.On 8/12/25 at 3:25 PM, an interview was completed with Nurse G. When queried if they were working when Resident #701 was transferred to the hospital on 7/22/25, Nurse G revealed they did not recall. When asked about Resident #701, Nurse G revealed the Resident was typically pleasant, did not always want to take their pills and would walk around all the time. When asked why Resident #701 did not return from the hospital when they went on 7/22/25, Nurse G revealed they did not know. An interview was conducted with Nurse H on 8/12/25 at 3:30 PM. When queried regarding Resident #701, Nurse H verbalized the Resident was never mean but wanted to do their own thing. When asked why Resident #701 did not return from the hospital when they went on 7/22/25, Nurse H was unable to provide a reason.An interview was completed with CNA J, CNA K and CNA I on 8/12/25 at 3:40 PM. When queried regarding Resident #701, all three CNA staff verbalized the Resident was nice, pleasant, and liked to walk around the facility. An interview with Transportation Company Staff D was completed on 8/13/25 at 11:50 AM. When queried regarding Resident #701, Staff D confirmed their company provided non-emergency transport from the hospital to the facility in a wheelchair can on 7/22/25. When asked what happened, Staff D verbalized the Resident exited the van and the police were notified. Staff D revealed there was nothing else in the record due to being a wheelchair transport. An interview was conducted with Social Worker (SW) E on 8/13/25 at 3:20 PM. When queried regarding Resident #701, SW E replied, (Resident #701) was here a couple of years, had a guardian, and was open to psych services. When queried regarding behaviors, SW E responded that the Resident could have behaviors and delusions. SW E was asked if the Resident was in the facility for long term care and replied they were and that they had a guardian. SW E stated, (Resident #701) didn't understand that they had a guardian and would say they didn't. When asked what happened on 7/22/25 when Resident #701 was transferred to the hospital, SW E revealed they were the Social Services staff member assigned to Resident #701 but were not working the day the Resident was transferred to the hospital. When queried why the Resident did not return from the hospital, SW E stated, From my understanding, the facility did not deny them coming back. When asked if Resident #701 had a planned discharge, SW E stated, No, (Resident #701) was long term. There was no plan for them to go anywhere. When queried if the Resident was a good fit for the facility and was able to receive all the care they needed, SW E replied, Yeah, I would say they were. On 8/13/25 at 3:41 PM, an interview was completed with SW B. When queried what occurred on 7/22/25 when Resident #701 was transferred to the hospital, SW B replied, (Physician C) and the NP (Nurse Practitioner) were there. (Resident #701) was very delusional and wouldn't get off the elevator. They called me to come up to fill out a petition for a psych eval. SW B revealed the police came and were able to convince the Resident to go to the hospital. When queried why it was a concern that the Resident would not get off the elevator, SW B replied, (Resident #701) had a wander guard on and the elevator won't move with the alarm going off. SW B was then asked if Resident #701 said what they wanted and replied, (Resident #701) said they didn't want to be here and has been here to long. When asked what interventions were attempted prior to calling the police, SW B indicated several staff had attempted to get Resident #701 to get out of the elevator. SW B then stated, Our psych NP was here, and they spoke to the hospital a few times and recommended to the ER that (Resident #701) have an injection to calm behaviors. When asked why Resident #701 did not return to the facility, SW B replied, There was no reason that (Resident #701) couldn't come back when we sent them out. An interview was conducted with the DON on 8/13/25 at 3:52 PM. When queried why Resident #701 did not return to the facility from the hospital ER, the DON replied, (Resident #701) didn't want to come back. When queried what the Resident's legal guardian wanted, as the Resident was unable to make their own decisions, an explanation was not provided. The DON was asked to explain what occurred and stated, We sent (Resident #701) to (hospital ER) for eval. (Resident #701) left the ER and (the hospital ER) put (Resident #701) in a wheelchair van. (Resident #701) got out of the van and walk to the area of [NAME] they wanted to be. With further inquiry, the DON stated, Found (Resident #701) a day or two later and then they went back (Hospital ER). The DON continued, (Resident #701) wanted to go live with a friend. A staff member saw him lying under a tree. The DON was asked if the Hospital contacted them for the Resident to return after the Resident was found laying under a tree in [NAME] and confirmed they had. When asked why the facility did not readmit the Resident, the DON stated, We meet as a team and decided that it was not our responsibility to take (Resident #701) back. When queried if a nursing assessment/evaluation transfer form should be completed when a Resident is transferred to the hospital, the DON replied, Should be. A review of Resident #701's EMR was completed with the DON and the DON confirmed a transfer assessment/evaluation form was not completed. When asked the reason the documentation was not completed, an explanation was not provided. When queried if a bed hold form was completed and provided to Resident #701 and their Guardian, the DON stated, I don't know that one was done. When asked if Resident #701's guardian was notified prior to the transfer, the DON verbalized there was no documentation of communication with the Resident's legal guardian prior to and/or immediately following the transfer to the hospital ER. When queried how facility bed hold information is communicated to the Resident/guardian, the DON stated, I don't know. Let me review the policy. When queried Resident #701 had personal items at the facility and if the items were still at the facility, the DON replied, I don't know. A copy of the facility policy/procedure related to transfers and bed holds were requested at this time. An interview was completed with the Administrator and DON on 8/14/25 at 10:41 AM. The timeline of events involving Resident #701's transfer was discussed. Per the Administrator and DON, Resident #701 left the building on 7/22/25 at 10:38 AM. On 7/22/25 at 6:50 PM, the transportation company called to notify the facility that the Resident had exited their vehicle. Resident #701's guardian was notified on 7/22/25 at 7:22 PM that the Resident was missing and facility staff looked for the Resident until approximately 11:00 PM and included homeless shelters. Facility staff continued to look for the Resident on 7/23/25. Facility Staff M found Resident #701 on 7/23/25 at 7:58 PM on King Street in downtown [NAME] under a tree and the Resident was sent back to the Hospital ER at this time. The Administrator and DON were asked when the facility was contacted by the Hospital ER related to readmitting Resident #701 and the Administrator verbalized the referral was received from the hospital on 7/24/25. When asked if the Hospital contacted them prior to 7/24/25, the Administrator revealed the hospital services called them on 7/23/24. The Administrator exited the room. The DON was asked if the Hospital contacted the facility after 7/24/25 and stated, On 7/25/25, (hospital) discharge planning called, and I told them no because I got that directive from Regional. The DON then revealed they had checked and Resident #701 did still have personal items at the facility. An interview was attempted to be completed with Hospital SW F on 8/14/25 at 12:35 PM. SW F was not currently working and a message with return phone number was left. On 8/15/25 at 8:53 AM, a return phone call was received from Hospital SW F and an interview was completed. When queried regarding Resident #701, SW F stated, (Resident #701) was seen the day before in ER for a psych eval. SW F revealed the Resident was evaluated and it was determined they did not need inpatient psychiatric treatment and were discharged back to the facility on 7/22/25 at 6:37 PM via a medical transportation company in a van. When asked what happened after the Resident left the hospital, SW F stated, At a stop light (Resident #701) got out of the (transport) van, went and did drugs and came back (to the ER) that night. SW F was asked when Resident #701 returned to the ER and stated, 7/23/25 at 9:30 PM. SW F verbalized the Resident was medically cleared to return to the facility on 7/23/25. SW F stated, We (hospital) tried to send (Resident #701) back (to the facility) on 7/23/25 and they would not take (the Resident) back because they had to wait to talk to the DON. SW F was queried if they knew who was contacted at the facility and the time and replied, At 11:41 PM (on 7/23/25), spoke to the (Administrator). (The Administrator) said (Resident #701) was discharged from the facility on 7/22/24 per documentation. SW F revealed they returned to work on 7/24/25 and tried to discharge Resident #701 back to the facility again. SW F stated, I spoke to (Resident #701's) guardian and (the facility) were trying to not take (the Resident) back. When asked if they spoke to anyone at the facility, SW F revealed they spoke to the DON and stated, (Facility DON) said (Resident #701) was discharged to (Hospital ER), and they were not taking (the Resident) back. SW F continued, They didn't provide 24-hour or 30 day discharge notice and you can't discharge a long-term patient to the ER. When queried if Resident #701 wanted to return to the facility, SW F stated, (Resident #701) lived there and had a legal guardian who wanted them returned there. SW F revealed Resident #701 had to be held in the hospital for several days before an appropriate alternate placement was able to be found. Review of Resident #701's hospital documentation revealed the following:- 7/22/25 at 10:49 AM: ED Provider Note. Psych was consulted, and they recommended no inpatient psych admission, and as soon as patient is medically clear can de-certify and discharge. determined medically clear. safe for discharge home.- 7/23/25 9:17 PM: ED Provider Note. At-risk Social Status. discharged yesterday, staff from facility stated was supposed to be brought to them yesterday by (transport company) after discharge, patient ran out of (transport) van and has been missing. [NAME] PD had a [NAME] (Be on Lookout) for them from the facility and dropped (Resident #701) off here today after finding them on the side of the road with a crack pipe. ED Course.:. Social work service was consulted regarding disposition recommendations. They contacted (facility) who states that patient is prohibited from returning to the facility at this time due to their behavior. Review of facility provided policy/procedure entitled Discharge Planning (Last Revised: 9/2023) revealed, The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of the resident to be an active partner in their care. 4. The discharge plan will be discussed with the resident and/or the resident representative.Review of facility policy/procedure entitled, Notification of Change (Last Revised: 2/14/24) revealed, The facility must inform the resident. and notify, consistent with his or her authority, the resident representative (s) when there is a change in status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI00153289 and MI00153294. Based on interview and record review, the facility failed to provide supervision for three residents (R5, R6, R7) of three residents reviewed for supervision, resulting in multiple resident to resident altercations. Findings include: Resident #5: R5 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include Huntington's disease, adjustment disorder with anxiety, cognitive communication deficit and schizoaffective disorder, bipolar type. R5 has a brief interview for mental status (BIMS) score of 8, indicating mild cognitive impairment. Resident #6: R6 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include alcoholic cirrhosis of liver with ascites, adjustment disorder with depressed mood, chronic diastolic heart failure and pulmonary hypertension. R6 has a BIMS of 0, indicating severe cognitive impairment. Resident #7: R7 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include unspecified disorder of adult personality and behavior, adjustment disorder with depressed mood, bilateral above the knee amputations and anxiety disorder. R7 has a BIMS of 15, indicating they are cognitively intact. Record review of an Incident and Accident Investigation Form and progress note revealed that on 05/16/2025 at around 4:47pm, R5 and R7 were involved in a resident to resident altercation. The facility conducted a review of their camera system to aid the investigation. R7 was sitting at the front reception desk and signing back in to the building. R5 was observed to be walking towards the front door, at this time the receptionist approached R5 and redirected him away from the front door. R7 appeared to say something to R5 and that upset him, and he pushed the wheelchair and right shoulder of R7. R7 hit R5 on the arm and R5 walked away until they were escorted by the Director of Nursing (DON). R6 was present during There were no injuries noted during this interaction. R5 was directed out on to the back patio placed on every 15-minute checks. Record review of an Incident and Accident Investigation Form and progress note revealed that on 05/16/2025 at around 5:30pm, R5 and R6 were involved in a resident-to-resident altercation. The facility conducted a review of their camera system to aid the investigation. R5 re-entered the building from the back patio and walked up and down the hall and then eventually to the dayroom. R6 was observed sitting in the hallway and then got up and went to the dayroom. R5 exited the dayroom appearing upset and knocked over a mop bucket. The facility conducted an interview with a resident who observed the incident, and he stated that R5 swung at R6 multiple times and hit him once in the face. R6 stated that he approached R5 to scold him for the incident prior to this one where he hit R7 by the front door. R6 stated he stood up eye to eye with R5 and that R5 clocked him in the face four times, R6 stated he sat back down and went back outside. R5 was placed on 1:1 monitoring, R6 had a skin assessment completed and it revealed a small abrasion near his left eye. On 06/04/25 an interview was conducted with the DON. The DON was asked about R5. The DON stated that R5 has Huntington's disease and schizoaffective disorder, he is truly good if he is left alone. On the day in question, he was trying to go out the front door and the receptionist was handling it, R7 started shaking her finger at him and scolding him, this upset him and he open hand shoved her in the right shoulder. R7 then hit him on the arm. The DON was asked what intervention was put in place at the time of the incident to prevent further incidents. We put R5 on 15-minute checks for 72hours. The DON was asked about the second resident altercation that occurred after that. The DON stated that after the second incident that occurred, R5 was placed on 1:1 monitoring for 72 hours after that he had an escalation of behavior and was placed on 1:1 monitoring full time. The DON was asked about the mood of R5 during the 15-minute checks after the first incident. The DON stated that during the first three 15-minute checks R5 was out on the patio with the activities director and then R5 came back in the building and had an incident with R6. Was the activity director aware that R5 was on 15-minute checks and why R5 was on them. The DON stated, yes, the activity director was aware he was on 15-minute checks. We were aware he was coming back in the building on his own. The DON was asked why someone didn't accompany R5 back in the building after he had just had an incident with R7. The DON stated that the 15-minute checks were more to run interference to stop other residents from provoking R5. The DON was asked if someone should have been with R5 once he came back in the building. The DON stated we were in between 15-minute checks so someone wouldn't have necessarily been with R5 at the time. Documentation of the 15-minute checks were requested from the DON. The DON stated that there is no documentation of the 15-minute checks in the EMR. On 06/04/25 an interview was conducted with Activity Director A. Activity Director A was asked if they knew why R5 was on every 15-minute checks. Activity Director A stated, I was not aware that R5 had an incident prior to him coming to the back patio, I told the DON that I didn't witness anything. But I came to the front reception area and took him out of the situation and out to the barbecue on the back patio. Activity Director A stated, when R5 was done at the barbecue I escorted him back into the building, I think R5 wanted something to drink, and I went and got that for him. When I returned with the drink, I was made aware that another incident had occurred with a resident. I have never seen him act out like that, I have seen him be frustrated in the past and knock stuff over. On 06/04/25 an interview was conducted with Receptionist B. Receptionist B was asked about the incident that occurred by the front door. Receptionist B stated that R5 was trying to go out the front door, I redirected him to come back in, he was mad at me at this time. R6 and R7 were sitting at the front desk, and I think one of them said something to R5. R5 then hit R7and she hit R5 back. Receptionist B stated, I'm thinking that R5 might have been mad that he couldn't go outside. R6 and R7 could have been talking together but R5 might have thought they were saying something to him. R7 knows better to say anything to provoke him, she is always encouraging him and being nice. When I redirected R5 from the door we had to walk in between R6 and R7 to get out of the area. That could've been why R5 thought R6 and R7 were saying something to him. On 06/04/25 an interview was conducted with Social Worker (SW) C. SW C was asked to tell me about R5 and his behavior in the facility. SW C stated that R5 is a very nice person, he has poor impulse control due to his Huntington's and psych diagnosis. When they did his Level 2, we were going to see if he could have specialized care, but they couldn't determine which diagnosis is more prevalent. SW C stated R5 can get upset, he does not like to be told no. He loves pop and will ask you for pop constantly and he enjoys watching Nascar. Does R5 have a history of physical aggression without being provoked? There was an incident on 9/10/24, where R5 and R7 had an altercation when R7 attempted to redirect him from eating out of the garbage can, R5 hit her on the shoulder at that time. SW C was asked what kind of services does R5 receive here. SW C stated R5 sees Behavioral Care Solutions (BCS), which includes the nurse practitioner and the social worker. SW C stated that R5 also has a case manager that visits him from the Department of Health and Human Services (DHHS). SW C was asked, if based on R5's history of past incidents, do you think someone should have been with him when he came back in the building from the barbecue after his previous incident? SW C stated, yes, someone should have been with him. SW C was asked what their role is during investigations. SW C stated, I follow up with the residents, follow up with psych and update care plans to address the changes. On 06/03/25, R5 was observed resting in bed, being monitored 1:1 by staff in the room. Attempts were made to interview R5, but he would not respond. An interview was conducted with Dietary Aide D, who was providing 1:1 care at the time. Dietary Aide D was asked if R5 leaves his room. Dietary Aide D stated, yes, when he does, I walk with him. He mostly just walks around. He doesn't really interact with any other residents and will sit in the lobby area. Dietary Aide D was asked if R5 seems confused when he talks. No, he seems pretty good to me. An interview was attempted with R6 to discuss the incidents and R6 refused to be interviewed. An interview was conducted with R7. R7 was asked about the altercation with R5. R7 stated that R5 thought I was talking to him, and he hauled off and hit me in the breast. R7 stated she was yelling at another resident (R6). R7 was asked if they thought R5 was purposeful in hitting her. R7 stated, yes, I believe it was, he knows better than that and he knows exactly what he is doing. He is much smarter than people give him credit for. When he sees me, he always calls me by name, he is more aware than they think. I have not had any issues with R5 since the incident. I told the DON that I would not interact with R5 for a while. R7 stated prior to this R5 elbowed me really hard in the right collar bone/shoulder area. R7 stated this happened a few months prior but could not recall when. I told the facility, and I don't think they did anything about. I believe they actually just threw the information out. Record review of the policy titled, Abuse Prohibition, revealed: Procedure: D. Identification: 5. The facility supervisory staff will integrate into the supervisory process monitoring the behavior of staff members and guest/residents that are indicative of high stress levels that lead to abuse/neglect or may escalate a continuum of aggression. F. Protection of Guests/Residents during the Investigation. 4. f. Accompany the guest/resident to an area away from the environment in which the behavior has occurred. Use interventions identified by the interdisciplinary team to calm the guest/resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00149971. Based on observation, interview and record review, the facility failed to address hospital discharge recommendations for blood glucose monitoring and insulin administration and follow parameters for insulin administration for two residents (Residents #1 and Resident #3) of three residents reviewed for glucose monitoring. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on [DATE] and re-admission on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with ketoacidosis. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 11/15 that indicated moderate cognitive impairment. The Resident went out of the facility for dialysis treatments. On 3/27/25 at 1:01 PM, an observation was made of Resident #1 dressed and sitting on the side of the bed with their lunch tray on the overbed table. The Resident had Visitor C seated in a chair by the Resident. The Resident answered questions and engaged in limited conversation; the Visitor assisted the Resident with answers. The Resident reported not going to dialysis today but had gone yesterday. The Resident was asked if they ate breakfast at dialysis. The Resident stated, I usually get it when I come back, don't eat at dialysis. When asked about blood sugar monitoring, the Resident reported that it goes up and down. On 3/27/25 at 1:10 PM, an interview was conducted with Resident #1's Nurse D. The Nurse was asked if the resident received insulin with her breakfast yesterday. The Nurse stated, No she was gone to dialysis. The Nurse was asked if the Resident had a blood sugar check after returning from dialysis and before eating breakfast, and the Nurse reported that she receives insulin when her blood sugar is high. The Medication Administration Record (MAR) was reviewed with the Nurse for 3/26/25 with documentation on the MAR of 5 that indicated hold see nurses note. The nurses note revealed, dialysis, and the Resident did not get the blood sugar checked or insulin given as per sliding scale. The Nurse reported that the Resident does come back and either eats a sack lunch or will get a tray and stated, Eats either her sack or the tray, it's either/or. A review of the orders revealed the Resident had a recent hospitalization where the Resident was sent out to the hospital from dialysis. The Progress Note dated 2/10/25 at 12:50 PM revealed, Dialysis called and they sent patient to hospital for ams (altered mental status) and bs (blood sugar) of over 900. The Resident was re-admitted to the facility on [DATE]. A review of Resident #1's discharge hospital records of the Discharge Summary Notes revealed .Labs showed hyperglycemia with BG (blood glucose) >920 and acidosis PH 7.19 with pseudohyponatremia of 122 and AG of 19 with lactic acid of 4.2. She was started on insulin drip and fluid per DKA protocol . DKA (diabetic ketoacidosis-a complication of diabetes that can be life-threatening when there is a lack of insulin causing blood to become acidic). A review of Resident #1's discharge hospital records revealed medication list that had the directions, START taking these medications: insulin aspart U-100 100 unit/mL (milliliter) vial, Commonly known as: Novolog. Inject 0-8 Units into the skin 3 (three) times daily before meals. A review of Resident #1's discharge hospital records revealed a FAX Cover Sheet dated 2/20/25 with a Medication List: START taking these medications insulin aspart . Inject 0-8 Units into the skin 3 (three) times daily before meals: 100-140= 0 Units Subcutaneous; 141-200= 1 Unit Subcutaneous; 201-250= 2 Units Subcutaneous; 251-300= 3 Units Subcutaneous; 301-350= 4 Units Subcutaneous; 351-400= 5 Units Subcutaneous. A review of the medical record revealed an order dated 3/14/25 for Insulin Aspart Subcutaneous Solution Cartridge 100 Unit/ML (Insulin Aspart). Inject as per sliding scale, three times a day before meals with the sliding scale of 100-140= 0U (unit), 141-200=1 U, 201-250=2 U, 251-300=3 U, 301-350= 4 U, 351-400=5 U. The medication was started on 3/15/25 but was not given in the morning on the Resident's dialysis days. The Resident went out to dialysis on Monday, Wednesday, Friday. Further review of the medical record revealed a lack of documentation of why the hospital discharge recommendations for medication were not followed, no progress note made that the recommendation was discussed with the doctor upon readmission. On 2/27/25 at 2:11 PM, an interview was conducted with Director of Nursing (DON) regarding Resident #1's hospitalization with treatment for DKA and the discharge orders for insulin sliding scale. The resident's return on 2/19/25 but the insulin sliding scale not ordered until 3/14/25 was reviewed with the DON. The notation on the hospital records of Physician Assistant A for 3/14/25 was reviewed. The DON was unsure why the medication orders from the hospital discharge were not followed and reviewed the medical record and revealed no documentation of why. The DON indicated that if the hospital discharge instructions were not going to be followed, there should be documentation of the rational and the nurse should document discussions with the practitioner if it had occurred. The lack of following the physician order to monitor the blood glucose and give insulin as needed per sliding scale with meals was reviewed with the DON and Nurse B who had been the interim DON prior to the DON. It was determined that the Resident ate breakfast when they returned from dialysis. The DON reported the Nurse should be checking the blood glucose and following the sliding scale for insulin after the resident returned from dialysis. It was reported that when the nurse identified the Resident was out for dialysis treatments, the glucose monitoring and sliding scale insulin would not show back up on the MAR to be given. The medication schedule for the glucose monitoring and insulin was not adjusted to accommodate the Resident's dialysis treatment schedule. On 3/28/25 at 10:37 AM, an interview was conducted with Physician Assistant (PA) A regarding Resident #1's order for blood glucose monitoring and sliding scale insulin. The hospital records were reviewed with the written note sent 3/14/25 and the PA signature. The PA reported that she had came upon a pile of paper in the office that had not been reviewed and that it could have been it that pile. The PA indicated that the medication orders should be addressed when the Resident came back form the hospital. When asked if the recommendations were not going to be followed, the PA indicated that there should be documented rational why it will not be followed. A review of facility policy titled, Diabetic Management, revised 9/22/23, revealed, . Evaluation: Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure: orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician . Blood glucose measurements are taken per the physician order . Anti-diabetic agents (insulin or oral anti-diabetic agents) are administered per physician order . Resident #3 (R3): R3 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include type 2 diabetes, anxiety, depression and alcohol abuse. On 03/28/25, record review revealed a physician's order Insulin Glargine, inject 10 units, subcutaneously two times a day for diabetes mellitus (DM). Hold for blood glucose (BG) less than 100. The start date for this order 03/09/2025. On 03/28/25, record review of the medication administration record (MAR) for March 2025 revealed that on three occasions the 10 units of insulin glargine was given outside of the parameters of administration. -03/14/25- Blood glucose was 79 and the medication was administered. -03/18/25- Blood glucose was 57 and the medication was administered. -03/22/25- Blood glucose was 71 and the medication was administered. Record review of the policy titled, Diabetic Management, revealed: Evaluation: -Orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician. Routine Care: -Blood glucose measurements are taken per the physician order. Results outside of ordered parameters are communicated to the physician immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00151298. Based on interview and record review the facility failed to update care plans and implement interventions to prevent falls for one resident (Resident #2) of three residents reviewed for incidents and accidents, resulting in repeated falls. Findings include: Resident #2 (R2): R2 is [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses that include above the knee amputation on the right leg, dementia, anemia and chronic obstructive pulmonary disease. R2 has a brief interview for mental status (BIMS) score of 5, indicating severe cognitive impairment. On 3/28/2025, a review of falls was completed for R2, it was revealed that R2 had sustained multiple falls in the facility. -On 1/5/25 at 04:03 AM, R2 was observed lying on his left side on the floor beside his bed. The fall was unwitnessed, and the care plan intervention was to perform a three-day sleep study. Results of the sleep study were unable to be located in the electronic medical record. -On 1/31/25 at 11:30 PM, R2 was observed holding onto the bed post and sliding off the left side of the bed, the care plan was not updated with a new intervention. -On 2/28/25 at 11:30 AM, R2 was found lying on the floor next to the bed. The care plan was not updated after the fall. -On 2/28/25 at 05:30 PM, R2 was observed sitting on his bottom next to his bed with his back up against the other bed (bed 2) in the room. The care plan was updated to perform checks on R2 every 15 minutes. Documentation of the 15-minute checks could not be located in the electronic medical record. -On 3/3/25 at 02:15 AM, R2 was observed on the floor, laying on his left side. The care plan was not updated in the electronic medical record. On 03/28/25 an interview was conducted with the Director of Nursing (DON). The DON was asked what the expectation is with updating care plan after falls. The DON stated, this will require education for the nursing staff, at the time of the fall I expect the nurse to put something (an intervention) in right away, the next day we can review the falls with the team and see if we can come up with an intervention based on what the root cause of the fall is. Going forward these incident forms will be filed in one spot so we can find them and ensure they get updated. The electronic medical record has a nice system in place to keep track of incidents and we plan to fully use that going forward. The DON was asked if they think the interventions should be meaningful and pertaining the fall. The DON stated, yes, the interventions should be meaningful and relevant to the fall. Review of the policy titled, Incidents and Accidents for Guests/Residents or Visitors, revealed: Policy: Incidents or accidents involving a guest/resident or visitor will be documented and reported to meet the regulatory requirements. The administrator and the director of nursing will be notified as outlined in this policy. Procedure: 7. For incident and accidents involving guests/residents, pertinent clinical information and observations must be recorded in the medical record. Documentation: 5. Record the relevant facts regarding the guest/resident in the medical record, e.g. where guest/resident was found, evaluation conducted, care provided, follow-up care provided, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Number MI00149049. Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment to ensure that resident rooms were clean, uncluttered, and in good repair for 3 Resident's #30, #39, #115 including two resident rooms (103 and 119) , resulting in an unclean physical environment. FACILITY Environment: On 1/29/2025 at 10:48 AM, room [ROOM NUMBER]'s bathroom was observed to be very soiled. The white toilet seat had many smears of brown dirt on it and the floor was covered in discolored brown stains near the toilet. Resident #39 was asked if he used his bathroom and he said he did; he said he tried to provide his own care, as much as he could. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #39 was admitted to the facility on [DATE] with a tracheostomy, a feeding tube, heart disease, COPD, anxiety, depression, GERD, arthritis and venous insufficiency. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident was independent with care. On 1/29/2025 11:42 AM, room [ROOM NUMBER] was observed to be very cluttered on the side near the window. There were many items, including bags, and boxes on the floor, mainly on the bedside near the window. There was no clear path on that side of the bed. Resident #115 was observed lying in bed. He did not want to answer questions. A record review of the Face sheet and MDS assessment indicated Resident #115 was admitted to the facility on [DATE] with diagnoses: Heart failure, cirrhosis of Liver, depression, malnutrition, hypothyroidism and lymphedema. The MDS assessment dated [DATE] with full cognitive abilities with a BIMS score of 14/15 and the resident needed some assistance with care. A review of the Care Plans for Resident #115 identified the following: (Resident #115) is at risk for fall related injury and falls (related to): diuretic medications, history of falls . date created 5/15/2024 and revised 8/14/2024 with Interventions: Keep the resident's environment as safe as possible with : even floors free from spills and /or clutter . date initiated 5/15/2024. On 1/31/2025 at 2:10 PM, the Environmental Services Manager J was interviewed about the soiled and cluttered rooms, he said he was new at the facility and would look into it. Resident #81: On 1/29/25 at 11:28 AM, an interview was conducted with Resident #81 who was in bed in their room. The Resident complained that the sink in the room would overflow and that it did not drain well. The Resident reported that their roommate would use the sink, or staff would put towels in the sink to get them wet, run the water to get it warm enough and then the sink would overflow. An observation was made of the sink turned to flowing and the sink basin filled with the water not going down timely before the water started to get warm. The Resident stated, before it gets warm, the sink is overflowing. Resident #97: A review of Resident #97's medical record revealed an admission into the facility on 9/26/24 with diagnoses that included anxiety disorder, depression, lymphedema, and open wound of lower leg. A review of the MDS revealed the Resident had intact cognition and needed substantial/maximal assistance with shower/bathing, partial/moderate assistance with personal hygiene and transfers. On 1/29/25 at 12:55 PM, an observation was made of Resident #97 sleeping in bed. The Resident did not arouse when their name was spoken. An observation was made of clutter in and around the Resident's bed area. There was a bag of pop cans positioned on the floor that was filled and overflowing. The top opening of the bag was not secured. Another bag was next to it that had a couple cans in the bag. An observation was made of multiple pop bottles under the Resident's bed. Resident #30: During initial tour on 1/29/25, Resident #30 was observed enjoying his lunch at bedside. The resident provided permission to enter his bathroom and on the floor in front of the toilet was a soiled brief with what appeared to be feces inside of the it. On the back of the toilet seat bowl was a clump of dark brown substance adhered to the toilet bowl. On 1/30/2025 at 9:05 AM, Resident #30 was observed resting in bed. His bathroom was observed again and the clump of brown, adhered substances was still on the back of the toilet seat bowl.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to review and revise care plans for 2 Residents (#39, #64) of 3 residents reviewed, including Resident #39 with a swallowing deficit, and Resident #64 who had weight loss and a change in condition, resulting in the likelihood for missed interventions in treatment and unmet needs. Finding include: Record review of the facility 'Care Planning' policy dated 6/24/2021 revealed every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessments and prepared by an interdisciplinary team who includes but not limited to; attending physician, a registered nurse who is responsible for the resident, a nurse aide, a member of food/nutrition services, the resident or resident representative, therapy staff as required and other an ancillary staff. (9.) The care plan and resident Kardex will be updated on admission, quarterly, annually and with significant changes. This includes adding new focuses, goals, and interventions and resolving ones that are no longer applicable as needed. Record review of the facility 'Standards of Nursing Practice' dated 4/11/2023 revealed the delivery of nursing care in the facility is based on a thorough evaluation of the resident to identify his or her needs. Once the resident needs are identified, a comprehensive care plan is developed to attain individualized resident goals. the care plan is implemented by the interdisciplinary team and is continually evaluated for effectiveness. the care plan is updated as necessary to meet the resident's needs. Resident #64: Observation on 01/29/25 at 9:50 AM of Resident #64 was lying in bed with breakfast meal tray on bedside table, no bites noted out of meal/foods, orange juice, milk, cereal soggy appearing. In an interview on 01/29/25 at 11:29 AM, Resident #64 stated that he had lost weight. Observed a carton of health shake on the over bed table. Resident #64 stated that his Hands are shaky and has hard time drinking the shake. Observation on 01/30/25 at 08:14 AM, Resident #64 was noted to be lying in bed with No breakfast tray in room yet. Resident #64 stated that he eats his meals in bed. Observation on 01/30/25 at 9:20 AM, Resident #64 was lying in bed with breakfast meal tray in front of resident no attempt to feed self. Resident #64 stated that his hands shake when he's eating, and no one helps him with meals. Record review of Resident #64's weight log revealed on 12/11/2024 weight 156.1 and on 1/13/2025 weight 147.5 equal a loss of 5.7% weight in 33 days. An interview and record review on 01/30/25 at 03:01 PM with Registered Dietitian (RD) F revealed Nutritional evals are quarterly every 3 months and a full nutritional assessment annually. RD F was asked about Resident #64' weight loss was recently identified at 5.6% loss his weight decrease could be affected by diuretic and anti-psych meds. Record review of Resident #64's nutritional care plan for interventions: new order for med pass twice daily started on 1/14/2025, and health shake daily started 2/21/2024. Begin weights weekly after the significant weigh. change, and prior in December 2024 was monthly. Record review of the nutritional care plan Interventions should have been added med pass and Health shakes 1220 cal and 46-gram protein daily. Assist the dining is nursing service to feed the resident intake is done by CNA's. RD F stated that Monitoring intake is done by the RD, the Resident #64 eats 0% to 25% according to his intake record. RD F stated that he did trigger Resident #64 for a significant change due to weight loss today (1/30/2025). In an interview and record review on 01/31/25 at 12:02 PM with the Registered Dietitian (RD) F record review of Resident #64's nutritional care plan noted nutritional supplement intervention on 2/20/2024, and that there were no other added interventions noted on the care plan related to the recent significant change of weight loss of 5.6% in a month. RD F reviewed the physician's orders of 1/14/2025 of Med Pass ordered by the other RD G. Record review of the nutritional care plan revealed the order for Med Pass was not placed on the care plan. Resident #64 has a Stage 4 pressure ulcer to right heel and an unstageable black eschar pressure ulcer to medial outer foot. RD F was not aware of pressure ulcers for Resident #64. Record review of Resident #64's protein intake currently is at 46 grams which is only 58% of his daily protein requirements, which is inadequate to promote healing of pressure wounds. RD F stated that Resident #64's protein needs should be 80 grams daily. Record review of documented intake is less than 75%-0% per meals. Significant change in weight loss of 5.6%. RD F will plan to re-weight Resident #64 and the if he gains weight will add med pass to 3x daily, if the resident does not gain weight, will add protein supplement Pro-stat 1x daily (Pro-stat 19 gram/ml, needs 65 grams). Resident #39: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #39 was admitted to the facility on [DATE] with a tracheostomy, a feeding tube, history of removal of his larynx, difficulty swallowing, heart disease, COPD, anxiety, depression, GERD, arthritis and venous insufficiency. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident was independent with care. On 1/29/2025 at 10:50 AM, Resident #39 was observed awake, lying in bed in his room. He whispered he had a feeding tube, and a tracheostomy. He pointed at both. The feeding tube site was dry; he said had the feeding tube for about 3 years. He said he was to receive his enteral/tube feeding 5 times a day. A record review of the January 2025 Medication Administration Record/MAR and Treatment Administration Record/TAR for Resident #39 indicated the resident received very little of the enteral nutrition. He refused it daily and would have a can one day and go several days with none. He also refused the extra water provided via the feeding tube ordered 3 times a day. He accepted water with his medication, but often refused that too. On 1/30/2025 at 3:13 PM, Registered Dietitian/RD F and RD G were interviewed about Resident #39. RD F said the resident weighed 139 lbs. on 1/24/2025. This was comparable to what he had weighed recently. He said the resident did not have an order to eat food, but he had an order for ice chips. He said the resident did not have a continuous tube feeding but was to receive 1 can of enteral/liquid nutrition via the feeding tube 5 times a day. He said this was because the resident liked to be mobile in his wheelchair in the building. The RD was asked how Resident #39 could receive almost none of the tube feeding or fluids and not lose weight or be dehydrated. From January 1st, 2025- January 30th, 2025, the resident had accepted 27 cans of tube feeding; there was a possible 148 cans for the month. The Dietitians said the resident left the building daily and he had been observed eating food orally/via mouth. A review of the Care Plans for Resident #39 identified the following: (Resident #39) has potential for Dehydration and fluid deficit related to: PEG/feeding tube present, often refuses tube feeding, date initiated 2/28/2024 and revised 12/17/2024 with Interventions that were all dated 2/28/2024. There was no mention of the resident also refusing the extra water flushes. It did not mention he received cups of ice chips. (Resident #39) requires Speech Therapy related to decline in function or to maintain/slow decline secondary to . decline in swallowing of liquids, Decline in swallowing of solids, date initiated and revised 11/14/2024 with interventions all dated 11/14/2024. On 1/31/2025 at 11:51 AM, RD F was interviewed about Resident #39. He said the resident was scheduled for a swallow evaluation on 2/13/2025 and it was ordered on 1/28/2025. Reviewed this was not mentioned on the Care Plan. Reviewed with RD F the resident's Care Plan said he required Speech Therapy but it did not say he was not receiving it. RD F said the resident was not currently receiving Speech Therapy. He also said there were progress notes indicating Resident #39 had been observed eating food, including a hamburger. The RD F said a Speech Therapist had seen the resident on 1/15/2025 and was awaiting the swallow evaluation to determine what services the resident might need as he continued to refuse enteral nutrition/tube feeding. On 1/31/2025 at 1:53 PM, Resident #39 was interviewed. He was sitting in the dayroom in his wheelchair, smiling. He was asked about refusing his enteral nutrition and said he took it sometimes and waved his hand and shook his head no. When asked if he was eating something else, he shook his head yes. When asked what he was eating, he said everything and threw his arms wide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #115: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #115 was admitted to the facility on [DATE] with diagnoses: Liver cirrhosis, heart failure, pulmonary hypertension, lymphedema, hypothyroidism, and depression. The Minimum Data Set/MDS assessment dated [DATE] revealed the resident had a full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 14/15 and performed most care per self. On 1/30/2025 at 11:42 AM, Resident #115 was observed curled up in bed, covered with a blanket, awake. He answered a few questions then said that was enough; he did not want to talk anymore. A review of the physician orders for Resident #115 identified an order Patient is to wear Life Vest at all times. Ensure spare battery is charged at all times, dated 8/15/2024. There was no further information or instructions. Per the Cleveland Clinic, dated reviewed on 5/19/2022, A LifeVest is a wearable defibrillator that can stop an abnormal heart rhythm without anyone's help. People at risk of sudden cardiac arrest wear it while waiting for a more permanent solution . It monitors your heart all the time. If a life-threatening arrhythmia starts, your LifeVest delivers a shock treatment to restore your heart to a normal rhythm . If you have ventricular tachycardia (rapid heartbeat) or ventricular fibrillation (rapid, uncontrolled, ineffective heartbeat), the device sounds an alarm to verify that you're not responsive. If you are conscious, you have less than one minute to respond to the alarms by pressing two buttons to stop the treatment. If you don't respond to the alarms, the device warns bystanders that you're about to receive a shock . You can get up to five treatment shocks . Risks or disadvantages of a cardiac LifeVest include: It doesn't work if you don't wear it; You need to be ready to respond to alarms at any time; You can't wear it while bathing; You need to change the battery every day; People near you risk injuring themselves if they touch you while you're receiving a shock . A record review of the progress notes identified the following: 1/27/2025 at 6:31 AM, a nurses note,Patient has life vest on but vest is not connected to battery. Writer asked resident if (he) could plug it in and resident stated No. Battery is on charger and vest is not plugged into monitor. Patient was educated on importance of the vest being plugged into the monitor for its effectiveness. Patient would not allow monitor to be plugged in. There was no documentation this was reported to the Physician or Nurse Practitioner. The next documentation for Resident #115 was on 1/29/2025: 1/29/2025 at 1:25 AM, a nurses SBAR summary for the Provider related to the resident falling. There was no mention of the Life Vest. 1/29/2025 at 3:03 AM, a nurses note, Resident had an unwitnessed fall. He was observed sitting on buttocks leaned against bed. Vitals 97.0, 75, 16, 83/46(blood pressure- very low). Resident appeared to be drunk. Bottle of liquor found on bedside table . There was no mention if the resident was wearing the Life Vest or if it was connected to the battery. A review of the Vital signs for Resident #115 revealed the resident often had very low blood pressure. 1/30/2025 untimed, a provider note related to the resident's fall did not mention the Life Vest. A review of the Care Plans for Resident #115 identified the following: (Resident #115) is at risk for cardiac complications related to multiple cardiovascular diseases: Edema, CHF, Pulmonary hypertension, oxygen usage, life vest, EF (ejection fraction) 20-25%, Date initiated 5/15/2024 and revised 1/29/2025. There were no interventions for the Life Vest to ensure it was worn correctly, monitoring or instructions for use and staff were aware of their responsibilities. A review of the Kardex (a document to guide care for the resident) revealed there was no mention of the resident wearing a Life Vest. There was one intervention that stated, Assist with charging batteries as needed. But it did not say what the batteries were for. A review of the Tasks documentation indicated there was no mention of the Life Vest. During an interview with the Director of Nursing on 1/31/2025 at 9:15 AM, indicated there was no education for staff for the Life Vest. A review of the facility policy titled, Wearable cardioverter-defibrillator use, dated revised August 19, 2024, provided, A wearable cardioverter-defibrillator (WCD), also know as a defibrillator life vest, is a device that a patient can wear under the clothing that delivers a shock to the heart when it detects ventricular tachycardia or ventricular fibrillation. It's a temporary therapy for patients at high risk for sudden cardiac death . The therapy isn't recommended for patients who: . are unwilling to wear the vest as necessary . If you're with the patient when the WCD alarms and sends out a voice alert, don't press the response button because the button was designed for patient use to assess the patient's ability to respond . Documentation: Documentation associated with WCD use includes: that the patient is wearing the WCD, tolerance of the WCD, ability to respond to the WCD alerts, defibrillation attempts made by the WCD . complications . practitioner notification . teaching . Based on observation, interview and record review the facility failed to 1. Ensure care was provided for a resident with a Life Vest Resident #115, and 2. Ensure wound care was ordered and completed timely for Resident #383 of two residents reviewed for standards of practice. Findings Include: Resident #383: 01/30/25 around 12:15 PM, Resident #383 was observed in the dining area with other residents enjoying his lunch. A bandage was observed spanding the length of his left forearm that was dated 1/27- at 2130 with the initials SS. When the resident was queried on what happened to his arm, he stated it occurred while he was jumping a fence. Review was completed of this TAR (Treatment Administration Record) and there were no current orders specifically for his left arm. The order that was initiated for his left rear forearm was discontinued on 1/27/2025. Furthermore, there was no wound care treatment documented on TAR as completed for this resident on 1/27/2025. On 1/30/2025 at approximately 1:00 PM, Nurse N was asked if she could locate the wound care order for Resident #383's left forearm. She was not able to locate an order in the chart for this treatment. On 1/30/2025 at approximately 1:30 PM, the DON (Director of Nursing) observed the Resident #383's dressing. The dressing was loose and not covering the injuries that were visible with date of 1/27. The DON reported she was unsure as to why there was not an appropriate order for the dressing or why it had not been changed in two days. Review was conducted of Resident #383's medical record and it indicated he admitted to the facility on [DATE] with diagnoses that included, Chronic Respiratory Failure, Alcohol dependency, Depression, Anxiety and Hypertension.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent a facility-acquired pressure ulcer/skin injury for one resident (Resident #64) of 5 residents reviewed for pressure/skin issues, resulting in Resident #64 developing two new facility-acquired pressure ulcers/skin injuries as a result of poor nutritional intake including a low protein diet and and also resulting in weight loss while residing in the facility. Findings include: Record review of facility 'Skin Management' policy, dated 9/19/2024, revealed it is the policy of the facility should identify and implement interventions to prevent development of pressure ulcers. Practice guidelines: (10.) A nutritional evaluation: a registered Dietitian will evaluate all residents identified with skin impairment for nutritional status in a timely manner. Review laboratory results pertinent to wound healing. (12.) If a new area of skin impairment is identified, notify the resident . Resident #64: In an interview on 01/29/25 at 11:24 AM, Resident #64 stated that he had sores on his right foot that hurt and were painful. He does not know how he got them. Observation of the left leg was an amputation. Observation on 01/29/25 at 11:25 AM with Certified Nurse Assistant D revealed the right foot heel with bandage in place with drainage coming through the dressing dated 1/28/2025. There was drainage noted on the bedding/sheet of dried dark ring with smears where the foot had been swiped across the sheet. Record review of Resident #64's Minimum Data Set (MDS), dated [DATE], quarterly revealed an elderly resident with Brief Interview of Mental status (BIMS) score of 9 out of 15, impaired cognitive ability. Section GG Functional abilities: Coded 01. Dependent- Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity for toileting, shower/bathe, upper/lower body dressing, putting on/off footwear, personal hygiene. Code 05. Set-up/clean-up assistance the helper sets up or cleans up, resident completes activity for eating and oral hygiene. Section M Skin conditions: Assessed Resident #64 at risk of developing pressure ulcers/injuries and had no unhealed pressure ulcers/injuries. Observation and interview was conducted on 01/30/25 at 12:42 PM with Wound Care Nurse Practitioner E and Licensed Practical Nurse (LPN) Wound Care D of Resident #64's right foot wounds. Nurse Practitioner E removed the old dressing revealed a right upper medial black (eschar) area below the back side of the smaller toes. Nurse Practitioner (NP) E palpated the blacked area, and the skin area was soft had a mushy texture per NP. Observation of the right heel area revealed a large open area with bone/tendons noted in the wound (Stage IV). Wound 1.) Odor and serosanguinous drainage of heel was noted. Heel area was cleansed with wound cleaner, dressing applied. Wound 2.) Right medial foot one up under toes, and wound cleanser applied, Medi-honey treatment applied, eschar to the upper toe area. Wound care Nurse Practitioner (NP) E stated that the Medial lateral upper foot had eschar, and the Medi-honey treatment will break down the bad tissue, and that an X-ray of the foot would be ordered. Both pressure ulcer/skin injuries were cleansed and ABD pad and wrapped with krilex gauze. In an interview on 01/30/25 at 12:51 PM, Licensed Practical Nurse (LPN) D wound care nurse revealed that Resident #64 kicks with that leg, has poor nutrition, and poor circulation, and resident will rest his foot on the foot board and kick off his soft boot. Record review of Resident #64's care plan, pages 1- 101, revealed Impaired skin integrity/pressure injury related to weakness, stroke with impairments, dementia. initiated on 2/14/2024 had interventions of: Encourage offloading pressure to right heel with pillows or heel boot as tolerated by resident, created 1/30/2025. Provide diet as ordered, observe and document food acceptance and offer substitutes as needed. Record review of Resident #64's progress notes, dated 12/24/2024, revealed total body skin assessment: skin turgor: good elasticity. Skin color: Normal for ethic group. Temperature of skin: Warm (normal). Skin Moisture: Normal. Skin condition: Normal. Number of new skin conditions: zero. Record review of Resident #64's progress encounter notes telehealth, dated 12/31/2024, revealed nurse reports right heel cleansed with wound clean skin prep and dressed with a 4 x 4 dressing and reported wound care. Due to boggy right heel and hard wound forming in the middle of the bogginess. Record review of Resident #64's Interact SBAR summary, dated 12/31/2024, revealed a change of condition-nursing observation of boggy right heel with harden broken down area. record review of Resident #64's progress note, dated 1/2/2025, revealed elderly resident seen today for assessment to acute pressure ulcer to right heel. He is lying in bed during examination, calm, and cooperative, orientation at baseline. On examination, an approximately 1.4 cm Stage II pressure ulcer noted to right heel, no drainage with partial thickness skin loss. Surrounding skin boggy Record review of Resident #64 wound care dated 1/9/2025 noted right heel pressure (ulcer) measuring: Length 1.72 cm and width 1.24 cm with eschar (black dead tissue). Record review of Resident #64's Minimum Data Set (MDS) significant change dated 1/9/2025 revealed Resident #64 with Brief Interview of Mental status (BIMS) score of 8 out of 15, impaired cognitive ability. Section GG Functional abilities: Coded 01. Dependent- Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity for toileting, shower/bathe, upper/lower body dressing, putting on/off footwear, personal hygiene, and oral hygiene. Code 05. Set-up/clean-up assistance the helper sets up or cleans up, resident completes activity for eating. Section M Skin conditions: Assessed Resident #64 of developing 1 pressure ulcers/injuries, as unstageable pressure ulcer as slough and/or eschar known but not stageable due to coverage of wound bed by slough and/or eschar. Record review of the facility 'Nutritional Services Documentation' policy dated 9/19/2024 revealed that at least once a month and additionally as needed, the Nutrition Professional shall document in the dietary progress notes or appropriate assessment form the current nutritional status of residents with the following criteria: (e.) Stage 2 or higher-pressure injuries. In an interview and record review on 01/31/25 at 12:02 PM with the Registered Dietitian (RD) F record review of Resident #64's nutritional care plan noted nutritional supplement intervention on 2/20/2024, and that there were no other added interventions noted on the care plan related to the recent significant change of weight loss of 5.6% in a month. RD F reviewed the physician orders of 1/14/2025 of Med Pass ordered by the other RD G. Record review of the nutritional care plan revealed the order for Med Pass was not placed on the care plan. Resident #64 has stage 4 pressure ulcer to right heel and an unstageable black eschar pressure ulcer to medial outer foot. RD F was not aware of pressure ulcers for Resident #64. Record review of Resident #64's protein intake currently is at 46 grams which is only 58% of his daily protein requirements, which is inadequate to promote healing of pressure wounds. RD F stated that Resident #64's protein needs should be 80 grams daily. Record review of documented intake is less than 75%-0% per meals. Significant change in weight loss of 5.6%. RD F will plan to re-weight Resident #64 and the if he gains weight will add med pass to 3 x daily, if the resident does not gain weight, will add protein supplement Pro-stat 1 x daily (Pro-stat 19 gram/ml, needs 65 grams).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00149049. Based on observation, interview and record review, the facility failed to implement a restorative therapy program and develop a plan of care for restorative therapy for one Resident #97 of one reviewed for rehab and restorative therapy, resulting in the potential for functional decline, reduction in range of motion, diminished mobility and decreased independence. Findings include: Resident #97: A review of Resident #97's medical record revealed an admission into the facility on 9/26/24 with diagnoses that included anxiety disorder, depression, lymphedema, and open wound of lower leg. A review of the MDS, dated [DATE], revealed the Resident had intact cognition and needed substantial/maximal assistance with shower/bathing, was dependent with toileting hygiene, lower body dressing and putting on/off footwear, needed partial/moderate assistance with personal hygiene and transfers. On 1/30/25 at 9:32 AM, an interview was conducted with Resident #97 who was lying in bed with the head of the bed elevated. The Resident was asked questions, who answered and engaged in conversation. An observation was made of Resident #97's walker in the room. The Resident was asked if they used the walker. The Resident reported she had therapy that had stopped, and she had not received as many days as what was originally planned. When asked about a restorative therapy program, the Resident reported that therapy department indicated that facility staff will walk with her once per shift to build on the progress they had made. The Resident stated, Staff has not walked me. The Resident reported she had been using weights in therapy, but stated, I was never given that opportunity to follow through with exercises, and explained no weights were made available for her to use. The Resident asked why can't they use the exercise bike or get equipment like the weights to keep up her strength. A review of Resident #97's electronic medical record (EMR) revealed a Task for Nursing Rehab: Restorative plan-To maintain ability to walk Ambulation-up to 30 feet Device-front wheel walker 1 person assist. The document was able to be looked back from 1/1/25 to 1/30/25. The question How many feet did the resident walk? was documented on 1/1/25 for 10 feet, on 1/2/25 for 15 feet, and on 1/25/25 10 feet; there was 22 days documented as Not Applicable; and one day of refusal on 1/14/25. A review of the progress notes for 1/14/25 revealed no documentation of why the Resident had refused and/or interventions to address the refusal. The second question for the task was Amount of minutes spent training and skill practice in walking. The documentation revealed on 1/1/25 15 minutes, 1/2/25 15 minutes, and 1/25/25 15 minutes; one refusal on 1/14/25; and 22 days of Not Applicable. Further review of the medical record revealed Resident #97 did not have a care plan developed for Restorative Nursing Therapy, a plan to maintain walking ability and/or strengthening of extremities. The Resident's [NAME] (resident care guide) revealed Mobility: Nursing Rehab: Restorative plan-To maintain ability to walk. Ambulation-up to 30 feet. Device-Front wheel walker, 1 person assist. On 1/31/25 at 11:20 AM, an interview was conducted with the Director of Nursing (DON) regarding the lack of Resident #97's restorative therapy plan. The DON reported the Resident had been on restorative therapy. The DON indicated that the Resident had been on starting on November 29 and indicated she was to be on for four weeks. When asked why the four weeks and why did the Resident not have a care plan to maintain strength, endurance and walking ability, the DON reviewed the medical record and indicated she was unsure and stated, She was supposed to be on one, (restorative therapy plan). The DON was asked for the instructions from therapy for the Restorative program, but the DON did not find the program in the electronic medical record. When asked if she should have a care plan for her restorative program that would include the plan to maintain ability to walk, the DON, indicated she should and reported she was working on a past non-compliance regarding Restorative Nursing Therapy but had not completed it. A review of facility policy titled Restorative Nursing, last revised 4/26/24, revealed, Purpose: The facility strives to enable the resident to attain and maintain the highest practicable level of physical, mental and psychosocial well-being. The Interdisciplinary team [IDT] works wit the resident and family to identify measurable restorative goals and practical interventions that can be implemented and achieved with nursing support . Nursing Restorative is available up to 6-7 times per week and is provided for residents meeting restorative program criteria . 6. Document any refusal in the resident's medical record. 7. Re-evaluate, at minimum quarterly . to determine if resident would benefit from restorative and if resident is willing and able to participate. 8. Identify restorative goals and interventions with input from the IDT and the resident and family/legal representative. 9. Document individualized restorative goals and interventions . 11. Document the resident's daily participation and actual number of minutes participating in the resident's EHR (electronic health record) .

Based on observation, interview and record review, the facility failed to prevent weight loss for 1 resident (Resident #64) of 7 residents reviewed for nutrition, resulting in Resident #64 having a 5.6% weight loss, low protein diet with development of pressure ulcers. Findings include: Record review of the facility 'Nutritional Services Documentation' policy dated 9/19/2024 revealed that at least once a month and additionally as needed, the Nutrition Professional shall document in the dietary progress notes or appropriate assessment form the current nutritional status of residents with the following criteria: (e.) Stage 2 or higher-pressure injuries. Record review of the facility 'Weight Management' dated 9/22/2023 revealed residents will be monitored for significant weight changes on a regular basis. Residents are expected to maintain acceptable parameters of nutritional status, such as usual body weight and protein levels . The dietary manager and/or dietitian will calculate the monthly and weekly significant weight changes (5% in one month, 7.5% in three months, and 10% in six months). Resident #64: Observation on 01/29/25 at 9:50 AM of Resident #64 was lying in bed with breakfast meal tray on bedside table, no bites noted out of meal/foods, orange juice, milk, cereal soggy appearing. In an interview on 01/29/25 at 11:29 AM, Resident #64 stated that he had lost weight. Observed a carton of health shake on the over bed table. Resident #64 stated that his Hands are shaky and has hard time drinking the shake. In an observation on 01/30/25 at 08:14 AM, Resident #64 was noted to be lying in bed with No breakfast tray in room yet. Resident #64 stated that he eats his meals in bed. In an observation on 01/30/25 at 9:20 AM, Resident #64 was lying in bed with breakfast meal tray in front of resident no attempt to feed self. Resident #64 stated that his hands shake when he's eating, and no one helps him with meals. An interview on 01/30/25 at 02:51 PM with the Certified Dietary Manager (CDM) H revealed that the residents Weights were monitored by Registered Dietitian, Record review of Resident #64's weight log revealed on 12/11/2024 weight 156.1 and on 1/13/2025 weight 147.5 equal a loss of 5.7% weight in 33 days. In an interview and record review on 01/30/25 at 03:01 PM, Registered Dietitian (RD) F revealed Nutritional evals are quarterly every 3 months and a full nutritional assessment annually. RD F was asked about Resident #64' weight loss was recently identified at 5.6% loss his weight decrease could be affected by diuretic and anti-psych meds. Record review of Resident #64's nutritional care plan for interventions: new order for med pass twice daily started on 1/14/2025, and health shake daily started 2/21/2024. Begin weights weekly after the significant weigh. change, and prior in December 2024 was monthly. Record review of the nutritional care plan Interventions should have been added med pass and Health shakes 1220 cal and 46-gram protein daily. Assist the dining is nursing service to feed the resident intake is done by CNA's. RD F stated that Monitoring intake is done by the RD, the Resident #64 eats 0% to 25% according to his intake record. RD F stated that he did trigger Resident #64 for a significant change due to weight loss today (1/30/2025). An interview and record review on 01/31/25 at 12:02 PM with the Registered Dietitian (RD) F and record review of Resident #64's nutritional care plan noted nutritional supplement intervention on 2/20/2024, and that there were no other added interventions noted on the care plan related to the recent significant change of weight loss of 5.6% in a month. RD F reviewed the physician orders of 1/14/2025 of Med Pass ordered by the other RD G. Record review of the nutritional care plan revealed the order for Med Pass was not placed on the care plan. Resident #64 has Stage 4 pressure ulcer to right heel and an unstageable black eschar pressure ulcer to medial outer foot. RD F was not aware of pressure ulcers for Resident #64. Record review of Resident #64's protein intake currently is at 46 grams which is only 58% of his daily protein requirements, which is inadequate to promote healing of pressure wounds. RD F stated that Resident #64's protein needs should be 80 grams daily. Record review of documented intake is less than 75%-0% per meals. Significant change in weight loss of 5.6%. RD F will plan to re-weight Resident #64 and the if he gains weight will add med pass to 3 x daily, if the resident does not gain weight, will add protein supplement Pro-stat 1 x daily (Pro-stat 19 gram/ml, needs 65 grams). 01/31/25 09:15 AM Observed resident with full meal tray in front of him: English muffin, with jelly, hash brown, corn flakes with milk, cream of wheat, orange juice, resident state he can't eat by himself, resident fell asleep while surveyor speaking with him.

Based on observation, interview and record review the facility failed to ensure oxygen was provided as ordered for one resident (Resident #79) of 3 residents reviewed for respiratory care, resulting in the potential for inappropriate treatment with potential for adverse reactions . Findings include: Resident #79: A review of Resident #79's medical record revealed an admission into the facility on 2/26/24 with diagnoses that included dementia, diabetes, heart failure, pulmonary hypertension and chronic obstructive pulmonary disease (COPD). A review of the Resident's Minimum Data Set assessment revealed the Resident had severely impaired cognition and needed partial/moderate assistance with bathing, dressing, personal hygiene, sit to stand and bed to chair transfers. A review of Resident #79's orders revealed an order dated 1/22/25 for oxygen 2L (liters) to maintain oxygen saturation above 90% r/t (related to) COPD. A review of the Resident's care plan revealed a focus for .a potential for difficulty breathing and risk for respiratory complications . dated 2/27/24 with an intervention .Use 2 liters of oxygen via nasal cannula continuous . with revision done on 7/6/24. On 1/29/25 at 12:42 PM, an observation was made of Resident #79 sitting in bed. The Resident was observed to have oxygen nasal cannula positioned in her nose. The tubing to the oxygen was connected to the humidification. The humidification was not connected to the oxygen concentrator. The humidification did not have any bubbles to indicate the oxygen was connected correctly to deliver oxygen to the Resident. The Resident was asked if she could feel the oxygen at her nose but did not answer questions appropriately. Nurse V was summoned to the room. The oxygen tubing was shown to the Nurse where it was not connected. The oxygen tubing was connected back to the concentrator and the Nurse took the oxygen saturation (O 2 sat) that registered at 85% and increased to 90% they 95%. The Nurse indicated that the staff that changes out the oxygen tubing had recently been in the room and must have not connected it correctly. The Nurse reported that the oxygen was to be humidified, and the tubing will be replaced. On 1/31/25 at 12:08 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #79's oxygen not delivering the needed oxygen to the Resident. The DON indicated they were aware and that the staff had been talked about the changing of the tubing and connectivity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure suicide precautions were ordered, for one Resident #32 of one resident reviewed for mood and behavior, resulting in the potential for a lack of continuity of care and an adverse outcome for Resident #32. Findings Include: Resident #32: Behavioral-Emotional On 1/29/2025 at 10:34 AM, Resident #32 was observed lying in bed. When asked where her call light was, she said the staff took it and gave her a bell to ring. A small bell was observed on the bedside table. When asked why they gave her the bell, she said she didn't know. On 1/29/2025 at 10:39 AM, Nurse Aide L was asked why Resident #32 did not have a call light and she said the resident was on suicide watch as of that morning 1/29/2025. She said a nurse took her call light so she did not have any long cords to hurt herself and gave her a bell. She said she didn't know any more than that. On 1/29/2025 at 10:45 AM, Nurse K was interviewed about Resident #32 being on suicide watch. She said the resident threatened to harm herself and her call light was removed, and a bell was given. Nurse K was asked what precautions were in place for Resident #32 and she said the staff were monitoring her every 15 minutes. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #32 was admitted to the facility on [DATE] with diagnoses: Cerebral Palsy, Major Depressive disorder, Bipolar disorder, heart failure, diabetes, chronic kidney disease, morbid obesity, epilepsy, and COPD. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and needed assistance with care. Further review indicated Resident #32 had discharged to the hospital on multiple occasions since admission. A record review of the medical record for Resident #32 indicated there was no mention on the Care Plan that Resident #32 was on suicide precautions to ensure staff were monitoring her and providing interventions to aid in prevention of suicide or that her call light was taken away and replaced with a bell. There was no mention of 15-minute checks. A review of the progress notes for Resident #32 identified the following: 1/29/2025 no time, a provider note by NP O, Patient went out to the hospital last night for suicidal ideation, and was sent right back, patient is asking to go to the hospital again for suicidal ideation with plans. Patient is following with psych at the facility. Recommended that the patient be sent back out for suicidal ideation. Rounding team notified. 1/29/2025 at 2:58 AM, a nurses note Resident states that she wants to kill herself. Writer attempted to talk to pt (patient) and see if she has a plan. Resident told writer that she wants to go to hospital because there was nothing we can do for her here. 15 minute checks initiated immediately. On call provider notified and ordered for pt to be sent out. DON (Director of Nursing) notified of transfer. 1/29/2025 no time, a provider note by Nurse Practitioner/NP N, . Per nursing, patient was sent to hospital overnight due to suicidal ideation. She was returned to facility with no changes in medications. Per facility protocol, suicide precautions attempted to be placed. Patient stated, You will not be taking my call light. I'm not going to do anything to myself. Attempted to re-educate patient on policy, to which patient replied, I just need to get out of here. I want to go to the hospital . I'm going to kill myself here . A review of the physician orders on 1/29/2025 at 12:00 PM, indicated there was no order for suicide precautions for Resident #32, to ensure all staff were monitoring and aware of necessary precautions and interventions. A Social Service note dated 1/29/2025 at 10:39 AM, SW was informed that the resident was sent out last night for suicidal ideations. The resident was placed on 15-minute checks and suicidal precautions . SW provided active listening . Call light and light cords were removed from the room and a bell was provided . On 1/30/2025 at 4:40 PM, the DON was interviewed about Resident #32. She said the resident was on suicide precautions and the staff were performing 15-minute checks on the resident. Reviewed with the DON, the Care Plans for Resident #32 did not indicate there were suicide precautions and reviewed there were no orders for suicide precautions. The DON said the resident had been on suicide precautions twice since November 2024. The DON was asked where the documentation for 15- minute checks was, as it could not be located in the resident's medical record, the DON said it was documented on paper at the nurse's desk. She said the Social Worker and Activities staff were to see the resident daily. On 1/30/2025 at 6:45 PM, a nurses note provided, Writer notified the on call provider regarding the resident holding her breath to attempt self harm. Per on call provider send resident to ER for further evaluation. DON aware. Physician orders for 15-minute checks for Resident #32 and an order for suicide precautions was dated 1/30/2025 at 7:15 PM; this was more than 24 hours after the resident had threatened to harm herself. The order for suicide precautions stated, Suicide precautions as needed for safety per resident verbal communication as needed for verbal expression of suicidal ideations, start date 1/30/2025 at 7:15 PM. On 1/31/2025 at 11:50 AM, Staff Education Nurse P was interviewed and said the staff had not received education on suicide precautions. A review of the facility policy titled, Suicide/Self-Harm Attempt, dated revised 9/26/2023 provided, To identify warning signs of suicide/self-harm and protect resident from harm . Most suicide attempts are preceded by warning signs. Do not ignore Warning signs. Suicide/self-harm attempts and completed suicides have occurred in nursing facilities . At such time that signs and/or symptoms of suicide or self-harm are exhibited, the resident is not to be left unattended (immediately place on 1:1 supervision) . Update care plan as needed . planned interventions, safety precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #90: Record review of Resident #90's January 2025 Medication Administration Record revealed that the resident received: Latuda (Lurasidone) 20mg tablet daily for delusional disorder. Zoloft (Sertraline) 25mg tablet daily for depression. Medical conditions included: Delusional disorder, vascular dementia unspecified severity with agitation, paranoid schizophrenia, adjustment disorder with depressed mood. An interview and records review on 01/31/25 at 09:24 AM with social worker S of Resident #90 and Resident #102 revealed that the facility did not use consents forms for anti-depressants or anxiety medications, even though the medications can have an effect/influence on the residents' behaviors/moods. Review of Resident #90 was treated for paranoid schizophrenic, paranoid delusional disorder and adjustment disorder with depressed mood. Resident #102 was treated for psychotic disorder with delusional psychological condition, mood disorder, depressant features, anxiety disorder, major depress disorder, anxiety disorder, restlessness, agitation, traumatic brain injury. Social worker S stated that the facility use consents for the psychotropic meds only. Resident #102: Record review of Resident #102's January 2025 Medication Administration Record revealed that the resident received: Ativan 0.5mg tablet twice daily for anxiety and agitation. Depakote sprinkles 125mg twice daily for psychotic disorder and delusions. Zyprexa 7.5mg tablet twice daily for restlessness and agitation. Medical conditions included: Major depressive disorder, General Anxiety disorder, Restless and Agitation, Mood Disorder due to unknown physiological condition with depressive features, anxiety disorder due to unknown physiological condition, psychotic disorder due to unknown physiological condition, history of traumatic brain injury, vascular dementia moderate with other behavioral disturbance, dementia in other disease classified elsewhere, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review on 01/30/25 at 01:36 PM of Resident #102's pharmacy reviews from April 2024 through January 2025 revealed there to be no reviews for the months of June 2024 and August 2024 found for the resident. In an interview on 01/31/25 at 12:53 PM with the Director of Nursing (DON) of Resident #102's Medication regimen review for a year look back revealed there were no June 2024 or August 2024 reviews found in the computer. The DON stated that at this point 6 months past those months the medication reviews should have been there (in the computer system). The DON stated that she did learn about looking up the monthly reviews. The Pharmacy consultant does the monthly and/or admission reviews. The DON stated that she could not know if there were any pharmacy recommendations for those months of June 2024 or August 2024 for that resident. Record review of the facility provided 'Antipsychotic Risk Benefit Medication Evaluation' clinical guideline form 106.02 (undated) revealed diagnosis included schezohophrenia, psychotic mood diorder, delusional disorder hallucinations, paranora and deliruim were noted on the form. Based on interview and record review the facility failed to ensure informed consent was obtained prior to administration of psychotropic medications for three (#27, #90 and #102) of five residents reviewed for unnecessary medications. Findings Include: Resident #27 On 1/29/2025 at approximately 2:15 AM, a review was conducted of Resident #27's medical record and it indicated the resident admitted to the facility on [DATE] with diagnoses that included Alzheimer's, Adjustment Disorder, Delusional Disorder, Dementia, Adjustment Disorder and Major Depressive Disorder. Further review yielded the following: Physician's Orders: Risperidone Tablet 0.25 MG (milligram)- give one table by month two times a day for psychotic disorder with delusion due to known psychological. Ordered on 10/17/2024. On 1/30/2025 at 2:50 PM, Social Work Director E was asked about their process regarding psychotropic medication consents. It was explained they only complete consents for antipsychotic medications. Review was completed of Resident #27's chart which indicated she is prescribed Risperidone (an antipsychotic) for psychosis. When looking under the resident's diagnosis tab there was not a diagnosis listed of psychosis. Director E looked as well and was not able to located the proper diagnosis to accompany the usage of the antipsychotic. The director was then asked to provide Resident #27's consent for Risperidone and she stated she was not able to locate the consent for Risperidone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow standards of practice and physician orders of parameters for blood pressure (BP) and heart rate (HR) when administering medication to one resident (Resident #22), of six residents reviewed for medication regimen review, resulting in the potential for adverse medication reactions, bradycardia (low heart rate), and re-hospitalization. Findings include: Resident #22: A review Resident #22's medical record revealed an admission into the facility on 8/16/18 and readmission on [DATE] with diagnoses that included chronic kidney disease with dependence on renal dialysis, dementia, bradycardia, seizure disorder or epilepsy, and hypertensive chronic kidney disease. A review of the Minimum Data Set assessment dated [DATE] revealed the Resident had severely impaired cognition and needed substantial/maximal assistance with eating, toileting hygiene, bathing, dressing, roll left and right, sit to lying, lying to sitting. A review of Resident #22's medical record revealed the Resident went to dialysis on Tuesday, Thursday and Saturday. On 12/30/24 the Hemodialysis Communication Form indicated Pulse down to 35, sent patient to ER. On 9/24/24 at 3:37 PM, Nurses Notes: Resident sent to hospital from dialysis and Nursing Summary on 10/7/24 at 3:01, Resident is a readmission from (hospital name) where he was seen for bradycardia . A review of History and Physical Report, dated 9/25/24, revealed, .Chief Complaint: Pt became bradycardic during dialysis . According to reports, patient found to be bradycardic with heart rates into the 40's . A review of discharge hospital records for 1/7/25 revealed, Discharge Diagnosis: 1: Symptomatic bradycardia . A review of Resident #22's Medication Administration Record (MAR) for January 2025 revealed the following: -Order for Nifedipine Extended Release 60 mg (milligrams), give 1 tablet by mouth two times a day for hypertension Hold for SBP (systolic blood pressure) <100, HR <50. Documented as given on 1/15/25 11:00 AM with BP (blood pressure) 171/69 and HR (heart rate) 45; 1/16/25 9:00 PM with BP 128/47, HR 45; 1/26/25 at 9:00 PM with BP 98/44, HR 47; 1/30/25 with 154/58, HR 45. The medication was documented as given when the vital signs were not within the range as ordered by the practitioner. -Order for Doxazosin 20mg, give 2 tablets one time a day for hypertension. The parameters for the medication had been to hold for SBP <100 with a start date on 10/30/24 and discontinued on 1/3/25 when the Resident had transferred to the hospital. The parameters were not applied to the Doxazosin after returning from the hospital. On 1/27/25 at the 11:00 am administration, the documented BP was 98/44 with a HR of 47 and the medication was documented as given. This was the same documented BP and HR from the administration of Nifedipine at the 9:00 pm administration. -Order for Midodrine 25mg, give one tablet by mouth two times a day for hypotension hold for b/p (blood pressure) >110, with a start date on 1/8/25. (Midodrine-Alpha-1-Agonist medication used for blood pressure support, often used to treat low blood pressure.) The medication was documented as given on 1/12/25 at 11:00 AM with BP 175/69, HR 60 and on 1/13/25 at 11:00 AM, with BP 129/59 and HR 59. A review of Resident #22's medication administration for the order Metoprolol Tartrate tablet, give 12.5 mg by mouth two times a day for hypertension. Hold for SBP <100, HR <55, with a start date on 10/22/24 and discontinued on 11/7/24. (Metoprolol Tartrate- a type of Beta blocker often used to treat hypertension and can cause lowering of the heart rate). The medication was documented as given on 10/23/24 9:00 AM with BP 133/75 and HR 53; 10/24/24 at 9:00 PM with BP 185/73 and HR 50; 10/27/24 at 9:00 AM with BP 176/86 and HR 54; 10/27/24 at 9:00 PM with BP 232/99 an HR 53; 1/28/24 at 9:00 AM with BP 177/69 and HR 42; 11/1/24 at 9:00 AM with PB 203/73 and HR 39; 11/2/24 at 9:00 AM with BP 173/78 and HR 51; 11/4/24 at 9:00 PM with BP 166/70 and HR 49; 11/5/24 at 9:00 AM with BP 123/68 and HR 54, 11/5/24 at 9:00 AM with BP 178/74 and HR 50; and 11/7/24 at 9:00 AM with BP 164/73 and HR 51. On 1/31/25 at 11:33 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #22's medications with parameters. The Resident had been hospitalized in September due to bradycardia during dialysis and then on December 30th the Resident went to the hospital again with heart rate of 35 and returned with diagnosis of symptomatic bradycardia. The administration of Metoprolol documented as given when outside of the ordered parameters, after the Resident had been transferred out to the hospital prior with bradycardia, was reviewed with the DON. Midodrine used for hypotension but given outside the parameters to hold if greater than 110, was reviewed. The DON reported indicated that the Nursing staff needed to use nursing skills and know the signs and symptoms and what the medications were for and reach out to the doctor with orders. The DON indicated that the Nurses should be following the parameters and reaching out to the doctor with any concerns. A review of facility policy titled, Medication Administration, effective 10/17/23, revealed, .Physician's Orders-Medications are administered in accordance with written orders of the attending physician. If a dose is inconsistent with the resident's age and condition or a medication order is inconsistent with the residents current diagnosis or condition, contact the physician for clarification prior to administration of the medication. Document the interaction with the physician in the progress notes and elsewhere in the medical record, as appropriate . 5. If applicable and/or prescribed, take vital signs or tests prior to administration of the dose, e.g., pulse with digitalis, blood pressure with anti-hypertensive, etc .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure timely dental services were provided and communicate with dental services regarding the need for dental x-rays for one resident (Resident #97), of one resident reviewed for dental services, resulting in a broken tooth not repaired/extracted, pain, infection and the Resident's lack of knowledge of the plan of care. Findings include: Resident #97: A review of Resident #97's medical record revealed an admission into the facility on 9/26/24 with diagnoses that included anxiety disorder, depression, lymphedema, and open wound of lower leg. A review of the MDS, dated [DATE], revealed the Resident had intact cognition and needed substantial/maximal assistance with shower/bathing, was dependent with toileting hygiene, lower body dressing and putting on/off footwear, needed partial/moderate assistance with personal hygiene and transfers. On 1/30/25 at 9:32 AM, an interview was conducted with Resident #97 who was observed to be in bed with the head of the bed elevated. The Resident was asked and answered questions and engaged in conversation. The Resident was asked about issues with eye and dental services. The Resident reported she had broken a tooth back around Thanksgiving and had not had it fixed or taken out and did not know what how, what or when it was going to be taken care of. An observation was made of a tooth on the Resident's upper left side of a tooth that was broken lengthwise and was pointed on the end. The Resident was asked if she had any pain or sensitivity and indicated she did have pain with it and had an infection as well. The Resident expressed frustration of not knowing when she would see the dentist and if they were going to pull it, if it could be done here or would she have to go out to get it fixed. A review of Resident #97's medical record revealed document from Dental Group with exam completed on 12/2/24 by the Registered Dental Hygienist. Treatment Notes revealed, Assessment and Prophy; . moderate calculus, plaque and bleeding; bleeding controlled with gauze; areas of demineralization; remaining roots and broken teeth are asymptomatic; gingiva is pink to dark pink, shiny and slightly puffy; recommend dry brushing from bed as necessary . deep fracture at #10 is painful when eating and feels sharp to her tongue . On 1/31/25 at 12:41 PM, an interview was conducted with Social Worker (SW) S regarding Resident #97's dental needs. A review of the Resident's medical record revealed the documentation from the hygienist. The SW indicated that the Resident was on the list to be seen by the dentist and the dentist was scheduled to be at the facility on 1/29/25. The SW did not know if the Resident had a plan to have the tooth pulled and did not think the dentist had come on 1/29. The SW put a call into the special service group to inquire about the plan for Resident #97 and the next visit from the dentist. Dental Group Staff T reported that the dentist had canceled and rescheduled for February 5th. The Dental Group Staff reported that the hygienist had seen the Resident on December 2nd, and the tooth was identified as a problem and requested to be seen by the dentist who seen the Resident on 12/9/24. The SW asked for the paperwork for the 12/9 visit which had not been given to the facility. The Dental Group Staff reported that the plan was to get x-rays taken and the dentist can't do anything until the x-rays were completed. The Dental Group Staff reported they had no hygienist available to do the x-rays. The SW reported that the facility was not made aware there was x-rays that needed to be completed or that the dental group did not have a hygienist to do the x-rays. The SW discussed options to get the x-rays prior to the dentist's upcoming visit so as when the dentist comes, treatment was not delayed longer. A review of the Resident that broke a tooth in November, seen by the hygienist and dentist in the beginning of December, but the facility and the Resident was not notified of when x-rays will be taken and a lack of available hygienist to do the x-rays that are needed prior to further treatment plans on extraction at the facility or if the Resident has to go out of the facility for extraction with a delay in treatment for needed dental services. The SW stated, We need to have a plan for her, and reported will see if they get a response back for another hygienist to do the x-rays. A review of Resident #97's Dental Group document with service on 12/9/24 by Dentist revealed, .Treatment Notes: .Carious fracture in #10 and 28, patient complains of pain with mastication due to sharp edges of fractured #10. Tooth is not restorable. Recommending extraction and fabrication of upper partial denture . FMX (full mouth x-ray) needed in order to properly diagnose treatment. If no radiographs before next visit, #10 will just be smoothed down, if patient is not open to extracting it that visit . Recommended treatment: .Extractions: tooth #10 .FMX .X-Ray 12/10/2024. A review of facility policy titled, Dental Services, effective 11/4/24, revealed, Policy: The facility will provide, or obtain from an outside resource, routine and twenty-four [24] hour emergency dental services to meet the needs of the resident and also when requested by the resident . Emergency dental services includes services needed to treat an episode of acute pain in teeth gums, or palate; broken or otherwise damaged teeth; or any problem of the oral cavity that requires immediate attention by a dentist . E. Progress notes from the service provider are to be obtained and placed in the resident's medical record. F. The resident's physician, family and/or resident representative should be informed of the results of the service and any recommendations should be reviewed with the physician .H. Follow up visits will be scheduled as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adaptive equipment was provided for meals and hydration for one resident (Resident #14), of one resident reviewed for adaptive equipment during meals, resulting in frustration with attempting to feed self, spilling water from Styrofoam cup and the potential for weight loss and dehydration. Findings include: Resident #14: A review of Resident #14's medical record revealed an admission into the facility on 6/8/23 and re-admission on [DATE] with diagnoses that included depression, contractures of right and left lower legs, aphasia, dysphagia, muscle weakness, adult failure to thrive, and need for assistance with personal care. A review of the Minimum Data Set assessment dated [DATE], revealed the Resident had moderately impaired cognition and needed set-up or clean-up assistance with eating and was dependent on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene and mobility and transfers. On 1/30/25 at 9:08 AM, an observation was made of Resident #14 in bed with the head of the bed raised. The Resident had the overbed table positioned near her. She had a Styrofoam cup that was on its side and a straw in the bed with her. The table was wet and there was water on the floor next to the bed and under the bed. The Resident reported she had spilled the water when she was trying to get a drink. The Resident was interviewed, answered questions but engaged in limited conversation. Staff came in to give the Resident her breakfast tray and wiped up the water next to the bed and on the table. Another staff came in and the resident was boosted up in bed to eat and the staff left the room with the Resident set up with her meal tray while in bed. An observation was made of a juice sized cup that was filled almost to the top and did not have a lid on it. The Resident was trying to pick up her utensils but was having a hard time getting the fork off the tray. An observation was made of poor hand control and the Resident expressed frustration. The Resident was asked if she could manage the cup of juice and the Resident reported she would spill it. An observation was made of a meal ticket on the tray that stated, Adaptive Equip (equipment): 2-Handled Spouted Cup, built-Up Utensils On 1/30/25 at 9:13 AM, during the interview, the Resident did not eat, and staff did not return with adaptive equipment as listed on the Resident's meal ticket. Nurse U was found and was asked about the adaptive equipment. The Nurse stated, She should have it on there, the built-up utensils and spouted two handled cup. The Nurse checked to see if dietary staff were still present in the dining area, and they were gone. She had retrieved a spouted two handled cup from a beverage area by the nurse's station for the Resident. The Nurse went down to dietary and retrieved the built-up utensils. On 1/30/25 at 2:40 PM, an interview was conducted with the Dietary Manager (DM) H regarding the adaptive equipment for Resident #14's meals. The DM reported that they did have the adaptive equipment available, and the Resident should have it for every meal. The DM indicated that the built-up utensils were to be placed on the tray by the dietary staff and the two handled cups were available on the coffee cart where the CNA's (Certified Nursing Assistant) would put the liquids into the cups. On 1/31/25 at 12:10 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #14's lack of receiving the adaptive equipment during the Resident's meal. The observation of a Styrofoam cup at the Resident's bedside was reviewed and the Resident spilling her water. When asked if the Resident was to get a two handled cup for the water pass for hydration, the DON stated, That would make sense. A review of Resident #14's care plan for a Focus for functional ability deficit and requires assistance with self care/mobility . with an Intervention for Eating: Limited 1 PA (physical assist), 2 handled cup with lid, built up utensils. A review of Resident #14's documents titled, Therapy Communication Care Plan from to Nursing/MDS, dated 1/7/2025 and signed by Therapist, revealed, .Feeding Max A (assist) -2 handled cup with lid and straw, -built up utensils .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Hydration/Water Pass: Observation and interview on 01/30/25 at 08:19 AM with the Director of Nursing (DON) of Resident #41 revealed the call light on the floor. The surveyor had the DON go into the resident room and give it to the resident, there is no clip to his call light. Resident #41 was lying in bed and stated that he still had Third shift water dated 1/29/2025 with no ice, and why was there no fresh water that morning. Resident #41 stated that the staff are lazy, they are good when they work, but they don't want to work. They talk to us like we live on the street, there's no respect, very rude to the way they talk to us. The DON stated that there was No clip on the call light, they break, and we have replaced them. Fresh Water passes are done at the end of each shift, night shift should have passed the fresh water for this morning before 7:30 am at the end of their shift. Observations and interview on 01/30/25 at 08:30 AM the Surveyor reviewed resident rooms 304, 303, 302, 301, for fresh waters, all were dated 1/29/25 3rd. room [ROOM NUMBER]-2 water was dated 1/27/2025. room [ROOM NUMBER]-1 dated 1/29/25 3rd, 305-2 undated, 306-2 water dated 1/29/2025 3rd, 311-1,2,3,4 all had water not dated and with no ice. The Resident in bed 311-4 stated that's last night's water when asked why his roommate had no ice in his water. Observation on 01/30/25 at 08:36 AM of Resident #102 in room [ROOM NUMBER]-2 noted that the call light was on the floor, and white Styrofoam glass with water dated 1/29 3rd. In an interview on 01/30/25 at 02:42 PM with the Certified Dietary Manager (CDM) H stated that the aides pass the water at the end of their shift, 3 times a day. Record review of the facility 'Oral Hydration' policy dated 12/10/2024 revealed it is the policy of the facility to assist residents to maintain adequate hydration whenever possible Procedure: (5.) Each resident will be provided bedside water unless contraindicated . Dining Observation: Observation and interview on 01/30/25 at 08:45 AM on the 3 North unit of resident rooms when checking for [NAME] pass, revealed that the residents complained of no breakfast yet this morning. Multiple rooms reviewed for water pass with no breakfast trays noted at 8:45 AM. Observed the 3 North dining with steam table set up in progress while waiting for the elevator. During the ride in the elevator down, The Certified Dietary Manager (CDM) H got on the elevator at the second floor, and was asked what time breakfast was served? she stated 8:00 AM. Observation on 01/31/25 at 08:42 AM on the 3 North unit revealed the First breakfast tray to the hallway from the dining room, by Certified Nurse assistant (CNA) I took the meal tray to room [ROOM NUMBER]-2. Dignity: Resident #94: In an interview on 01/29/25 at 01:08 PM with Resident #94 revealed that the facility staff on the 3 south unit are rude and disrespectful. If Resident #94 goes over to the 3rd floor south unit side of the building the staff tell the resident to get out of there and are nasty to the resident. Resident #127: In an interview on 01/29/25 at 09:42 AM with Resident #127 during the initiate screening task of the survey revealed the resident had concerns stating: 'they are so disrespectful, they yell at us residents, they don't care about us, they will ignore the residents and stand around and talk. Call lights take over 15 minutes to get answered. Here's an example, last night I took a nap, and I woke up to a chemical smell in my room, and asked the staff if they could smell it, they said no, and walked out. They just walk away and don't address the issues. Record review of the facility 'Certified Nursing Assistant' job description undated, revealed the position requires patience, compassion and a desire to care for the residents in a gentle and empathetic manner. essential functions included: record fluid intake and output, assist with eating and hydration, make routine rounds on each assigned resident every two hours, provides and reinforces other behavior consistent with the resident's dignity. Resident Rights: Promotes and protects resident's rights; treats residents with dignity and respect . This Citation pertains to Intake Number MI00149049. Based on observation, interview and record review, the facility failed to ensure that residents' rights/dignity was maintained for Resident #'s 6, 38, 60, 81, 82, 94, 97 and 127, of a sample of 26 reviewed for residents' rights, dignity and ADL (activities of daily living) care, and two residents in room [ROOM NUMBER], resulting in long call light wait times, Resident complaints of food served at an unpalatable temperature, menu not followed, lack of assistance with dressing, lack of ADL care, long and jagged fingernails, complaints of staff rudeness with Resident interaction and the potential of unmet care needs, weight loss and dissatisfaction with care, services and meals. Findings include: Resident #6: A review of Resident #6's medical record revealed an admission into the facility on 4/25/13 and recent admission on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, acquired absence of right leg below knee, and anxiety disorder. A review of the Minimum Data Set assessment revealed intact cognition, and the resident was independent for most activities of daily living but needed setup or clean-up assistance for bathing. On 1/29/25 at 10:20 AM, an observation was made of Resident #6 seated in a wheelchair, in the hallway, with a towel over top his lap, and his legs were bare. The towel was small and did not cover the resident past mid-thigh. The Resident was asked questions, responded with answers and engaged in conversation. The Resident was upset and indicated he could not find any sweatpants. When asked if he had let staff know, the Resident reported he had told the nurse earlier today and reported they were going to call down to laundry and get them but has not gotten any yet. The Resident is holding a tee shirt and a blue sweatshirt and reported he got them for his birthday and now the pants were missing as well as his orange pants and another pair of pants. On 1/29/25 at 10:35 AM, an observation was made of Resident #6 seated in a wheelchair with a towel over his lap and legs bare in the hallway. The Resident remains upset over his clothing missing and Certified Nursing Assistant (CNA) R came down the hall and told the Resident that laundry was called but there was no answer. The Resident was upset and told the CNA he had no pants and that he was also missing other pants and expressed frustration. The CNA left the Resident in the hall with a towel across his bare legs. On 1/29/25 at 10:45 AM, an interview was conducted with Resident #6 in his room. The Resident answered questions and engaged in conversation but was not always understandable in some of his explanations. The Resident indicated the facility does his laundry and he got his sweatshirt back but did not get his sweatpants back that match. The Resident indicated that he was missing three pairs of pants. The Resident had boxes of personal belongings stacked on the floor across from his bed. When asked if staff came to look for other clothes, the Resident indicated they had not, and he wanted his ones back that matched his sweatshirt. The Resident was in his room at this time and continued to have a hand towel over his lap and his legs were bare. Resident #38, Resident 81: On 1/29/25 at 11:28 AM, an interview was conducted with Residents #38 and #81 who shared a room together. The Residents were interviewed, answered questions and engaged in conversation. The Residents were asked if there were any issues with care. Both Residents voiced complaints of food being cold when received in the room. The Residents reported they liked to eat in their room, and it will often be cold. Resident #81 expressed that it did not matter which meal because they would come cold for all three meals. Resident #81 reported that the trays will come up and sit in the hall, and pointed outside the door, indicated sometimes seeing or hearing the cart but will not get their tray for a while after. Resident #81 reported breakfast was at 8:00 in the morning but they don't get it sometimes until 9:00 or 9:30 am. Resident #38 reported, when it's like that, I just leave it. When asked when the food was not warm, she did not eat it, the Resident stated, I can't eat it like that. Resident #60: A review of Resident #60's MDS revealed intact cognition, and the Resident needed substantial/maximal assistance with shower/bathe, upper body dressing, lower body dressing and needed partial/moderate assistance with personal hygiene. On 1/29/25 at 11:05 AM, an interview was conducted with Resident #60 who was in bed with the head of the bed elevated. The Resident answered questions and engaged in conversation. The Resident was observed to have very long fingernails. The Resident stated, They are too long, and indicated that his daughter was coming and will take care of them. When asked if staff offered to trim his nails, the Resident stated, They are too busy to do them. When asked if they offered with his shower, the Resident indicated he had a shower yesterday and stated, They didn't get done, they are starting to curl, and showed the edges of the nails are starting to curl under. The Resident reported I scratch myself; they are too long right now. Resident #82: On 1/30/25 at 10:03 AM, an interview was conducted with Resident #82. The Resident was asked questions and engaged in conversation. The Resident had been in the bathroom, came out and had her breakfast tray on her bedside table. When asked if the food was still warm, the Resident reported that it was cold. The breakfast consisted of scrambled eggs, toast that was well done and very dark, and oatmeal. The Resident reported there was no jelly, no butter and the toast was burnt and stated, I can't eat that. The Resident reported not wanting the oatmeal either with no sugar to go on it. There was no sugar on the tray, no jelly and the toast did not look like it had been buttered. During the interview, staff came by and handed out a menu. The staff did not check on the Resident's breakfast tray, offered to warm the tray or removed the tray. The Resident looked at the menu and reported they were to have biscuits and gravy and scrambled eggs. The Resident did not receive the biscuits and gravy. Resident #97: A review of Resident #97's medical record revealed an admission into the facility on 9/26/24 with diagnoses that included anxiety disorder, depression, lymphedema, and open wound of lower leg. A review of the MDS revealed the Resident had intact cognition and needed substantial/maximal assistance with shower/bathing, partial/moderate assistance with personal hygiene and transfers. On 1/30/25 at 9:32 AM, an interview was conducted with Resident #97 who was lying in bed with the head of the bed elevated. The Resident answered questions and engaged in conversation. The Resident was asked about bathing and the Resident reported she liked to shower and that her days to shower were on Tuesday and Friday. The Resident reported that the staff don't always offer a shower, that she must remind them and had recently missed a shower that was not offered at another time having to wait for the next shower day. The Resident reported that staff can be rude or have an attitude towards her or disrespectful. The Resident had reported they had long call light wait times and had incontinence when waited for assistance with the call light on. The Resident reported problems with cold food and stated, 50:50 chance the meal is cold. The Resident reported that the menu was not always followed, the alternative was not always available if it was not ordered ahead of time, but the menus are passed out late and you don't know what you are going to get, so how would you know to order something else. The Resident reported not getting a menu today to know what was on the menu for breakfast. Resident #38, Resident 81: On 1/29/25 at 11:28 AM, an interview was conducted with Residents #38 and #81 who shared a room together. The Residents were interviewed, answered questions and engaged in conversation. The Residents were asked if there were any issues with care. Both Residents voiced complaints of food being cold when received in the room. The Residents reported they liked to eat in their room, and it will often be cold. Resident #81 expressed that it did not matter which meal because they would come cold for all three meals. Resident #81 reported that the trays will come up and sit in the hall, and pointed outside the door, indicated sometimes seeing or hearing the cart but will not get their tray for a while after. Resident #81 reported breakfast was at 8:00 in the morning but they don't get it sometimes until 9:00 or 9:30 am. Resident #38 reported, when it's like that, I just leave it. When asked when the food was not warm, she did not eat it, the Resident stated, I can't eat it like that. On 1/30/25 at 2:40 PM, an interview was conducted with Dietary Manager H regarding complaints of food not at a palatable temperature for residents. When asked about complaints, the DM indicated they have had some complaints regarding cold food. When asked if they had done any audits, she reported she had not done a test tray, but the Dietician had. An observation of breakfast passed in the 300 hall area at 9:22 AM this morning was reviewed. The DM reported breakfast started to be served about 8 AM in the dining room, then room trays were assembled after that and that the trays were passed depending on when the aides were available. The DM indicated that breakfast was a slower meal with them (residents) just getting up, and reported that they were working on getting the trays out earlier. On 1/31/25 at 11:15 AM, an interview was conducted with the Director of Nursing (DON) with a review of multiple concerns. Resident #97's shower/bathing was reviewed with a shower documented as given on 1/7/25 and then 10 days later on 1/17/25. There was no documentation that the Resident had refused. The DON indicated that had staff documented that the Resident refused, they would have gotten an alert and it would have been addressed by finding out issue and reschedule the shower. The DON reported because it had not been charted at all, that they did not get the alert. The DON reported that a grievance form had been filled out with all the Resident's concerns and the concerns were addressed. The grievance/complaint form had been requested earlier in the survey and was not received by the facility. The DON was asked for the form and the DON reported that they should have a copy. The DON was asked about nail care and reported that the nails were offered during bathing and as needed. The DON was informed of the Resident complaints of cold food. The DON reported that they serve in the dining room first then put the trays together, put on the tray cart and they go to the hall for the Residents that eat in their room. On 1/31/25 at 1:48 PM, an interview was conducted with the Assistant Administrator (AA) Q regarding complaints voiced by Resident #97. The AA indicated that the Resident had voiced concerns, and they had filled out a concern form and had provided follow through with the concerns. The facility Grievance form for Resident #97 was not received prior to the exit of the survey. Residents in room [ROOM NUMBER]: On 1/29/25 at 1:07 PM, an observation was conducted with Resident in room [ROOM NUMBER]-1 of long fingernails with debris underneath the fingernails. The Resident was asked when their last shower was, but they reported they were unsure. When asked if staff had offered to trim their fingernails, the Resident indicated staff had not offered and they would not refuse. The Resident in 328-3 reported having a recent shower but had not been offered nail care. An observation was made of the Resident nails being long and jagged. A review of facility policy titled, Resident Rights, effective 5/14/24, revealed, Policy: The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that two Residents (#21, #83) received consistent pre and post dialysis weights, and failed to ensure that two Residents (#22, #107) received medications post dialysis when the residents returned to the facility from dialysis, resulting in the potential for decline in condition, lack of medication therapy, and prolonged health issues. Findings include: Record review of the facility 'Hemodialysis' policy dated 9/26/2023 revealed residents receiving hemodialysis will be assessed pre and post treatment and receive necessary interventions Record review of the facility 'Medication Administration' policy dated 10/17/2023 revealed resident medications are administered in an accurate, safe, timely and sanitary manner. Procedure: (6.) Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility Resident #107: Record review of Resident #107's December 2024 Medication Administration Record (MAR) noted that on 12/3/24, 12/5/24, 12/7/24, 12/10/24, 12/12/24, 12/14/24 and 12/17/24 Resident #107 did not receive medications of Norvasc 10 mg (blood pressure), pantoprazole 40 mg (GERD), Valsartan 160 mg (blood pressure), Coreg12.5mg (blood pressure), Eliquis 2.5 mg (blood thinner), Nepro 2 times daily (dialysis), Reglan 5 mg (nausea), and sevelamer carbonate 2.4 grams (dialysis) were not administered on those dialysis days as ordered by physician. Record review of Resident #107's January 2025 Medication Administration Record (MAR) noted on 1/25/25, 1/28/25 that Aspirin 81 mg, Folic Acid 1 mg, Norvasc 10 mg (blood pressure), pantoprazole 40 mg (GERD), Valsartan 160 mg (blood pressure), Coreg12.5mg (blood pressure), Eliquis 2.5 mg (blood thinner), Nepro 2 times daily (dialysis), and sevelamer carbonate 2.4 grams (dialysis) were not administered on those dialysis days as ordered by physician. An interview and record review on 01/31/25 at 01:52 PM with the Director of Nursing (DON) revealed Resident #107's December 2024 and January 2025 Medication Administration Record (MAR) of missed medications. The DON stated that she could not explain why the nurses are not giving the resident medications on dialysis days before going to dialysis or why after the resident comes back. The DON stated that she will have to educate the nurses on changing med times. Resident #21 Dialysis A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #21 was admitted to the facility on [DATE] with diagnoses: history of a stroke with left-sided weakness, Dementia, diabetes, chronic kidney disease, need for dialysis, feeding tube, history of seizures. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 0/15 and the resident needed assistance with all care. ON 1/30/2025 at 10:33 AM, Resident #21 was observed lying in bed, awake. He did not verbalize answers to questions, but would point or make gestures. Nurse aide M was with him and said she was going with the resident to dialysis and they were waiting for the transport to arrive. The nurse aide said the resident went to dialysis on Monday, Wednesday, and Friday and needed someone to go with him because he would become restless and try to get out of the chair and fall. The resident was asked where his dialysis catheter was and he pointed to his left groin; the nurse aide confirmed that was where his catheter was. The resident pointed to his abdomen and a feeding tube was observed. On 1/30/2025 at 2:51 PM, Registered Dietitians/RD F and G were interviewed about Resident #21's weight. He weighed 120.8 lbs. on 1/6/2025. RD G said the resident had experience a weight loss over several months. RD G said she used the resident's weights on the Dialysis Communication Forms to determine the resident's nutritional status. The weight was obtained pre and post treatment on Monday, Wednesday and Friday when the resident went to dialysis. The RD G said the dialysis center did not always document the weights on the resident's Dialysis Communication Form and the last weight in the Weights and Vitals section of the electronic medical record for Resident #21 was dated 1/6/2025. A record review of the electronic medical record for Resident #21 indicated the most recent Dialysis Communication Form was dated 12/27/2024. A review of the Dialysis Communication Forms indicated they were not consistently completed. Many were missing pre or post or pre and post dialysis weights. Some of the forms were mostly blank. Resident #83 Dialysis A record review of the Face sheet and MDS assessment indicated Resident #83 was admitted to the facility on [DATE] with diagnoses: Diabetes, end stage kidney disease, need for dialysis, anxiety, depression, absence of left leg below the knee due to amputation, and heart failure. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a BIMS score of 15/15 and needed some assistance with care. On 1/30/2025 at 9:05 AM, Resident #83 was observed sitting in his wheelchair in the hallway. He said he went to dialysis on Monday, Wednesday and Friday. A record review of the electronic medical record for Resident #83, revealed there was one Dialysis Communication Form in the medical record dated 11/11/2024. A review of the weight for Resident #83 indicated they were obtained less than weekly at the facility and the last weight was dated 1/21/2025 with a weight of 208.2 lbs. The resident had gained 8.6 lbs. from the prior weight on 1/9/2024. A review of the Care Plans for Resident #83 identified the following: (Resident #83) is at risk for complications related to needs dialysis due to : possible infection, CKD/chronic kidney disease, date initiated 11/7/2024 and revised on 11/8/2024 with Interventions: Dialysis, with pickup time of 11 am and chair time 1130 am, dated 12/2/2024; For Hemodialysis: Facility will utilize the Dialysis Communication form to communicate with the dialysis center . date initiated 11/12/2024; For Hemodialysis: Obtain daily weights as ordered. Notify physician of weight changes per physician ordered parameters, date initiated 11/12/2024; Observe for signs of fluid retention: peripheral edema, weight gain . dated 11/7/2024. On 1/30/2025 at 3:26 PM, RD F was interviewed about Resident #83. He said the resident was monitored for weight loss or gain, but the weights were not consistently obtained. The dialysis center did not always provide pre and post dialysis weights and the facility did not obtain pre and post dialysis weights. He said the resident had experienced a weight gain possible related to fluid build up. Resident #22: A review Resident #22's medical record revealed an admission into the facility on 8/16/18 and readmission on [DATE] with diagnoses that included chronic kidney disease with dependence on renal dialysis, dementia, bradycardia, seizure disorder or epilepsy, and hypertensive chronic kidney disease. A review of the Minimum Data Set assessment dated [DATE] revealed the Resident had severely impaired cognition and needed substantial/maximal assistance with eating, toileting hygiene, bathing, dressing, roll left and right, sit to lying, lying to sitting. A review of Resident #22's medical record revealed the Resident went to dialysis on Tuesday, Thursday and Saturday. The Resident had been transferred to the hospital on [DATE] and returned to the facility on 1/7/25. A review of Resident #22's Medication Administration Record (MAR) revealed medications scheduled in the morning at 9:00 am and 11:00 am were not always given on the days the Resident was scheduled for dialysis and not documented as given before leaving or after returning to the facility. The facility did not accommodate the Resident's dialysis treatments in the medication regimen. Review of the January 2025 MAR included the following: -Doxazosin 2 mg (milligram), give 2 tablets one time a day for hypertension, scheduled at 9:00 am on 1/8 then changed to 11:00 am. The following days were documented with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Escitalopram Oxalate 10 mg, given 1 tablet one time a day for depression, scheduled at 9:00 am on 1/8 then changed to 11:00 am on 1/9. The following days were documented with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Furosemide 20 mg, give 1 tablet by mouth one time a day for diuretic, scheduled at 9:00 am on 1/8 then changed to 11:00 am on 1/9. The following days were documented with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Losartan 50 mg, give 1 tablet one time a day for hypertension, scheduled at 9:00 am on 1/8 then changed to 11:00 am on 1/9. The following days were documented with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Colace 100 mg, give 1 capsule two times a day for bowel regimen, scheduled at 11:00 am and 9:00 pm. The following days were documented on the 11:00 am administration with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Levetiracetam 250 mg, give one tablet two times a day for epilepsy, scheduled at 11:00 am and 9:00 pm. The following days were documented on the 11:00 am administration with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Midodrine 5 mg, give one tablet two times a day for hypotension, scheduled at 11:00 am and 5:00 pm. The following days were documented on the 11:00 am administration with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Nifedipine Extended Release 60 mg, give one tablet by mouth two times a day for hypertension, scheduled at 11:00 am and 9:00 pm. The following days were documented on the 11:00 am administration with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Quetiapine Fumarate, 25 mg, give one tablet by mouth two times a day for depressive disorder, scheduled at 11:00 am and 9:00 pm. The following days were documented on the 11:00 am administration with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. On 1/31/25 at 11:33 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #22 and the lack of accommodations of medication regimen with dialysis treatments. The DON indicated that the medications should be given when returned or earlier in the mornings. The DON indicated that the Resident was picked up at 8:15 for a chair time at dialysis at 9:00 am and gets back about 1:00 pm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #102: Record review of Resident #102's January 2025 Medication Administration Record revealed that the resident received: Ativan 0.5 mg tablet twice daily for anxiety and agitation; Depakote sprinkles 125 mg twice daily for psychotic disorder and delusions. Zyprexa 7.5 mg tablet twice daily for restlessness and agitation. Record review on 01/30/25 at 01:36 PM of Resident #102's pharmacy reviews from April 2024 through January 2025 revealed there to be no reviews for the months of June 2024 and August 2024 found for the resident. An interview on 01/31/25 at 12:53 PM with the Director of Nursing (DON) of Resident #102's Medication regimen review for a year look back revealed there were no June 2024 or August 2024 reviews found in the computer. The DON stated that at this point 6 months past those months the medication reviews should have been there (in the computer system). The DON stated that she did learn about looking up the monthly reviews. The Pharmacy consultant does the monthly and/or admission reviews. The DON stated that she could not know if there were any pharmacy recommendations for those months of June 2024 or August 2024 for that resident. Resident #40 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #40 indicated an admission to the facility on 3/8/2024 with diagnoses: Diabetes, kidney disease, anemia, hypertension, anxiety, depression, psychiatric disorder. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 1/15 and needed assistance with care. On 1/30/2025 at 1:53 PM, during a record review of the Medication Regimen Reviews/MRR for Resident #40, it was identified there were 4 MRR recommendations from the monthly MRR reviews over the past year. The recommendation dates identified by the facility pharmacist included: 3/11/2024, 5/28/2024, 10/30/2024 and 1/30/2025 (which was newly completed). Of the 3 recommendations in 2024, the Director of Nursing was able to provide a copy of the pharmacy recommendation for one date: 10/30/2024. The recommendations for 3/11/2024 and 5/28/2024 were not located by the facility and it could not be determined what they were or if the physician/provider reviewed them and acted upon them. Resident #42 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A record review of the Face sheet and MDS assessment indicated Resident #42 was admitted to the facility on [DATE] with diagnoses: Alzheimer's, depression, COPD, Heart Disease and Non traumatic brain injury. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a BIMS score of 15/15. On 1/30/2025 at 1:23 PM, the monthly Medication Regimen Reviews/MRR reviewed indicated 2 of the reviews had recommendations: 1/28/2025 (newly completed) and 12/31/2024. Neither recommendation could be located in the medical record for Resident #42. On 1/30/2025 at 2:30 PM, the Director of Nursing/DON was asked about the pharmacy reviews for Resident #40 and Resident #42. She said she would look for them. On 1/31/2025 at 10:30 AM, the DON said she found 1 pharmacy review for Resident #42 dated 12/31/2024. The recommendation from the pharmacist was Please obtain a BMP (bloodwork) on the next convenient lab day and every 6 months thereafter. The provider signed the document with I accept the recommendations above, please implement as written, on 1/3/2025 and the DON signed on 1/8/2025. During a review of the medical record for Resident #42, a laboratory result with a BMP (basic metabolic panel- which included electrolytes, glucose and tests for kidney function), were not located. The last blood work in the resident's chart was dated 6/12/2024. Based on interview and record review, the facility failed to ensure that pharmacist medication regime reviews (MRR) were reviewed, acted upon and addressed in the residents' clinical record for five (#27, 40, 42, 86, 102) of five residents reviewed for MRR. resulting in medications not being adjusted with physician response to accept or decline the pharmacy recommendations. Findings Include: Resident #27 On 1/29/2025 at approximately 2:15 PM, a review was conducted of Resident #27's medical record and it indicated the resident admitted to the facility on [DATE] with diagnoses that included Alzheimer's, Adjustment Disorder, Delusional Disorder, Dementia, Adjustment Disorder and Major Depressive Disorder. On 1/30/2025 at approximately 4:00 PM, a review was conducted of Resident #27's monthly pharmacy recommendations from May 2025 to December 2024. The pharmacist noted an irregularity on 9/24/2024 but the specifics were not in the resident medical record. On 1/31/2025 at 10:13 AM, an interview was conducted with the DON (Director of Nursing) regarding monthly pharmacy recommendations. She explained contact was made with their pharmacist who emailed the recommendation which was addressed timely for Resident #27 in early October 2024; but they do not have the signed copies of them within the medical chart nor is there a subsequent binder for other residents MRR. Resident #86 On 1/30/2025 at approximately 4:15 PM, a review was conducted of Resident #86's monthly pharmacy recommendations from May 2025 to December 2024. The pharmacist noted irregularities in March 2024, May 2024 and October 2024 but the specifics of their recommendations were not located in Resident #86's medical record. The facility provided pharmacy consultation reports that were unsigned by the physician and DON: 3/26/2024: .Please consider discontinuing Senna and docusate and adding PEG 3350 17 gms qd and titrating to BID if needed . 5/28/2024: .Please monitor for involuntary movements now and at least every 6 months or per facility protocol. It is recommended that monitoring frequency increase following dose adjustments . 10/29/2024: .Please monitor for involuntary movements now and at least every 6 months or per facility protocol. It is recommended that monitoring frequency increase following dose adjustments .

**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 appropriately stored in 3 of 3 Medication carts, and an unlocked treatment cart, resulting in a opened and unsecured treatment cart, opened and undated medications, lack of appropriate storage with loose tablets noted in carts, of temperature sensitive medications with irregular refrigerator temperature monitoring, and the potential for residents to receive medications with altered efficiency and potency. Findings include: Record review of the facility provided 'Medication Storage Guidance' form dated 2024, revealed that multi-dose vials for injection are dated when opened and discard unused portion after 28 days or in accordance with manufacture's recommendations . Record review of the facility 'Vaccine Storage Temperature Log' form dated January 2025 revealed instructions: Place a check in the box that corresponds with the temperature (rows), day of the month, and am or pm (columns) for your temperature check. Then enter your initials and the time you monitored the temperature in the boxes at the top of the chart. Observation and interview on 01/29/25 at 10:02 AM with Licensed Practical Nurse (LPN) V of the second-floor north medication cart revealed: Resident #40 to have Lispro insulin dated 12/17/2024, LPN V stated that's only good for 28 days after opening. Resident #43 (unsampled) had a bottle of liquid Valproic acid 16 oz. 250mg/5ml that was opened and not dated, observed less than 16 oz. in the bottle. Resident #21 had a bottle of liquid Valproic acid 250mg/5ml bottle not dated estimated 20ml left in bottle, also had a bottle of liquid oxcarbazepine 300mg/5ml, opened and not dated. New Resident unsampled had a bottle of liquid Valproic acid 250mg/5ml, opened and not dated. Resident #42 had a bottle of Lactulose 10gm/15ml opened and not dated. Review of the second-floor medication cart revealed there to be 4 loose tablets, (3 white and 1 pink). Observation and interview on 01/29/25 at 10:02 AM with Licensed Practical Nurse (LPN) W of the third-floor north medication cart revealed: top drawer insulins- Resident #71 had Lispro insulin bottle opened not dated. LPN W did not know when the insulin had been opened. Resident #118 (unsampled) had liquid Risperidone 1ml/ml bottle opened and not dated. Resident #102 had liquid bottle of levetiratracin 100mg/ml that was opened and not dated. There was also a Bryna 160/4.5mcg inhaler used with the seal broken and not dated. Resident #31 (unsampled) had Albuterol sulfate HFA 90 mcq inhaler was used with no date when opened. Resident #92 had Symbicort 160/4.5mcq inhaler that was opened and used with no date when opened. Review of the third-floor medication cart revealed there to be 1 white loose tablet found on bottom of 2nd cart drawer. Observation and interview on 01/29/25 at 11:35 AM The state surveyor stepped on a white tablet on the floor of the 300 hallways in front of room [ROOM NUMBER]. Licensed Practical Nurse (LPN) W was at the medication cart in the hallway and took care of the white round tablet, stating 'that is Tylenol tablet, I don't know how that got there'. Observation and interview on 01/30/25 at 07:50 AM with Licensed Practical Nurse (LPN) X of the first-floor north medication cart revealed: Resident #37 (unsampled) had Glargine insulin bottle 100units/ml, 10ml bottle opened with top off and puncture marks noted in top undated. Fluticasone 50mcg nasal spray with the seal broken and used with no open date. Resident #65 had Lispro insulin 100units/ml with no date on bottle noted top off with puncture marks noted in rubber stopper, Ipratropium Bromide 0.5mg aerosol treatment ampules a box of 30 with some missing with no date when opened. Resident #74 (unsampled) had Nitroglycerin 0.4mg tablets with red seal strip removed and no date of when opened that was Dispensed date of 12/18/2024. Record review of first floor north Medication room with Licensed Practical Nurse (LPN) X revealed an Omni cell tower with nurse passwords and to remove a Narcotic takes 2 nurses. Review of medication refrigerator noted tuberculin purified protein derivative opened with puncture marks in rubber stopped with no date on the bottle when opened. Record review of the first-floor north refrigerator temperature checks log for January 2025 noted 9 shifts failed to consistently check the medication refrigerator temperatures. Dates missing: 1/15/25 AM shift, 1/19/25 PM shift. 1/20/25 PM shift, 1/21/25 AM shift, 1/22/25 AM shift, 1/23/25 AM shift, 1/24/25 AM shift, 1/27/25 AM shift, 1/28/25 AM shift. Observation and interview on 01/30/25 at 10:08 AM with Licensed practical Nurse Z of the 2 south medication room refrigerator noted Tuberculin Purified derivative opened and undated with puncture marks on the rubber stopper and that the refrigerator temperature log for January 2025 was not checked consistently the medication refrigerator temperatures. Dates missing: 1/21/25 AM shift, 1/23/25 AM shift. Treatment cart not secured: On 1/29/25 at 11:40 AM, an observation was made in the 300 hall area of a treatment cart that was stored in an area near the nurses station and adjacent to the common area. The treatment cart was unlocked, and a drawer was partially opened. The treatment cart did not have a Nurse attending to the unsecured cart. Two Residents were in wheelchairs in the common area watching TV and there were Residents in the vicinity of the unsecured treatment cart. Staff were at the Nurses station but left the area. A Resident was observed to be propelling himself in the area and passed by the open treatment cart. On 1/29/25 at 11:47, the Nurse returned to the area and was asked about the unsecured treatment cart. The drawers were able to be opened on the cart and an observation was made of dressing supplies for wounds, treatments and prescribed treatments. The Nurse indicated the treatment cart should be locked and secured the treatment cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1). Safe handling of ice and 2). Proper storage of personal items to prevent contamination, resulting in the potential for spread of infection, which could cause serious illness. Findings Include: FACILITY Infection Control On 1/31/2025 at 1:10 PM an Activity Aide entered the facility elevator carrying 2 large basins stacked on top of each other; each basin was filled with ice. Neither basin was covered, and the ice was open to the air with the aide's body leaning against the basins. The aide was asked what was in the basins and she stated, It's ice for daquiris. The aide exited the elevator and walked in to the resident activity area. On 1/31/2025 at 1:20 PM, Infection Prevention and Control/IPC Nurse A was interviewed related to the observation of an activity aide entering the elevator with 2 large uncovered basins each filled with ice. The IPC Nurse A said the facility had covered pitchers that were used to transport ice, and the aide should have used those. A review of the Centers for Disease Control and Prevention/CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in all Settings, dated April 12, 2024 provided, Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered . Room Observations room [ROOM NUMBER]/318 On 1/29/25 at 10:31 AM, an observation was made in the bathroom between rooms [ROOM NUMBERS] of a urinal that was dirty around the rim and had residual urine in the container. The urinal had a date of 1/17/25 but did not have a name or resident identification on it. There was a bedpan that was not in a bag but positioned in the handrail by the toilet. The bedpan did not have any resident identification on it to identify which resident the bedpan belonged. There were four Residents that shared the bathroom. room [ROOM NUMBER] On 1/29/25 at 11:09 AM, an observation was made of room [ROOM NUMBER]. The Resident in bed 2 had a bedpan that was positioned on the bedside table upside down and laying on top of personal items that included food items. room [ROOM NUMBER] On 1/29/25 at 11:17 AM, an observation was made of room [ROOM NUMBER] that had four residents residing in the room. An observation was made of a urinal in the bathroom that had residual urine in the bottom. The urinal did not have a name or room number to identify who the urinal belonged to. The Resident in bed 4 reported he did not know who the urinal belonged to and indicated he had one at the bedside. The urinal did not have a name or identification on it. The Resident reported the urinal had been in the sink and he removed it and set it aside. room [ROOM NUMBER] On 1/29/25 at 12:12 PM, an observation was made of room [ROOM NUMBER]. There was a sink in the room. An observation was made of toothpaste and a toothbrush stored next to the sink underneath the towel dispenser and there is a denture cup with no lid positioned in the same area beneath the soap dispenser and towel dispenser. There is no name on the denture cup and a top was not in the vicinity. The two residents that share the room were not in the room at the time. On 1/30/25 at 9:02 AM, an observation was made in room [ROOM NUMBER]. The Residents were eating breakfast in the room. An observation was made of the sink in the room that had the toothbrush wrapped in a paper towel positioned under the towel dispenser and the denture cup that had water and dentures inside the cup. There was no lid on the denture cup and the cup was positioned underneath the soap dispenser. room [ROOM NUMBER] On 1/29/25 at 1:15 PM, an observation was made of room [ROOM NUMBER] that had four residents residing in the room. A urinal was in the bathroom, appeared to be used. The urinal had no identification or which resident it belonged to. On 1/31/25 at 12:22 PM, an interview was conducted with the Director of Nursing (DON) regarding the storage of personal items such as urinals and bedpans. The DON was asked if the items needed to have identification to which resident the items belonged to. The DON indicated that they should be marked with identification. The DON was informed of the bedpan over the personal items and food items and reported they will take care of that.

Based on observation and interview the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food, foodborne illness and improper kitchen sanitization, potentially affecting all residents who consume meals from the kitchen. Findings Include: On 1/29/2025 at approximately 10:00 AM, a tour of the kitchen was started with Assistant Administrator Q and concluded with Dietary Manager AA upon entering the kitchen, dietary staff were actively cleaning out the walk-in cooler. The following expired and/or unsanitary conditions were observed during the tour: Walk-in Cooler: -Floors had spills in different areas of what appeared to milk, and the floor was sticky in some areas. -There were miscellaneous items strewn across the floors such as lids and onion peelings. -18 cups of orange juice inside an extended white tray- some of the juices lids were off and there was spilled juice in the bottom of the tray. It was dated 1/26/25. -1 gallon of jalapenos with expiration date of 1/21/25 -Both fan covers in the walk-in cooler were riddled with build on dirt and debris. The fans itself also were observed with grayish particles on the fan blades. The encapsule containing the fans had unknown dust/debris/particle buildup around the perimeter. Maintenance Director BB reported it was unknown the last time the fans in the cooler or freezer were cleaned but he would provide the logs for it. Walk-in Freezer: -10-pound ham with no expiration date -Small container of purer meat- expired 1/24/24 -2-3 pounds of Spaetzle Dumplings- no expiration date -5-pound bag of Pepperoni- expired 7/19/24 -7- biscuits in unsealed bag with no expiration date -5-pound hamburger - with no expiration date -3- pound bag of chicken with no open/use by date -Both fan covers were riddled with build on dirt and debris. The fans itself also were observed with grayish particles on the fan blades. Dry Storage: -18- Evaporated milk cans- expired 5/2024 -20 pack or tortillas- expired 1/24/25 -1 box- pasta- expired 1/24/2024 -35 oz box of raisins - expired 4/26/24 35 oz container of Frosted Flakes- no use by date. Manager AA reported those items should have been discarded and she's unsure how they were missed in her walkthroughs. Kitchen Area: -Underneath both pop machine spigots was a black/brown dried substance and other unknown splattered substance. -Underneath pop machine was a dried brown substance that was circular in shape -Inside individual toaster was brown/blackened particles at the bottom. -20-pound container of thickener expired 1/7/25 -20-pound container of sugar expired on 11/7/24 Dishwashing Area: The top of dishwasher had observable debris in multiple areas and the entrance to the dishwasher had a white/beige clumpy build up around the edges. Manager AA reported it appeared to be calcium build up, but she was not 100% certain. Manager AA was asked to run a test strip to verify if the appropriate temperature was reached for sanitization. As the 1st cycle was completing the wash temperature was at 140° and 3rd cycle- wash temperature at 140 ° and rinse temperature at 180 °. On 1/29/2025 at 11:30 AM, an interview was conducted with Dietary Manager AA regarding the kitchen tour. The manager reported she started in July 2024 and is working toward maintaining structure within the kitchen. Review was completed of the kitchen cleaning logs with many of the daily tasks being blank. She explained they are cleaning in the kitchen but have not initialed them. Manager AA stated cleaning atop the dishwasher and the white buildup observed at the entrance of the machine, is not on the cleaning log so it's nothing they would complete. When asked if she could provide cleaning logs from the prior month, she stated they would be incomplete like the current ones. Everything that was found in the cooler and freezer should have at least had an open date at the very least. Review was completed of the cleaning log from 1-20-2025 to 1-26-2025 and it showed of the four pages of tasks they rarely were completed daily. The log was 85% blank. Review was completed of the facility policy entitled, Use by Date Storage Chart, revised 3/2018. It stated, All unopened prepackaged processed products should be used or discarded by the Manufacturers expiration date .Meat and poultry - 30 days in freezer .Hard sausage- pepperoni slices-6 months in freezer . Review was completed of the facility policy entitled, Dish Machine Usage and Sanitation, revised 11/12/2021. The policy stated, .the dish machine will be cleaned inside and out after each meal. Dish Machine will be de-limed, as needed .Minimum wash temperature 150-170° . final rise temperature must be at least 180° F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake MI00138079. Based on observation, interview and record review, the facility failed to ensure dignified treatment during dining and ensure the provision of Resident rights for two Residents (#71 and 228), of a sample of 24, resulting in potential feelings of embarrassment, decreased self-worth, lack of knowledge of Resident rights and to act upon deprivation of rights. Findings include: Dining Observation On 2/1/24 at 9:05 AM, an observation was made of Resident #71 seated in a wheelchair in the hallway across from the Nurses' Station. There were other Residents seated in wheelchairs up against the wall with Resident #71. Resident #71 had a meal tray on a table that was infront of the Resident. An observation was made of a CNA (certified nursing assistant) standing in front of the table to the right side of the Resident and feeding the Resident the food. The CNA was not seated next to the Resident but stood and gave the Resident multiple spoonfulls of food. The observation was made until 9:16 AM when the surveyor left the area and the Resident was not completed with her meal. On 2/5/24, an interview was conducted with the Director of Nursing (DON) regarding the observation made of Resident #71 receiving assistace from staff during the breakfast meal on 2/1/24. The DON indicated the staff usually sit with the Resident and stated, That is not a usual occurrance. Will do education with staff on that. Resident #228 Review of intake documentation dated as received on 7/3/23 detailed a concern that Resident #228 did not receive a copy of their resident rights when they were admitted to the facility. Record review revealed Resident #228 was admitted to the facility on [DATE] with diagnoses which included sepsis (infection throughout the body), anxiety, and depression. Review of the admission assessment dated [DATE] revealed the Resident was cognitively intact and required one-to-two-person assistance to complete Activities of Daily Living (ADLs). Review of Resident #228's Electronic Medical Record (EMR) revealed no documentation demonstrating that a copy of the Resident Rights was provided to the Resident. An interview was completed with the Administrator and Director of Nursing (DON) on 2/6/24 at 2:50 PM. When queried where regarding location of documentation of the provision of resident rights in the medical record for Resident #228, the Administrator stated, Not able to show proof of rights provided. Review of facility policy/procedure titled, Guest/Resident Rights (Dated: 4/28/22) revealed, Procedure . 1. Prior to or upon admission, a representative . will provide the guest/resident with a written copy of the guest/resident rights . 3. The guest/resident . will be required to sign a statement acknowledging . receipt of a written copy of guest/resident rights .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Numbers MI00133967, MI00135210 and MI00140848. Based on the interview and record review, the facility failed to allow the resident's family to visit the facility regularly per resident legal representative's preference for one resident (Resident #43) of two sampled residents reviewed for visitation rights in a total of 24 sampled residents resulting in feelings of sadness, loneliness, isolation from a relative and lack of socialization. Findings include: Resident #43 (R43): A review of Resident #43 (R43) record revealed that R43 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of Hemiplegia, Hemiparesis following unspecified Cerebrovascular Disease affecting the right dominant side, Adjustment Disorder, Major Depression, and Eczema, in addition to other diagnoses. R43 was nonverbal and had a legal representative living outside the state. R43's Brief Interview for Mental Status (BIMS) score dated 12/16/2023 was 2 out of 15. A score of 0 to 7 points suggests severe cognitive impairment. According to the Quarterly Minimum Data Set (MDS), dated [DATE], R43 depended on staff with her daily care and activities, including toileting, grooming, and dressing. R43 was frequently incontinent with bowel and bladder elimination patterns and was non-ambulatory. During an interview with R43's legal representative on 2/1/24 at 1:01 PM, she indicated that she relied on family to visit R43 regularly to ensure R43's daily needs (physical, mental, or emotional) were met and would not be sad and lonely. R43's guardian expressed concern for R43's loneliness, isolation, and sadness. R43's legal guardian revealed how significant R43's great-niece was to R43 because her great-niece served as a family companion, providing hair grooming, manicures, trim toenails, and daily lotion application for her extensive dry skin condition. R43's guardian wished for the facility to reconsider lifting the ban to allow visits for her mom to provide R43 with family companionship regularly and provide personalized care, especially the application of a lotion to all dry areas of R43's body for R43's severe dry skin. R43's guardian indicated that R43 enjoyed getting a manicure and trimming her toenails and loved her hair combed and styled personally by R43's great-niece. The guardian indicated that she was worried that R43 would miss the companionship and bonding with their great-niece since the facility banned her from entering the facility in October 2023. R43's guardian revealed that she asked the Administrator for an incident report or examples of rules their great-niece violated and what made them deny her from visiting. However, the facility has not provided any documentation as requested as of this date. According to R43's guardian, the Administrator simply told the guardian that banning her great-niece was because she violated some rules, but nothing was specified. Furthermore, the guardian was concerned and indicated no follow-up discussion of alternative plans to replace the missing visits, companionship, and personalized care from R43's family. R43's legal guardian revealed that the facility did not consider visitation in a common area of the facility, like, for example, on the first-floor dining area, just for R43 to see familiar faces, especially during winter when it is too cold to get her mother out because of the weather. On 2/5/24 at 2:30 PM, an interview with R43's Roommate (R FF) was conducted. R FF explained that R43 was unable to speak understandably due to her stroke. R FF described her roommate's facial expression when R43 was happy, sad, or frustrated. R FF revealed that R43 would shake her head when she means no or nods if she means yes. The R FF denied witnessing any incident that would indicate physical or verbal harm from R43's great niece during visits. R FF was never fearful nor have seen the great-niece be out of line. R FF described that R43's great niece was a great joy and a very sweet person. (R43's name) loves her so much, and she does a lot for her when she visits to make (R43) so happy. R FF had expressed that she felt safe alone with the great-niece in the room. However, R FF mentioned a couple of aides (CNA) who didn't like it when the great-niece visited because she advocated for her grandmother and aggravated the staff to care for R43. R FF stated that her roommate's great niece was very sweet, and (R43) is always happy when she visits. On 02/05/24 at 11:45 AM, the Administrator revealed that she had talked to the guardian about the ban sometime in October 2023. The Administrator stated that R43's guardian reported the facility to the Ombudsman and stated, I assumed that the Ombudsman followed up with the guardian. The Administrator revealed that education was provided to the great-niece. However, the Administrator denied talking to the guardian regarding the final decision in November 2023. The Administrator did not discuss what plans were in place and the options available since the visitation ban to R43's guardian. The Administrator recalled in October 2023 and indicated that she had informed R43's guardian that her niece was banned from entering the facility because of incidents in which the great-niece violated the facility policy. The Administrator indicated that the Ombudsman was in the facility in November and attended the Resident Council meeting. The Administrator furthermore stated, The Ombudsman should have communicated the decision of banning R43's great niece to the guardian because they filed a complaint against us. A review of the Resident/Family Education Record dated 7/14/23 noted that the niece received education in July 2023. No other incident reports, witness statements, or grievance reports were filed between July 2023 and November 2023. No incident report or grievance documentation was submitted to the surveyor for review. The social worker, Administrator, and unit manager did not witness nor document any physical harm or potential harm caused by the niece to R43 or any residents in the facility. During the education dated July 2023, it was noted that the visitor (R43's great-niece) was to encourage the visitor to promote advocacy for the care needed by the resident. The Social Worker (SW A), during an interview conducted on 02/01/24 at 1:30 PM, denied discussing the outcome of the visitation ban with the resident's representative. SW A stated, I assumed that the Administrator did it. SW A revealed that she initiated the care plan for R43 on 2/2/24 at 3:00 PM for participation in group program activities and entered a social worker progress note related to the visitation ban. The nurse (MDS RN F) on 2/6/24 at 10:05 AM confirmed that R43's care plan was initiated on 2/2/24 by the SW. MDS RN F revealed that the interdisciplinary team (IDT) did not meet during R43's Quarterly Care Conference on December 20th, 2023. The MDS RN F explained that the IDT sometimes did not hold an actual care conference. The care conference for R43 was scheduled for 12/20/23 but did not occur. Each discipline filled out its forms but did not necessarily meet as a group to discuss and create a team effort person-centered care plan. We did not discuss the banning of R43's great-niece at all. The MDS Nurse F revealed that no care plan was initiated when the facility implemented the ban on R43's family sometime in October 2023. The Social Worker started the care plan just recently, dated 2/2/24. There was no care plan before 2/2/24, and R43's representative was not given an opportunity to participate in the person-centered care planning, particularly the visitation issue for R43. On 02/05/24 at 11:45 AM, the Administrator indicated that the issue of banning the visitor was presented to the Resident Council dated 11/30/23. The meeting minutes revealed that the Administrator discussed R43's case with the council of 12 residents in attendance. It was noted and written that: The Administrator spoke with residents about a visitor who was asked not to return inside the facility due to aggressive behavior. Residents voted to continue the ban on visitors at that time. Meanwhile, R43's representative on 2/1/24 at 1:01 PM revealed that she was not informed or had given consent to discuss R43's matters with 12 attendees of the Council Meeting. As R43's representative, she was not made aware and was not provided an opportunity to represent and speak on R43's behalf. According to the Ombudsman JJ, on 2/1/24 at 1:55 PM, she remembered attending the Resident Council in November 2023. The Ombudsman indicated that she was unaware of the facility's process of informing or communicating with the resident's guardian. The facility did not discuss any other alternative plans for visitations. At the Resident Council Meeting in November 2023, the Ombudsman indicated that the residents discussed the case of the banning of the resident's great-niece. The Ombudsman revealed that the great-niece did not pose a danger or threat to R43 nor any other residents, nor had anything been reported as physical harm or threat to staff. The Ombudsman indicated that the great-niece only advocated for R43, and no care planning was discussed regarding alternative visitation. The Facility's Residents Rights Policy (last revised date on 4/28/2022) was reviewed. The Policy stated: .The facility protects and promotes the rights of each guest/resident. The guest/resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. .The facility staff will safeguard the privacy of the guests'/residents' protected health information from improper use and disclosure. It will inform the guest/resident both orally and in writing of their rights as a guest .Facility staff will assist guests/residents in exercising their rights . .Facility staff will not hamper, compel by force, treat differently, or retaliate against a guest/resident for exercising her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00134673. Based on interview and record review, the facility failed to implement and operationalize timely assessment, care, and transfer following a change in condition for one resident (Resident #76) of one resident reviewed resulting in a delay in transfer and care following feeding tube dislodgment, delayed provision of nutrition/hydration, and medications, untreated pain, and the likelihood for gastrostomy (surgically created opening in the abdominal wall to the stomach for the introduction of nutrition- commonly called a PEG or G-tube) malfunction. Findings include: Resident #76: On 1/30/24 at 12:07 PM, Resident #76 was observed sitting in a geri-chair (reclining, high back wheeled chair used for positioning) in their room. When spoke to, Resident #76 made eye contact and stated, To much pressure on my stomach. When asked questions, Resident #76 did not provide meaningful responses. Record review revealed Resident #76 was most recently admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, colon tumor, dysphagia (difficulty swallowing), and gastrostomy (surgically created opening in the abdominal wall to the stomach for the introduction of nutrition through a feeding tube- commonly called a PEG or G-tube). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, had impaired Range of Motion (ROM) in both upper and lower extremities, required a feeding tube for nutrition, and required maximum to total assistance to complete Activities of Daily Living (ADL). Review revealed Resident #76 was receiving Hospice services. Review of Resident #76's care plans revealed a care plan entitled, (Resident #76) has alteration in nutritional and/or hydration status . NPO (Nothing by mouth) status . (Initiated: 3/3/22; Revised: 2/5/24). The care plan included the interventions: - Resident has NPO status as ordered (Initiated: 3/3/22) - Observe and report to physician PRN . Tube dislodged/removal . Infection at tube site, Tube malfunction . Abdominal pain, distension, tenderness . An interview was completed with Family Member Witness D on 2/7/24 at 8:06 AM. Witness D verbalized concerns related to a delay in care for Resident #76. When queried what occurred, Witness D verbalized they received a phone call from Registered Nurse (RN) H yesterday informing them that Resident #76's PEG tube had come out. Witness D stated, (RN H) said they weren't sending (Resident #76) out to the hospital because the State was there (in facility). When queried what time they received the phone call informing them that Resident #76's PEG tube had come out, Witness D stated, They called at 12:40 PM and didn't send (Resident #76) out until after 7:00 PM. Review of Resident #76's Electronic Medical Record (EMR) revealed the Resident was transferred to the hospital on 2/6/24 and had not returned. Documentation detailed the following: - 2/6/24 at 1:14 PM: eINTERACT SBAR Summary for Providers . Change In Condition . Abdominal pain Gastrostomy tube blockage or displacement .Findings . Abdominal pain, Abdominal tenderness, pain . Recommendations . Sent to (hospital) . - 2/6/24 at 7:06 PM: Nurses Notes . Resident peg tube displaced. On call provider aware. Resident is being transferred to (hospital) to have a peg tube replacement. Review of Resident #76's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the Resident did not receive their tube feeding on 2/6/24 and/or any of their ordered afternoon and evening medications. Review of pain documentation in Resident #76's EMR detailed that on 2/6/24 at 12:01 PM, Resident #76's pain level was eight out of 10 (with ten being the worst imaginable pain). Review of documented pain levels for February 2024, within the Pain Level Summary revealed all other pain level documentation for the month was zero out of 10. No follow up pain level documentation was present in the Pain Level Summary or on the MAR. Review of documentation and staff schedules/assignment sheets for 2/6/24 revealed RN H was assigned to care for Resident #76 on day shift and RN I was the Resident's assigned nurse on afternoon/night shift. On 2/7/24 at 8:59 AM, RN H was contacted via phone. A voicemail with return number was left. A return call was not received by the conclusion of the survey. On 2/7/24 at 9:34 AM, an interview was completed with the Director of Nursing (DON). When queried regarding Resident #76, the DON revealed the Resident had been sent to the hospital due to their PEG tube becoming dislodged. When asked how the PEG tube became dislodged, the DON indicated they were not sure. The DON was then asked if there were any problems with transfers on 2/6/24 and replied that there was not. When asked why Resident #76 was not transferred to the hospital related to their PEG tube dislodgement until after 7:00 PM, the DON indicated the nursing staff may have been waiting to hear back from Resident #76's hospice provider. When asked why there was no documentation of communication with hospice in the EMR and/or of when the PEG tube became dislodged, the DON was unable to provide an explanation. On 2/7/24 at 11:40 AM, an interview was completed with Hospice Registered Nurse (RN) S. When queried if the facility had contacted them regarding Resident #76's gastrostomy tube, RN S stated, I did get a call from the facility. RN S was asked what time they were notified and replied, 12:39 (PM). With further inquiry, RN S revealed RN G called them to tell them that Resident #76's PEG tube was not functioning and was painful to the touch. RN S stated, (RN G) let me know they were gonna send (Resident #76) out to the ER. When asked if the facility had asked permission to send the Resident to ER, RN S revealed the facility told them they were sending them which is necessary as Resident #76 is unable to eat or drink anything orally. When queried if they were aware the Resident was not transferred to the hospital until after 7:00 PM, was having pain, and had not received their medications, RN S replied they were not. When asked if there was any reason that they were aware to explain why Resident #76 had not been sent to the hospital sooner, RN S replied they were not aware of any reason why the Resident was not transferred sooner. An interview was completed with the DON on 2/7/24 at 12:30 PM. The DON was informed that RN G contacted Resident #76's Hospice RN on 2/6/24 at 12:39 PM to inform them that Resident #76 was being transferred to the hospital due to PEG tube dislodgement. When asked why the Resident was not transferred in a timely manner, as it was not related to Hospice coordination, the DON was unable to provide an explanation. The DON was queried regarding Resident #76 not receiving their medications, tube feeding, and hydration due to tube feeding dislodgement. The DON confirmed the Resident was unable to take anything orally and would not have received any medications, nutrition, and/or hydration. When queried regarding Resident #76's documented pain level including lack of detailed location assessment, reassessment of pain, and lack of ability to receive medications, the DON was unable to provide an explanation. When asked about Witness D stating RN G had informed them that the facility was waiting to transfer Resident #76 due to the State Agency being in the facility, the DON did not provide a response. A policy/procedure related to change in condition and transfer was requested at this time 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 ensure interventions were enacted to prevent a fall and assess the resident post fall for neurological changes for one Resident (#30), of five reviewed for accident hazards/falls, resulting in Resident #30 having a multiple falls, hospitalization, dislocation and fracture to the left arm, pain, decreased mobility and the lack of assessment of potential change in mental status to go undetected and untreated. Findings include: A review of Resident #30's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included Alzheimer's disease, anxiety, delusional disorders, difficulty in walking, weakness, and need for assistance with personal care. A review of the Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status score of 3/15 that indicated severely impaired cognition and the Resident needed partial/moderate assistance with lying to sitting on side of bed, sit to stand, toilet transfer and walking. A review of Resident #30's incident report dated 10/17/23 of a fall at 4:45 pm, revealed, Incident Description: At 4:45 the aide went to answer a call light across from the resident's room and heard her calling for help. Resident was observed on the floor in a sitting position with her back against the wall. The aide grabbed the nurse and the nurse came to assist the resident. Upon arrival resident was still in the same seated position and was asked if she fell on her butt and at first she said yes then she said she fell forward and hit her head. The resident's story was unclear and didn't correlate to the location in which she was sitting. She said she fell trying to use the bathroom but was found closer to sink with her wheelchair so the side. She said she had generalized pain but was she was assisted in her chair and assessed she localized pain in her right hip and a budge was observed. She also said she had a headache from hitting her head. The provider, DON (Director of Nursing) and unit manager were notified at 4:47 pm. Provider instructed that the resident be sent out for a CT due to her taking ASA (aspirin). Vitals and neuro checks were done every 15 minutes until she was taken to the hospital . A review of Resident #30's Post Fall Evaluation, dated 10/17/23, revealed the Resident was Observed on the floor (unwitnessed), location in the Guest/resident room, what was the guest/resident doing during or just prior to fall: Attempting to self-transfer, Describe initial intervention to prevent future falls: Call light within reach. A review of Resident #30's progress note dated 10/17/23 at 10:45 PM, Resident returned from the ER, A&O (alert and oriented) x (times) 1, makes needs known, denies pain or discomfort and vss (vital signs stable). Resident is neurologically intact, d/c stated CT scan and x-ray showed no fx or injuries, no new orders at this time. A review of Resident #30's incident report dated 10/18/23 of a fall at 2:00 am, revealed, Incident Description: Resident's roommate came and alerted the nurse that she was on the floor. Nurse observed resident laying on her back on the floor in between the L foot of the bed and the sink. With her head at the foot of the bed and feet pointing towards the sink. Stated she was trying to go to the bathroom and didn't make it. The Immediate Action Taken: Resident was assessed for injuries, L arm appears to be fx (fracture), R (right) hip protruding from body. Vitals obtained BP (blood pressure) is very elevated, vitals otherwise stable. 10 out 10 pain. Neuro checks were initiated and resident is neurologically intact. Because there is a suspected fx resident was not moved from floor, pillow placed under head. On call physician notified and call out for EMS (ambulance). A review of Resident #30's progress note date 10/18/23 a 7:09 PM, revealed, Resident returned from hospital at 11:05 am, with cast on L (left) arm, (hospital name) stated that resident dislocated/fractured arm which was reset and to follow up with ortho. Resident stated she was in pain . A review of the facility document Neurological Assessment for Resident #30, revealed the assessments started after the first fall for every 15 minutes x (times) 4, the assessments for every 30 minutes x 4 were not completed due to the Resident going out to the hospital after the first fall. The neurological assessments continued after the Resident returned from the hospital staring with third every one hour x4 assessment at 10:30 PM. The Resident had another assessment completed at 2:30 AM after the second fall and then was transferred out to the hospital. The Neurological Assessments continued when the Resident returned for every 4 hours x two at 11:30 AM and 3:30 PM. The assessments had not been restarted after the second fall. The assessments were to continue for every 8 hours x two days with two entries for the six required assessments. On 2/5/24 at 4:53 PM, an interview was conducted with Unit Manager, Nurse B regarding Resident #30's falls on 10/17/23 at 4:45 pm with transfer to the hospital, returned at 10:45 PM, had the second fall on 10/18/23 at 2:00 AM, transferred to the hospital, returned with diagnoses of dislocation and fracture to the left arm, returned with a cast from the hospital at 11:05 AM. A review of the incomplete neurological assessments was reviewed. When asked if the neurological checks should be restarted after the first fall to monitor for neurological changes, the Unit Manager indicated the Nurse should be restarting the neuro checks after the second fall and complete them through. The Unit Manager was asked what interventions were put into place after the first fall to prevent the second fall. The Unit Manager indicated there was a lack of interventions placed after the Resident returned from the hospital after the first fall. The Unit Manager indicated that after the second fall the initial intervention to prevent future falls included to anticipate bathroom needs, and toilet the Resident every 2 hours. On 2/6/24 at 11:48 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #30's falls on 10/17/23 and 10/18/23 with the Resident sustaining injury to the left arm. The Neurological Assessments were reviewed with the DON of the assessments not restarted when the resident came back from the hospital after the first fall and no completed for the every 8 hours x 2 days. The DON was asked about interventions to prevent future falls after the Resident had returned from the hospital after the first fall. The DON reported that generally, she (Resident #30) was not incontinent, and that the Resident was trying to go to the bathroom and stated, They should be putting an immediate intervention in place even if I go through and put in another one later after investigating the fall. Review of the facility policy titled, Fall Management, effective 9/22/2023, revealed, Policy: The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls . Practice Guidelines: .3. When a fall occurs, the licensed nurse will evaluate the resident for injury . A fall huddle will be held to determine the root cause of the fall. 4. The licensed nurse will complete: incident/accident report in PCC; Review and/or revise care plan and link to the resident [NAME] . 5. If a potential head injury is present, complete the Neurological Record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to properly label the enteral nutritional solution (nutrition provided by means of surgically placed percutaneous endoscopic gastrostomy tube-PEG tube) and infusion tubing set for one Residents (#118), of three reviewed for tube feeding, resulting in the potential for food borne illness from ingesting contaminated enteral feeding solution. Findings include: A review of Resident #118's medical record revealed an admission into the facility on [DATE] with diagnoses that included osteomyelitis of right ankle and foot, anxiety disorder, stroke, muscle weakness, dysphagia, aphasia, and need for assistance with personal care. Further review of the medical record revealed the Resident had a PEG tube and received enteral feedings of Jevity at 90 ml (milliliters) per hour for 16 hours or until 1440 ml infused. On 1/30/24 at 2:04 PM, an initial tour of the Covid-19 unit was conducted. During the initial tour, Resident #117 was observed in bed with eyes closed. The Resident had an enteral nutritional solution hanging on a pole with tubing connected. The enteral nutritional solution was partial empty and an observation was made of no date, time, name or room number on the container or the infusion tubing set. The irrigation syringe had a date of 1/30. On 1/30/24 at 2:45 PM, an interview was conducted with Nurse V who was assigned care of Resident #118. The Nurse was asked about the enteral nutritional solution and infusion tubing set. The Nurse indicated that the prior shift had hung the enteral feeding and tubing but was unsure what time they had hung it and reported it will run for 16 hours or when 1400 ml was infused. When asked about facility policy on labeling the enteral nutritional solution and infusion tubing set, the Nurse indicated that the tubing and solution should be dated and timed, and the solution should have the Resident's name and room number. On 2/6/24 at 12:15 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #118's enteral nutritional PEG tube feeding. The lack of labeling of the enteral solution and the infusion set during the initial tour of the facility was reviewed with the DON. The DON indicated she had been made aware and reported doing education with staff. A review of facility policy titled, Enteral Nutrition, revised 9/22/23, revealed, .a. If an open delivery system is used, administration sets are changed every 24 hours. b. If closed delivery system is used, administration sets are changed per manufacturer's instructions. 13. The irrigation syringe is changed every 24 hours and is labeled with the resident's name and date .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 1.) ensure assistance with obtaining an appointment to fix broken eye glasses for Resident #3; 2.) ensure call lights were accessible for Residents #2, 25, 48, 70, 72, 80, 97, 107, 117, and 118; and 3.) ensure menus met resident preferences for Resident #73 and a Confidential group of Residents, resulting in impaired vision, frustration, unmet care needs, and unpalatable food. Findings include: Initial Tour of the Covid-19 Unit Resident #25 On 1/30/24 at 2:04 PM, an initial tour of the Covid-19 unit was conducted. Resident #25 was in bed, answered questions and engaged in conversation. An observation was made of the call light on the floor and the cord was not positioned on the bed. The call light was not in reach for the Resident. An observation was made of Resident #25's roommate (Resident #118) without the call light in reach and the door closed. The Resident was asked about his call light. The Resident stated, I would use it if it was in reach, and reported he uses the call light when needing assistance to the bathroom, empty the urinal and if I need something. I can't get it off the floor. On 1/30/24 at 2:04 PM, an initial tour of the Covid-19 unit was conducted. Resident #72 was in a room by herself with the door closed. An observation was made of the Resident's call light on the floor and the cord was not in reach for the Resident to use. The Resident answered questions and engaged in conversation. The Resident reported that she did use the call light if she needed something but was unable to reach it. The Resident indicated she wanted the call light in reach. Resident #118 On 1/30/24 at 2:04 PM, an initial tour of the Covid-19 unit was conducted. During the initial tour, Resident #118 was observed in bed with eyes closed. The Resident had an enteral nutritional solution hanging on a pole with tubing connected. An observation was made of the Resident's call light positioned underneath the pillow and not in reach for the resident. The Resident was sleeping and did not arouse to verbal stimuli. The Resident's call light cord can be seen up by the top of the pillow and the device is positioned underneath the pillow. CNA W who was assigned to the Covid-19 Unit, was notified of the call lights not in reach for Resident #25, 72 and 118. Initial Tour of the Facility Resident #70 On 1/30/24 at 12:15 PM, an observation was made of Resident #70 lying in bed with the head of the bed flat. The Resident was interviewed, answered questions and engaged in conversation. When asked about call light response time the Resident reported that it can take 30 minutes to an hour sometimes to answer, and complained they needed more staff. The Resident was on isolation precautions due to a rash on her skin. The Resident was asked where her call light was and reported that it was not in reach. An observation was made of the call light on the floor and the cord was not in reach. The Resident indicated she was not able to get the call light off the floor and that she does use the call light when needing something. Resident #97 On 1/30/24 at 11:29 AM, Resident #97 was observed awake and lying in her bed. The Resident did not answer questions and did not engage in conversation. The Resident's roommate was not in the room and Resident #97 was alone in the room. An observation was made of the Resident's call light on the floor and not in reach of the Resident. Resident #117 On 1/30/24 at 1:23 PM, an observation was made of Resident #117 in the hall sitting in a chair and was observed to ambulate unassisted into her room. The Resident was asked questions but did not respond appropriately or engage in conversation. An observation was made of Resident #117's call light on the floor at the head of the bed and next to the wall. The call light was not easily accessible for the Resident. Nurse X was alerted to the Resident's call light not within reach and indicated call lights should be in reach and that Resident #117 would move things around in her room. The Nurse placed the call light on the bed and reported it did not have a clip on the cord to hold the call light in place. On 2/6/24 at 12:15 PM, an interview was conducted with the Director of Nursing (DON) regarding call lights not accessible to the Resident's and a concern in the Covid-19 Unit of the Resident's with doors closed and no having a call light within reach. The DON indicated she had been made aware of the concern and was doing education with the staff. A review of the facility policy titled, Call lights, effective 4/1/2022, revealed, Policy: Call lights will be placed within the guest's/resident's reach and answered in a timely manner . Procedure: .3. When a guest/resident is in bed or confined to a chair be sure the call light is within easy reach of the guest/resident . Responding to a Call Light: .5. When finished, turn the call light off and replace the call light within guest's/resident's reach . FACILITY On 1/29/2024 at 1:45 PM, during a tour of the 200 hall, lunch trays were observed being served to rooms in the hallway. Nurse N was asked what time lunch was normally served and she said it was usually between 12:30 PM and 1:00 PM. On 1/30/24 at 11:15 AM, Resident #73 was observed sitting on her bed in her room. When asked about her meals at the facility, she stated, The food is cold, all the time. The resident was asked what time lunch was served and she stated, Lunch is usually at 1:00 PM, but it was 2:00 PM yesterday. I don't know why. On 1/30/24 at 2:03 PM, during a meeting with a Confidential group of residents they said they had a problem with cold food at breakfast. When asked what type of food was cold, the residents said the eggs were often cold in the morning. The residents were asked if other foods were delivered cold on their meal trays and they said, No, it was usually the eggs. The residents were asked if they had told anyone about the cold eggs and they all said they had reported it to the staff. On 1/31/24 at 10:39 AM, Registered Dietitian/RD L was interviewed about resident complaints of cold food. The RD said that morning, (Resident #73) told him her eggs were cold this morning. He said he ordered her another tray. He said a new tray was brought up and she wasn't complaining after that. The RD was asked if residents had complained of cold food previously and he said the Dietary Manager usually handled the food questions. On 1/31/24 at 10:45 AM, Certified Dietary Manager/CDM M was interviewed, and asked if she had heard resident complaints about food being delivered to the residents cold and specifically cold breakfast eggs. She said there was one resident that frequently complained of cold breakfast. The CDM said she talked to the residents and routinely met with them at the resident council meetings about food. The CDM stated, Normally the food is taken on a steam table to the floors, and it is served hot. It's delivered faster. The CDM said currently there was a Covid outbreak in the facility and the food was being served from the kitchen; not from the steam tables on the floors. The trays were placed on a covered cart and taken to each floor, where they were served to the residents. The CDM said she temped the food prior to it leaving the kitchen to go to the floors and the temperatures were appropriate in the kitchen. She said she wasn't sure how quickly the residents were served their trays once they reached the floors/halls. A review of the Facility policy titled, Meal Service, dated 8/1/2011 and revised 11/11/2021 identified the following: It is the policy of this facility to provide a dining experience that is conducive to meal acceptance . Guests/Residents meals will be distributed promptly by facility staff . A review of the facility policy titled, Guest/Resident Rights, dated 9/1/2013 and revised 4/28/2022 provided, . The guest/resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . Facility staff will assist guests/residents in exercising their rights . Resident # 107 On 1/29/24 at 2:10 PM, an initial tour of unit three south (3S) was conducted. Resident 107 was awake in bed, although he was non-verbal, he was able to nod to say yes and shook his head to answer yes or no questions. An observation was made of the call light on the floor and the cord was not positioned close to or within reach for R107 while the resident was on the bed. Staff came in the room and found the call light was not in reach for R107. Resident # 48 On 1/29/24 at 2:12 PM, an observation was made of Resident #107's roommate (Resident #48). R48 was found without the call light in reach and the curtain drawn. R48 was non-interviewable with the Brief Interview for Mental Status (BIMS) score of 99 dated 10/14 2023. The observation was made with Staff HH and found the call light to be not within reach of the Resident in bed but tucked in the drawer of the resident's bedside table. Staff HH positioned the call light button with in reach right next to R48 that was in bed. Resident #80 On 1/29/24 at 2:15 PM, an initial tour of the Three South (Unit 3-S) was conducted. Resident #80 was in a room by theirself with the door closed. An observation was made of the Resident's call light on the floor and the cord was not in reach for R80 to use. The Resident answered questions and engaged in conversation. The Resident reported that they would use the call light but was unable to reach it. R80 indicated they wanted the call light within reach in case they needed anything. Resident #2 On 1/29/24 at 2:17 PM, an observation was made with Staff HH and CNA GG. Resident #2 (R2) was sleeping on the bed. R2 was found without the call light within reach and the call button was found by staff wrapped around underneath the residents grab bar. Staff HH untangled the call light cord and positioned the call button close for R3 to use. Resident #3 On 1/29/24 at 2:20 PM, during the initial tour, Resident #3 (R3) was in bed, awake with the TV on. R3 asked if the surveyor would take a look at the letter she just received in the mail from an insurance company. She revealed that she would read the letter but her glasses had been broken and had not been fixed for a little but over a year. When queried, R3 indicated it was broken while at the facility and she has not see the eye doctor. R3 pointed out her eyeglasses that was on the side table. The eye glass frame was intact but the lens came out from the frame. R3 indicated that she loved to read books and would do more word puzzles if she had her glasses. Resident 3 (R3) was admitted to the facility on [DATE] and readmitted on [DATE] with the primary diagnosis of Alzheimer's Disease, Gout, and bipolar disorder, in addition to other diagnoses. According to the Minimum Data Set (MDS) dated [DATE], R3's Brief Interview Mental Status (BIMS) score performed by the facility was 14/15. A score of 13-15 Indicated that the person was cognitively intact. An interview with CNA GG was conducted on 1/29/24 at 2:20 PM. CNA GG revealed that she was unaware that R3 had glasses and had not seen her wear them. On 1/31/24 at 03:39 PM, an interview with Social Worker A was conducted. SWA revealed that R3 was last seen by the eye doctor on 2/10/22. SW indicated that she was unaware about R3's glasses being broken and stated that the policy was that when something was broken, staff will let the social worker know so the resident can see the specialist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake MI00138079. Based on observation, interview and record review, the facility failed to ensure linens were sufficiently available and in good condition for Residents #40, 75, 117 and 375, of 13 reviewed for safe, clean and homelike environment, resulting in a potential for contamination and illness, embarrassment and dissatisfaction with their living conditions. This deficient practice had the potential to affect Residents residing in the facility with a census of 115. Findings include: Resident #75 01/29/24 02:45 PM, an observation was made of Resident #75 lying in bed on his back. The Resident's head of the bed was elevated with two pillows beneath his head. The Resident was interviewed, answered questions and engaged in conversation. The Resident indicated that he had multiple wounds on his buttock and had a wound vac and that he did not have use of his legs. An observation was made of another pillow on a chair in the Resident's room that was ripped in multiple places of the plastic protective covering. The Resident was asked if he used that pillow. The Resident reported that staff use the pillow to help position him in bed. Resident #117 On 1/30/24 at 1:23 PM, an observation was made of Resident #117 sitting in the hall on a chair then ambulating unassisted into her room. The Resident was asked questions but did not answer and did not engage in conversation. Observations were made in the Resident's room of a pillow with rips noted on the plastic covering on the pillow. Nurse X was summoned to the Resident's room to check the other pillow that was covered by a pillowcase. The Nurse was asked to check the condition of the pillow. Of the two pillows, one had tears in the plastic covering and the other was a type of thin cloth that was soiled/dirty. The Nurse was asked what was on the pillow but was unsure. The Nurse explained to the Resident that the pillow was ugly and that they will get fresh pillows. On 1/31/24 at 11:19 AM, an interview was conducted with CNA BB regarding the availability of pillows on the 1 North unit. The CNA checked the linen closet and there were not any pillows available. The CNA indicated they could get them from laundry in the basement. The CNA went with the surveyor to get pillows from the laundry for the unit. The Laundry Aide Y was asked about the supply of pillows. The Laundry Aide found 5 pillows that were available for use. Upon inspection of the pillows, two of the pillows had tears in the plastic protective covering. The Laundry Aide indicated the pillows were not fit for use and discarded the ripped pillows in the garbage. One pillow was covered in stains and the Laundry Aide indicated it was not suitable for use. The remaining 2 pillows had what appeared to be melted plastic or material over the plastic covering. The Laundry Aide was uncertain what looked melted on the pillows and indicated they would be cleaned. That left no pillows that were retrieved for the 1 North unit. On 1/31/24 at 11:27 AM, an observation was made with Nurse CC of the 2 South unit pillow availability. There were beds that were not occupied on the unit and the beds did not have pillows on the made beds. An observation made with Nurse CC revealed no available pillows in the linen closet. An observation was made with Nurse CC of the 2 North unit. There were no available pillows in the linen closet for the unit. At 11:47 AM, the third floor North Unit was checked for a supply of pillows. An observation was made of no pillows on the beds that were not occupied. One Resident did not have a pillowcase covering the pillow that the Resident was using. Nurse CC had gotten a pillowcase for the Residents pillow. An observation was made in the linen room of three pillows on the linen rack. One pillow was identified as a personal belonging to a Resident that was no in the facility, one was badly ripped, and one had melted plastic on the pillow. A review of 3 South Unit revealed no available pillows in the linen closet and two unoccupied beds without pillows. On 1/31/24 at 11:59 AM, an interview was conducted with the Administrator (NHA) regarding the tattered pillows in use and the lack of available pillows. The NHA indicated that pillows in poor condition should be removed from use. The NHA was asked about census and if the facility was at capacity. The NHA indicated that the census was 115, 139 bed capacity with 20 beds offline and reported the facility could have a total capacity of 139 Residents. The NHA was asked if the facility had enough supply of pillows. The NHA stated, No one reported that we need pillows. We can definitely get some, and indicated they should be letting housekeeping know, the DON or Nurse and stated, No one brought the need up that pillows were needed. Resident #40 On 1/31/24 at 9:00 AM, Resident #40 was observed in their room during medication pass observation with Registered Nurse (RN) DD. Resident #40 was laying bed on their back with no pillow. The Resident was observed attempting to hold their head up. When queried regarding not having a pillow, Resident #40 stated, They (staff) left it downstairs. When asked to explain, RN DD revealed the Resident recently returned to their room after having been in isolation due to being positive for Covid-19. When queried if they wanted a pillow, Resident #40 revealed they did and stated, They (staff) said they didn't have any (pillows) up here. Resident #40 was asked how long they had not had a pillow and replied they had not had one since they got back to their room about 1:00 PM yesterday. RN DD asked Resident #40, That was your pillow from home, wasn't it? and Resident #40 replied, Yeah. After exiting the Resident's room, RN DD was asked why no facility staff had obtained/given Resident #40 a pillow but was unable to provide an explanation. Record review revealed Resident #40 was most recently admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), difficulty walking, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and was dependent upon staff to complete all Activities of Daily Living (ADLs). Resident #375 On 1/29/24 at 2:13 PM, Resident #375 was observed in their room. The Resident was in bed, positioned on their back wearing a hospital style gown. The sheets and blanket on the bed were visibly soiled with chunks of unknown dark colored substances. The fitted bed sheet was threadbare and had holes in the fabric. A large rip/hole was present in the plastic of the mattress cover on the left side of the mattress with a foam substance exposed and visible. Resident #375 was unshaven and a dark brown/black substance with present under their fingernails. An interview was completed at this time. When queried regarding the level of assistance they require from staff, Resident #375 revealed they could not get up and were unable to turn and reposition themselves in bed. Resident #375 was asked if they had received a shower or bed bath since arriving at the facility and revealed they had not. Resident #375 was asked how often facility staff changed their bedding and the fitted sheet on their bed and indicated staff do not change the bedding unless it gets soiled. Record review revealed Resident #375 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) and hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), diabetes mellitus, kidney disease, and gastrostomy (surgically created opening in the abdominal wall to the stomach for the introduction of nutrition- commonly called a PEG or G-tube). Review of admission assessment dated [DATE] revealed the Resident was alert to person and time and required total assistance to complete Activities of Daily Living (ADLs). On 1/31/24 at 11:00 AM, an observation and interview were completed with Resident #375. The Resident was in their room, positioned on their back in bed. The fitted sheet on Resident #375's bed remained threadbare with holes in the same place as prior observation in the fabric. The zip/hole was present in the same place on the mattress. An interview was conducted with Unit Manager Licensed Practical Nurse (LPN) B on 2/1/24 at 8:33 AM. When queried if regarding Resident #40 not having a pillow, LPN B revealed they were not aware. With further inquiry regarding why the Resident was not provided a pillow, LPN B stated, (Resident #40) should have had a pillow. No further explanation was provided. When queried regarding the facility process/procedure to ensure linens and mattresses are in good repair, LPN B revealed linens are disposed of when they become worn and that they round to ensure items are in good repair. On 2/1/24 at 9:08 AM, an observation of Resident #375's bedding and mattress was completed with LPN B. After exiting the room, LPN B was queried why Resident #375's fitted bed sheet had holes in the same place since 1/29/24 and why their mattress had a zip/hole in it. LPN B stated, That should have been changed. I will see when (Resident #375's) shower day is and get a new mattress. No further explanation was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 3 residents (#'s 23, 67, 95) of 34 reviewed, resulting in the potential for unmet care needs. Findings Include. Resident #23 Accidents A review of the Face sheet and Minimum Data Set (MDS) assessment indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: History of a stroke, with left side weakness, hypertension, history of seizures, diabetes, depression, dementia, end stage kidney disease, received dialysis, difficulty talking, feeding tube, and difficulty swallowing. The MDS assessment dated [DATE] indicated the resident had severe cognitive loss with a Brief Interview for Mental Status (BIMS) score of 2/15 and the resident needed total assistance with care. During a tour of the facility on 1/29/2024 at 2:18 PM, Resident #23 was observed lying in bed; it was a low bed, with a perimeter mattress. The resident had his right leg over the side of the bed and was very restless. He was alert but did not answer questions; his fingernails were observed to be very long, and soiled. On 1/30/2024 at 11:00 AM, Resident #23 was observed in the day room; he was sitting in a Geri-chair. The chair was leaned back, and the resident was sleeping with his leg dangling over the side of the chair. A review of the medical record indicated Resident #23 had multiple falls while at the facility: 1/22/24, 12/25/23, 12/17/23,, 12/14/23, 11/20/23, 11/19/23, 11/7/23, 10/20/23, 10/17/23, 8/19/23, 7/26/23, and 5/9/23; most of the falls were in his room. The resident rolled out of bed or fell from his chair. A review of the Care Plans for Resident #23 revealed the following: (Resident #23) is at risk for fall . date created 4/22/2022, date initiated 10/3/2023 and revised 1/23/2024, with Interventions: Geri chair, low bed, date initiated 10/18/2023, date created 7/26/2023, revised 10/23/2023. There was no additional explanation or guidance for 'Geri chair or low bed. On 1/31/2024 at 2:15 PM, Resident #23 was observed lying in bed. Nurse O went into his room to see the resident. His fingernails were long and soiled, she said the residents' nails were to be trimmed by the nurse aides when the resident had a bath or shower. On 1/31/2024 at 2: 25 PM, Unit Manager Nurse P was asked about Resident #23's nail care. She said the resident was diabetic and the nurse would trim them. She said each resident had Shower sheets/skin assessments that were completed by a nurse when the resident had a bath or shower and a skin assessment was completed. A review of the shower sheets/skin assessments with Nurse P indicated there weren't any shower sheets/skin assessments for January 2024 for Resident #23. she looked and said she didn't have any others; there was no documentation the fingernails were trimmed. A review of the Care Plans for Resident #23 identified the following: (The resident) is at risk for impaired skin integrity/pressure injury r/t (related to): stroke, dementia, date initiated 4/22/2022 and revised 5/5/2022 with Interventions: Observe finger and toenails on shower days to see if they need to be trimmed, date initiated 9/6/2022. The Care Plan did not indicate when bath/shower days were or who should trim the resident's nails. (Resident #23) has a functional ability deficit and requires assistance . date initiated 10/11/2023 and revised 1/2/2024 with Interventions: Personal Hygiene: Dependent, date initiated 1/2/2024; Bath/Shower: Dependent, date initiated 1/2/2024 On 2/01/24 at 1:57 PM, the Director of Nursing/DON was interviewed related to Resident #23's falls and she stated, He had a stroke before he came and then again last fall. He has had a decline and is not the same; an aide goes with him every day to dialysis since he had his stroke. The DON was asked about Resident #23's interventions to prevent falls and she said the resident Shakes his right leg a lot and it moves him in bed and in the chair; so he uses a Geri chair, and has a perimeter mattress. If he is sleeping we want him in bed; it is a low bed. Reviewed the care plans with the DON related to hygiene/nail care and fall interventions. The Care Plans were not specific to aid in ensuring the resident's care was provided as planned. Discussed who should be completing the nail care and when, as nurses were not sure if it was the nurse aides or nurses who should perform the task or how often. Also, the interventions for Geri chair and low bed had no other information with them. They did not provide guidance to the staff to aid in preventing falls. The DON said Care Plans were a team effort and would be reviewed again. Resident #67 Activities of Daily Living A record review of the Face sheet and MDS assessment indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Depression, COPD, anxiety, Asthma, neuropathy and a liver disease. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 13/15 and the resident needed assistance with care. On 1/29/24 at 2:51 PM, Resident #67 was observed lying in bed; he was awake and alert answering questions. The residents' fingernails were very long. His hair appeared unkempt and unwashed. He said sometimes he received a bed bath, and sometimes a shower; he said the last one was a week or so ago. When asked about his fingernails, he said they are getting long. On 1/31/24 at 2:39 PM, Certified Nursing Assistant/CNA Q was interviewed when she entered Resident #67's room. She was asked about the resident's long nails. The resident held out his hand and showed his nails to her; they were very long, jagged, and soiled. CNA Q said she usually trimmed his nails and was getting ready to trim them. She said he normally had his shower on the 2nd shift and they would trim his nails. The resident said he wanted his nails trimmed. On 1/31/2024 at 2:50 PM Unit Manager P was interviewed about Resident #67's nail care. She said it would be documented on the shower sheets. Upon review of the shower sheet book, there were no shower sheets or skin inspections for the resident in the book. Unit Manager P said the nurse would have done them with a shower or bath. The nurse said the resident usually refused a shower. She was asked what additional interventions had been implemented to encourage the resident to shower or bathe. She wasn't sure. A review of the Care Plans for Resident #67 identified the following: (Resident #67) has a functional ability deficit and requires assistance . date initiated and revised 12/13/2023 with Interventions: Bath/shower: extensive 1 pa(person-assist); Personal Hygiene: extensive 1 pa, both dated initiated and revised 12/13/2023. There was no mention of nailcare or when his bath/showers were scheduled. It did not mention that he refused showers, bathing or nailcare. It did not specify alternate interventions to encourage activities of daily living (ADL) care. Resident #95 Activities of Daily Living A record review of the Face sheet and MDS assessment indicated Resident #95 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, schizoaffective disorder, anxiety, chronic pain, hypertension and COPD. The MDS assessment dated [DATE] indicated the resident had mild cognitive loss with a BIMS score of 12/15 and the resident needed some assistance with care. On 1/29/24 at 2:27 PM, the Resident was observed sitting on her bed in her room. She said she had not had a shower since moving to this part of the building (unit/hallway). She said it had been 4 days since she had a bath. Her hair was observed to be greasy and unkempt. She said it had not been washed. The resident stated, I liked it better on the other hall. They would help you. On 1/31/24 at 2:22 PM, Unit Manager P was interviewed about ADL care and showers for Resident #95, she said the resident would refuse showers and was independent with care. On 1/31/24 at 2:32 PM, Resident #95 was interviewed and stated, They don't offer me a shower; on the other side they would offer me a shower. I don't want to make any waves. They have never offered me one. You shouldn't have to ask; they should ask you. On the other side they had specific people to go in the shower and make sure you wouldn't slip or anything; I appreciated that. The resident was observed to have her nails painted and stated, I wanted them clipped originally but nobody had any clippers. They are almost too long to text with. My toenails are really bad. You get tired of asking at some point. A review of the Care Plans for Resident #95 identified the following: (Resident #95) has a functional ability deficit and requires assistance . dated initiated and revised 12/15/2023 with Interventions: Bath/Shower: Independent; Personal Hygiene: Independent, both interventions dated initiated and revised 12/20/2023. The interventions did not mention nailcare or assistance with ADL's. The Care Plan said independent with showers/bathing, resident prefered some stand by assistance. There were no alternate interventions identified as attempted. A review of the facility policy titled, Care Planning, dated 9/1/2011 and revised 6/24/2021 revealed, Every resident in the faiclity will have a person-centered Plan of Care developed and implemented that is consistent with the residents rights . The care plan must be specific, resident centered, individualized and unique to each resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00134673, MI00134692, MI00136760, and MI00133158. Based on observation, interview and record review, the facility failed to provide activities of daily living (ADL) care for Residents dependent on assistance from staff to provide care for Residents # 3, 23, 25, 36, 59, 67, 95, and 375 of 14 reviewed for ADL care, resulting in a lack of bathing, nail care, shaving, hair care and dressing, with the potential for body odor, infection, embarrassment, and lack of self-esteem. Findings include: Resident #25 A review of Resident #25's medical record revealed an admission into the facility on 6/29/16 with readmission on [DATE] with diagnoses that included multiple sclerosis, depression, anxiety, diabetes, chronic pain syndrome, and polyarthritis. A review of the Minimum Data Set assessment for Resident #25 revealed a Brief Interview of Mental Status (BIMS) score of 14/15 that indicated intact cognition and the Resident needed substantial/maximal assistance with toileting hygiene, and shower/bathing, and needed partial/moderate assistance with personal hygiene. On 1/30/24 at 2:54 PM, an observation was made of Resident #25 lying in bed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about showering/bathing and nail care. The Resident complained that his fingernails were too long, and he needed his toenails trimmed. An observation was made of the Resident's toenails long and some were broken. The Resident indicated his fingernails needed to be trimmed as well. When asked if staff had offered to do nail care on his hands or feet the Resident indicated no staff had offered recently. 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 stroke with hemiplegia and hemiparesis affecting left side, need for assistance with personal care, dementia, anxiety, and contracture of left wrist and left elbow. A Review of the Minimum Data Set assessment dated [DATE] revealed a BIMS score of 7/15 that indicated moderately impaired cognition and needed substantial/maximal assistance with toileting hygiene, shower/bathing, and personal hygiene. On 1/30/24 at 11:05 AM, an observation was made of Resident #36 sitting in a wheelchair by the Nurses' Station. The Resident was interviewed, answered questions and engaged in short conversations. An observation was made of Resident's left hand with fingers curled into the palm. The Resident was asked if he could open his hand. The Resident explained that he could not use the hand and could not open it unless he opened it with his other hand. The Resident showed how he opened his left hand with his right hand. An observation was made of the Resident's left hand with long nails but did not have any wounds on the palm of the hand where the nails rested on the skin of the palm of the hand. The Right hand had long fingernails. When asked if staff have offered to clip the fingernails, the Resident reported that he was unable to clip them and that they have not offered. When asked if he would let them trim his nails, the Resident stated, I would not refuse. They can do it. Resident #59 A review of Resident #59's medical record revealed an admission into the facility on [DATE] with readmission on [DATE] with diagnoses that included syncope and collapse, atrial fibrillation, heart disease, diabetes, and legally blind. A review of the Minimum Data Set assessment revealed the Resident had intact cognition and needed supervision or touching assistance with self-care for personal hygiene and bathing activities. On 1/30/24 at 11:45 AM, during the initial tour of the facility, Resident #59 was observed in his room, dressed and sitting on the side of his bed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about bathing activities. The Resident he had a shower recently and was ok with the facial hair growth on his face. An observation was made of fingernails that were long with some that were chipped and/or jagged on each hand. The Resident complained of them being too long. The Resident indicated that he was blind. The Resident was asked if staff had offered to trim his nails and the Resident replied, No one has offered to cut my nails. On 2/5/24 at 11:10 AM, an interview was conducted with the Director of Nursing (DON) regarding concerns identified during the survey. The concern of the lack of nail care was reviewed with the DON. The DON indicated that she had identified the lack of nail care over the weekend and had started education for staff. A review of facility policy titled, Routine Resident Care, effective 3/7/2023, revealed, .Guidelines . 3. Daily personal hygiene minimally includes assisting or encouraging residents with washing their face and hands, shaving, nail care, combing their hair each morning, and brushing their teeth and/or providing denture care . Resident #375 On 1/29/24 at 2:13 PM, Resident #375 was observed in their room. The Resident was in bed, positioned on their back wearing a hospital style gown. Resident #375 was unshaven and a dark brown/black substance with present under their fingernails. An interview was completed at this time. When queried regarding the level of assistance they require from staff, Resident #375 revealed they could not get up and were unable to turn and reposition themselves in bed. Resident #375 was asked if they had received a shower or bed bath since arriving at the facility and revealed they had not. When queried when they last had a shower, Resident #375 replied, Two weeks ago. When asked if that was okay with them, Resident #375 stated, No. Record review revealed Resident #375 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) and hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), diabetes mellitus, kidney disease, and gastrostomy (surgically created opening in the abdominal wall to the stomach for the introduction of nutrition- commonly called a PEG or G-tube). Review of admission assessment dated [DATE] revealed the Resident was alert to person and time and required total assistance to complete Activities of Daily Living (ADLs). On 1/31/24 at 11:00 AM, an observation and interview were completed with Resident #375. The Resident was in their room, positioned on their back in bed. The Resident remained unshaven and was noted to have a foul odor to their breath. An unopened toothbrush was present in a basket on the Resident's bedside dresser table. No toothettes or other oral cleaning supplies were present. When asked if staff had assisted them to get cleaned up, Resident #375 revealed the staff had did what they could the last time they changed their wound dressings. When Resident #375 opened their mouth, their tongue was observed to be coated in a white colored substance. When asked if their tongue or mouth hurt, Resident #375 revealed it did. On 1/31/24 at 11:10 AM, Registered Nurse (RN) DD was asked if they were aware of the white colored substance on Resident #375's tongue. RN DD revealed they were not but would let the provider know. At 11:30 AM on 1/31/24 11:30 AM, RN DD informed this Surveyor that the provider had assessed Resident #375's mouth and tongue. When asked what the outcome of the assessment was, RN DD stated, The NP (Nurse Practitioner) just think (Resident #375) needs oral care. When queried when Resident #375 had last received oral care, RN DD indicated they did not know and stated, (Resident #375's) hospice. RN DD was asked if facility staff still provide ADL to hospice Residents, RN DD indicated they did. Resident #23 A review of the Face sheet and Minimum Data Set (MDS) assessment indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: History of a stroke, with left side weakness, hypertension, history of seizures, diabetes, depression, dementia, end stage kidney disease, received dialysis, difficulty talking, feeding tube, and difficulty swallowing. The MDS assessment dated [DATE] indicated the resident had severe cognitive loss with a Brief Interview for Mental Status (BIMS) score of 2/15 and the resident needed total assistance with care. During a tour of the facility on 1/29/2024 at 2:18 PM, Resident #23 was observed lying in bed; it was a low bed, with a perimeter mattress. The resident had his right leg over the side of the bed and was very restless. He was alert but did not answer questions; his fingernails were observed to be very long and soiled. On 1/31/2024 at 2:15 PM, Resident #23 was observed lying in bed. Nurse O went into his room to see the resident. His fingernails were long and soiled, she said the residents' nails were to be trimmed by the nurse aides when the resident had a bath or shower. On 1/31/2024 at 2: 25 PM, Unit Manager Nurse P was asked about Resident #23's nail care. She said the resident was diabetic and the nurse would trim them. She said each resident had Shower sheets/skin assessments that were completed by a nurse when the resident had a bath or shower and a skin assessment was completed. A review of the shower sheets/skin assessments with Nurse P indicated there weren't any shower sheets/skin assessments for January 2024 for Resident #23. she looked and said she didn't have any others; there was no documentation the fingernails were trimmed. A review of the [NAME] for Resident #23 identified the following: Bath/Shower: Dependent; Observe finger and toenails on shower days to see if they need to be trimmed; Personal Hygiene: Dependent. A review of the Tasks electronic medical record (emr) documentation for ADL care from 1/2/2024 to 1/31/2024- ADL Care Statement: Have you provided routine standard care which includes evaluating skin daily and reporting changes, shaving and nail care as needed . The nursing staff had checked Yes for each day. The staff documented Yes, but the nail care was not provided. On 2/01/24 at 1:57 PM, the Director of Nursing/DON was interviewed related to hygiene/nail care for the Resident. She said she had heard about this. Resident #67 Activities of Daily Living A record review of the Face sheet and MDS assessment indicated Resident #67 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Depression, COPD, anxiety, Asthma, neuropathy and a liver disease. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 13/15 and the resident needed assistance with care. On 1/29/24 at 2:51 PM, Resident #67 was observed lying in bed; he was awake and alert answering questions. The residents' fingernails were very long. His hair appeared unkempt and unwashed. He said sometimes he received a bed bath, and sometimes a shower; he said the last one was a week or so ago. When asked about his fingernails, he said they are getting long. On 1/31/24 at 2:39 PM, Certified Nursing Assistant/CNA Q was interviewed when she entered Resident #67's room. She was asked about the resident's long nails. The resident held out his hand and showed his nails to her; they were very long, jagged, and soiled. CNA Q said she usually trimmed his nails and was getting ready to trim them. She said he normally had his shower on the 2nd shift and they would trim his nails. The resident said he wanted his nails trimmed. On 1/31/2024 at 2:50 PM Unit Manager P was interviewed about Resident #67's nail care. She said it would be documented on the shower sheets. Upon review of the shower sheet book, there were no shower sheets or skin inspections for the resident in the book. Unit Manager P said the nurse would have done them with a shower or bath. The nurse said the resident usually refused a shower. She was asked what additional interventions had been implemented to encourage the resident to shower or bathe. She wasn't sure. A review of the Tasks electronic medical record (emr) documentation for ADL care for Resident #67 from 1/2/2024 to 1/31/2024- identified the following: ADL Care Statement: Have you provided routine standard care which includes evaluating skin daily and reporting changes, shaving and nail care as needed . hair care . The nursing staff had checked Yes for each day. The staff documented Yes, but the nail care and hair care was not provided. Showering/Bathing Tues/FRI P and PRN (as needed), It was documented Yes on 5 days for the month that the resident received a shower/bath/or bed bath: 1/2/2024, 1/12/2024, 1/16/2024, 1/23/2024 and 1/30/2024. There were 4 instances documented Resident Refused, a shower or bath- 1/5/2024, 1/19/2024 and 1/26/2024. There was no documentation of additional interventions to encourage the resident to receive bathing. Resident #95 Activities of Daily Living A record review of the Face sheet and MDS assessment indicated Resident #95 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, schizoaffective disorder, anxiety, chronic pain, hypertension and COPD. The MDS assessment dated [DATE] indicated the resident had mild cognitive loss with a BIMS score of 12/15 and the resident needed some assistance with care. On 1/29/24 at 2:27 PM, the Resident was observed sitting on her bed in her room. She said she had not had a shower since moving to this part of the building (unit/hallway). She said it had been 4 days since she had a bath. Her hair was observed to be greasy and unkempt. She said it had not been washed. The resident stated, I liked it better on the other hall. They would help you. On 1/31/24 at 2:22 PM, Unit Manager P was interviewed about ADL care and showers for Resident #95, she said the resident would refuse showers and was independent with care. On 1/31/24 at 2:32 PM, Resident #95 was interviewed and stated, They don't offer me a shower; on the other side they would offer me a shower. I don't want to make any waves. They have never offered me one. You shouldn't have to ask; they should ask you. On the other side they had specific people to go in the shower and make sure you wouldn't slip or anything; I appreciated that. The resident was observed to have her nails painted and stated, I wanted them clipped originally but nobody had any clippers. They are almost too long to text with. My toenails are really bad. You get tired of asking at some point. A review of the [NAME] for Resident #95 revealed the following: Personal Hygiene: Independent; Bath/shower: Independent; There was no mention of nail care. The MDS assessment indicated the resident needed some assistance. The resident verbalized she wanted some assistance. On 2/01/24 at 1:57 PM, the Director of Nursing/DON was interviewed related to the lack of hygiene, bathing and nail care for the Residents. She said she had heard about this. A review of the facility policy titled, Routine Resident Care, dated 3/1/2013 and revised 3/7/2023 revealed, Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene . Showers, tub baths, and/or shampooing are scheduled according to person centered care . Daily personal hygiene minimally includes assisting or encouraging residents with washing their face and hands, shaving, nail care, combing their hair each morning, and brushing their teeth and/or providing denture care. Any concerns will be reported to the nurse . Resident's call lights are answered timely, and resident's requests are addressed . Resident #3 A review of Resident# 3 (R3) medical record revealed that R3 was admitted to the facility on [DATE] and was readmitted on [DATE] with the primary diagnosis of Alzheimer's Disease, Gout, and bipolar disorder, in addition to other diagnoses. According to the Minimum Data Set (MDS) dated [DATE], R3's Brief Interview Mental Status (BIMS) score performed by the facility is 14/15. A score of 13-15 Indicates that the person is cognitively intact. R3 requires extensive two-person assistance with activities of daily living ADL, which includes dressing, bed mobility, and grooming. R3 does not ambulate and is transferred using a mechanical lift. R3 was always incontinent with bowel and bladder elimination patterns. The ADL care plan for R3 care plan dated 11/28/2023 indicated a functional ability deficit requiring assistance with self-care/mobility related to fatigue, weakness, impaired balance, impaired cognition, and impaired mobility. R3 required substantial maximum assistance up to fully dependent on ADL and was always incontinent with bowel and bladder elimination. On 02/01/24 at 09:45 AM, R(3) was observed in bed with the breakfast tray on the bedside table. R(3) call light was on. The room overwhelmingly smelled of urine and feces. R3 stated, I'm supposed to be cleaned out and changed for breakfast, but I think the girl was new, and she did not know that I have to get cleaned before I eat breakfast. I wait to get cleaned out before eating. When asked if it happens often, R3 indicated that it happens, especially when they are short. I have to wait a long time soaked down here. (pointing at below her waist). She also indicated that she preferred her hair combed daily, but the staff did not come yesterday when they said they would. R3 stated: They don't seem to have enough help. I hope they come today. I like it when my hair is combed. At 09:50 AM, two certified nursing aides CNA came into the room to respond to the call light and assisted R3.

Based on observation, interview and record review, the facility failed to 1.) properly dispose of expired medication and medical supplies; 2.) properly label medication containers; 3.) sign out narcotic medication timely; and 4.) properly secure medication carts for four of five medication and treatments carts and 3 of 3 medication rooms reviewed for medication storage and labeling, resulting in the potential for administration of expired medications with decreased efficacy, medical procedures and treatments performed with expired medical equipment/treatments and medication diversion. Findings include: On 2/1/24 at 9:26 AM, a review of the 3 South medication room with Unit Manager, Nurse B was conducted. A bottle of Bisacodyl tablets were expired on 1/2024. A container of urinalysis reagent strips was opened with a date labeled 6/28/23. The container of urinalysis reagent strips revealed to be used within 90 days of being opened. Nurse B removed the container of urinalysis reagent strips and the Bisacodyl medication. The 3 South treatment cart was reviewed with Unit Manager, Nurse B. The following observations were made: -Puracol ultra powder, collagen wound dressing, 6 packages with an expiration date 9/1/22. -Microkill Bleach wipes, two individual packages with an expiration date of 4/2020 and 6/2022. -Iodoform packing strips with an expiration date of 1/2021. -Collagen powder in tubes, not dated with an open date and no expiration date of the containers. When asked if the containers were good and how old they were, the Nurse was unsure, indicated the opened one should be dated with an open date and removed both tubes from the treatment cart. On 2/1/24 at 10:32 AM, a review of the 3 North medication room was conducted with Unit Manager, Nurse B. The following observations were made: -Curad Emulsion Dressing, full box, with an expiration date on 6/2022. -Ketoconazole cream, expiration date 1/2024. -Medi honey, opened, Resident's name was not readable. The Nurse was asked who the wound treatment belonged to. The Nurse reported she was unsure due to the label unreadable, indicated it should have a label that was legible and discarded the wound treatment. -Iodoform packing strips, expired 7/2023. -Peri-stoma cleanser, full box, with an expiration date on 12/2023. -UTI-STAT, opened container, not dated, sticky bottle, on the shelf with unopened containers and medications. The Nurse indicated that the bottle should be in the medication cart and not stored on the shelf in the medication room. -Multiple 23 G (gauge) needles, with an expiration date on 10/30/23. On 2/6/24 at 2:01 PM, the 1 North medication cart was reviewed with Nurse I. The following observations were made: -Atropine eye drops, not labeled with an open date. Nurse I was asked about the dating of the eye drops and how long were they good for once opened. The Nurse reviewed a list and indicated they were good for 42 days and should be labeled with an open date. -Ammonia Lactate, opened with no open date and the container did not have a manufacturer expiration date. Nurse I indicated it should be dated when opened. -Random narcotic medication was compared to the narcotic medication sign out sheets. The Hydrocodone/Acetaminophen liquid was compared to the narcotic sign out sheet and was not accurate. Nurse I was questioned why the sign out sheet had more amount of liquid then what was in the bottle. The Nurse reported that she had not signed out the medication from the medication pass in the morning. When asked what time she had given the medication, the Nurse indicated 9:00 am. When asked about facility policy, the Nurse indicated that when you pull a narc, you sign it out. A review of Gabapentin with 15 capsules of the medication in the narcotic drawer and the narcotic medication sign out sheet indicated 16 capsules, the Nurse indicated she had not signed out the medication. The medication room on the 1 North Hall was reviewed with Nurse I. The following observations were made: -Wound cleanser was opened and not dated with an open date. -Rena Vite tablets, with an expiration date of 12/2023. -Refrigerator freezer box was packed with ice around it and had needed to be defrosted. -Laboratory supplies stored underneath the sink area. -Box of laboratory supplies stored on the floor. On 2/7/24 at 10:45 AM, an interview was conducted with the Director of Nursing (DON) regarding the concerns of the medication storage and labeling survey task. The observations made were reviewed with the DON. The DON indicated that the eye drops were to be labeled with an open date. When asked about facility policy on signing out of narcotics, the DON indicated that the narcotics need to be signed out when they are given. A review of facility policy titled, Storage and Expiration Dating of Medications, Biologicals, revision date on 8/7/23, revealed, . 3.3 Facility should ensure that all medications and biologicals are stored separately from internal use medications and biologicals .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication date once opened or opened . 5.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g. needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. 5.4 Wen an ophthalmic solution or suspension has a manufacturer shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container . 6. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels or cautionary instructions. On 1/29/24 at 1:32 PM, the medication cart in the low 300 hallway of the facility was noted to be unlocked and unattended by nursing staff. Several facility residents were present in the hallway near the cart. From 1:32 PM to 1:41 PM, two Certified Nursing Assistants (CNAs) walked past the unlocked medication cart and multiple facility Residents were observed moving past the cart. At 1:41 PM on 1/29/24, Registered Nurse (RN) DD was stopped and asked if the medication cart was unlocked. RN DD went to the cart and confirmed it was unlocked. When queried if the medication cart should be left unlocked and unattended, RN DD revealed it should not be left unlocked. A tour of the low 300 hall medication cart was completed with RN DD at this time. The following items were identified: - Atropine 1% eye drops, Open and Undated, labeled for administration to Resident #35. When queried how long Atropine eye drops are able to be used after being opened, RN DD stated, Usually like two weeks. - Lispro insulin 100 units/milliliter (mL), Dated as opened 11/22/23, Labeled for administration to Resident #90. When queried how long Lispro insulin is able to be used after opening, RN DD did not provide a response but indicated it was no longer good and they would dispose of the insulin. - Lantus Solostar 100 units/mL insulin pen, Undated, Labeled for administration to Resident #90. When queried, RN DD indicated the insulin pen had not been used. RN DD was asked if insulin pens should be stored in the refrigerator until opened and replied, Yes. When asked why the insulin pen was not in the refrigerator, an explanation was not provided. - Admelog Solostar 100 units/mL insulin pen, Open and Undated, Labeled for administration to Resident #375. - Advair 500/50 mcg (microgram) diskus inhaler, Open and Undated, Labeled for administration to Resident #81. - Open and Undated Glucometer testing strips. When queried how long testing strips are able to be used for after being opened, RN DD stated, About 30 days. An interview was conducted with the Director of Nursing (DON) on 2/6/24 at 11:56 AM. When queried if medication carts should be locked when unattended by staff, the DON confirmed they should be. The DON was then informed of medications and glucometer strips noted in the low 300 hallway medication cart. When queried, the DON verbalized understanding of concerns but did not provide further explanation.

Based on observation, interview, and record review, the facility failed to serve, store, and prepare food under sanitary conditions in the facility kitchen, resulting in the increased potential for foodborne illness. This deficient practice had the potential to affect all residents who ate meals prepared by the facility out of a census of 115 residents residing in the facility. Findings include: An initial tour observation of the kitchen was conducted with the Dietary Manager (DM M) and the Assistant Administrator (Staff T) on 1/29/2024 at 12:30 PM. While the kitchen staff were preparing the lunch trays for the residents, the following items were observed: During tray line at approximately 12:42 PM, the DM M was asked to take the temperature of the food in the tray line. After a couple of food temperatures were checked, DM M was asked to refrain from checking the food temperature because DM M was observed checking the food temperature with her bare hands and not putting disposable gloves on. Staff T was present and observed that DM M did not wear gloves during the food temperature check, and instead of using alcohol wipes, DM M used Clorox bleach wipes to wipe the thermometer from food to food in the steam table with her bare hands. When DM M was asked, she indicated they were out of alcohol wipes and used Clorox bleach wipes as an alternative. When asked if it was an appropriate disinfectant alternative, DM M did not answer. DM M was observed putting on disposable gloves and continued to check the food temperature. On 1/29/2024 at approximately 12:44 PM, it was noted that when the DM M turned the faucet on at the three-compartment sink, and observed a leak coming from the hose that runs the water mixed with the sanitizer solution. The DM M indicated that it was her first time seeing the hose squirting everywhere and that no one had reported a problem. DM M confirmed that there was a significant leak coming from the hose and that it needed to be fixed immediately by maintenance. On 1/29/24 at 12:46 PM, the metal rack that stored clean metal pots, metal trays, mixing bowls, and pans was inspected. The clean metal pots, pans, trays, and bowls were stacked and found wet. They were wet and moist when stacked with other metal pots, pans, and trays on top of the other. Staff T separated several metal trays, pots, and pans that were found wet to be washed and processed again. They were removed from the dry rack area. Staff T indicated it needed to go through the wash and dry process again. On 1/29/24 at 12:48 PM, The shelf attached to the wall that held various seasonings was covered with accumulated powdered debris. The DM M indicated that the seasoning area should be wiped down and cleaned at every end of the shift to minimize accumulation. On 1/29/24 at 12:48 PM, The steamer equipment was observed to be turned off. The power and temperature monitor were off. When queried, the afternoon cook (Staff U) indicated that she did not know if there was anything inside it. When the steamer door was opened, Staff U found and validated that inside the steamer contained a bowl of chicken noodle soup and steamed spinach. Although the steam machine was confirmed off, Staff U further explained that she was unaware of how long the food had been left inside the steamer because she had just come in for the afternoon shift. The dayshift must have prepared something and forgotten to tell me. Staff U further indicated that the steamer would automatically shut off when out of water or when the water was low. Staff U stated: I don't know how long the food has been left there since the steamer had stopped. Staff U denied knowing who placed the food inside the steamer or how long the chicken noodle soup and spinach bowl had been there but will be discarded immediately. On 1/29/24 at approximately 12:50 PM, the dietary staff measured the milk temperature and observed that the first Vitamin D milk (individual carton) was 43.1 degrees Fahrenheit and the second Vitamin D milk (individual carton) measured 42.6 degrees Fahrenheit. The dietary staff was asked what the values should be. The dietary staff stated it should be below 42 degrees and discarded the two milk cartons in front of DM M and Staff T. On 1/29/24 at 1:03 PM, DM M and Staff T proceeded to the walk-in refrigerator. There was no thermometer inside the walk-in thermometer found. The DM M and the Staff T confirmed they could not locate the thermometer inside the walk-in refrigerator. The outside digital screen showed 42 degrees Fahrenheit. The walk-in refrigerator contained mixed refrigerated food items (cooked and uncooked), meat, vegetables, pasta, and beverages that required refrigeration or cooling at the right temperature. At 1:05 PM, the outside thermometer registered 41 degrees Fahrenheit, and the Dietary Manager M opened a brand new handheld thermometer package and placed the thermometer inside the walk-in refrigerator, visible for everyone to find. The DM M had indicated that it is in the policy that there must be a thermometer inside the walk-in refrigerator and walk-in freezer. On 1/29/24 at approximately 1:06 PM, the drying rack that held plastic bins, containers, and plastic trays was observed. DM M indicated that the plastic trays, bins, and containers must be completely dry before they are stacked. Staff T and DM M had found several wet plastic trays and plastic containers stacked on each other. The damp plastic trays and containers were immediately separated by Staff T and removed from the rest of the dry plastic containers and plastic trays. The kitchen observation concluded on 1//29/24 at 1:16 PM. On 2/1/24 at approximately 11:00 AM, a kitchen tour with the Registered Dietician (RD L) was conducted. During the interview, RD L was notified of the kitchen findings observed on the first day of the survey. RD L indicated that he had been told of the findings by the kitchen staff. The RD L explained his role as a registered dietician focused on monitoring the residents' clinical dietary status. Meanwhile, the dietary manager and kitchen staff were responsible for preparing, cooking, and serving the food to the residents. On 1/29/24 at 1:15 PM, the policies were explicitly requested for the kitchen's food and beverage temperature policy, use of the steam machine and maintenance policy, and stacking of drying trays, pots, and pans policy. The requesting surveyor did not receive the requested policies prior to the exit date. On 1/30/24 at 3:00 PM, a review of the Safety Data Sheet (SDS) for the Clorox Healthcare Bleach Germicidal Wipes dated January 5, 2015, submitted by the facility was conducted. It specified that the product name is Clorox Healthcare Bleach Germicidal Wipes. The SDS revealed The SDS as specified on page 3, item number four: 4. First Aid Measures . Ingestion . If ingested, drink a glassful of water. Call a doctor or poison control center. On page 4, item number seven specified the following: 7. Handling and Storage . Precautions for safe handling . Handle in accordance with good industrial hygiene and safety practices. Avoid contact with eyes, skin, and clothing. Do not eat, drink, or smoke when using this product. On 2/5/24 at 4:00 PM, the facility policy on Food Purchasing and Storage (last revised date: 11/11/2021) was reviewed. According to the policy under 4. Perishable Storage Facilities: . A thermometer will be permanently displayed inside each refrigerator and freezer .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 100 Hall Covid Unit observations during the initial tour of the facility. On 1/30/24 at 2:04 PM, an observation was made of the 100 Hall unit with the doors closed to the unit. There was a sign on the door that read Stop see nurse before entering. There was no PPE (personal protection equipment) available at the entrance to the unit. The unit was not designated as a COVID-19 unit. Upon entering the unit, there was not a nurse available at the entrance and no PPE was found inside the doors of the unit. The Nurse was found and was asked about the requirements for PPE. The Nurse indicated that an N95 mask was to be worn on the unit and PPE was available outside the Resident's rooms. PPE included N95 mask, face shield or goggles, gown and gloves. The Nurse indicated that everyone on the unit was positive for Covid-19. An observation was made of PPE bins outside of the Resident rooms but not all the bins were properly stocked with the needed PPE when entering the Residents' rooms. The garbage containers were found to be outside of the rooms, positioned in the hall, and were filled with discarded PPE. Hand sanitizer was not readily available outside of each room but had a dispenser on the wall down either side of the hallway. An observation was made of one Resident's room with the door open. When asked about the door not being closed, CNA (Certified Nursing Assistant) W indicated the Resident does not like his room door closed and will open it himself. The CNA indicated that PPE was to be worn while on the unit. An observation was made of room [ROOM NUMBER] with a fan blowing in the room. The door to the room was closed but was opened to enter and exit the room. Nurse V was asked about the fan blowing in the room of a Resident positive with Covid-19. The Nurse indicated having a fan was not recommended, but that family had come in today and wanted the fan blowing for the Resident to be able to rest. The Nurse indicated they recommended not having the fan going but the family had insisted. This citation pertains to Intake #MI00133396. Based on observation, interview and record review, the facility failed to follow evidence-based practices for Infection Control, including Transmission Based Precautions to prevent the spread of the Covid-19 virus. The failure to maintain infection control practices resulted in a likelihood for a serious adverse outcome including the spread of infectious illness. Findings Include: FACILITY Infection Control CDC: Centers for Disease Control and Prevention: Isolation and Precautions for People with Covid-19, updated May 11, 2023, If you have COVID-19, you can spread the virus to others. There are precautions you can take to prevent spreading it to others: isolation, masking and avoiding contact with people who are at high risk of getting very sick. Isolation is used to separate people with confirmed or suspected COVID-19 from those without COVID-19 . On 1/30/2024 at 2:32 PM, a Confidential Group of residents voiced concerns about rooms designated for Covid-19 positive residents. They said the doors to the rooms were open and residents were wandering in the hall, sometimes into the Isolation room and Covid-19 was spreading to many residents on the hall. They said they were worried for themselves and others. On 1/30/2024 at 3:00 PM, the 1st floor North hall was observed to have closed double doors to the unit. There was no sign for Isolation Precautions or Personal Protective Equipment available prior to entering the unit. On 1/31/24 at 11:26 AM, Infection Control/IC Nurse K was interviewed about the Infection Prevention and Control Program. She said there was a Covid-19 outbreak currently in the building. The facility created an enclosed Covid unit on the 1st floor North Hall: IC Nurse K said there were currently 14 residents on the 1st floor Covid unit and another 3 Covid positive residents on the 3rd floor; She said there had been more positive residents (greater than 20) but some were since recovered and out of isolation. The residents on the 3rd floor were co-horted in one room; they were placed in one room because the Covid unit on the 1st floor was full, with 20 residents at that time. She said Nurse R contacted her on Monday 1/29/2024 about co-horting the residents for Covid. Per the IC Nurse, the staff were reluctant to care for the resident's with Covid on the 300 hall. They wanted them transferred to the Covid unit on the 100 hall (1st floor). During the interview with the IC Nurse, on 1/31/2024 at 11:40 AM, she said some staff were reluctant to work in the Covid unit or care for the residents in the 300 hall Covid isolation room. They were worried about contracting Covid and did not want to work with covid positive residents. She said some staff were upset because there was an outbreak of Covid in December 2023 and again in January 2024. The IC Nurse was asked about the Isolation precautions on the Covid unit on the 1st floor. She said there were two hand sanitizers on the wall for the unit for approximately 20 residents. When asked if hand sanitizer was available outside of the resident isolation rooms, she said it wasn't right outside the rooms with the Personal Protective Equipment (PPE). The IC Nurse was asked about the closed doors to the 1st floor Covid unit, and she said the doors to the unit were kept closed. Reviewed that there was no signage for the unit; it was not identified as a Covid unit nor were there signs indicating someone was entering a Covid unit. There was no PPE available outside the covid unit on the 1st floor. She said staff would enter the Covid unit and get an N95 respirator from the nurse's desk inside the unit. The IC nurse was asked if the resident rooms on the Covid unit had their doors closed and she said not all of them. All of the residents on the unit were Covid positive. It was reviewed with the IC Nurse that the 300 hall Covid isolation room also was observed to have the door open, with 3 Covid positive residents inside the room. When asked why the doors to the resident rooms were not closed to aid in preventing the spread of Covid, she stated, The room doors should be closed. When asked if it was a resident safety issue, in leaving them open, she said it was related to resident preference. Some residents liked to look out of the door. She said some of the residents did not want to stay in their rooms or wear a mask, even though they were Covid positive. Staff were not wearing PPE unless they entered a resident room, even if the resident was out of the room. During the interview with the IC Nurse on 1/31/2024 at 12:15 PM, she described the course of the Covid outbreak in the facility. She said it included both residents and staff: one positive staff member 12/13/2023 and one positive resident 12/15/2023, then 4 more residents (100 hall) 12/17/2023 and then one resident 12/19/2023- one staff 12/20/2023 and one staff 12/22/2023. The IC Nurse said the outbreak started 12/13/2023 and went until 12/22/2023. The Current outbreak began 1/17/2024 with 2 positive staff on the 300 hall and continued to 5 staff and 23 residents as of 1/30/2024 with another positive resident on the 300 hall. She said all employees positive in the current outbreak were from the 300 hall. She confirmed the designated Covid isolation room on the 300 hall did not consistently have the door closed and residents wandered in the hall and there was potential exposure of additional residents and staff to Covid. On 2/1/2024 at 1:00 PM, the IC Nurse K was interviewed about the 1st Floor Covid unit, she said there was now signage placed on the closed double doors to the unit indicating it was a Covid unit and there was PPE available at the entrance to the Covid unit to put on prior to entry to the unit. She said additional PPE was present at the entrance to each residents room on the Covid unit. Reviewed isolation rooms on the 300 hall- she said they continue to have PPE outside the doors including N95 masks, gowns, gloves, eye protection and hand sanitizer to be worn prior to entry into the covid positive rooms and to be removed prior to exit and the door was closed. A review of the facility policy titled, Coronavirus (COVID-19), dated origination 3/1/2020 and revised 12/5/2023 provided the following: 'Appropriate measures will be utilized for the prevention and control of the Coronavirus (COVID-19) . Appropriate staff use of Personal Protective Equipment (PPE) . Effective co-horting of residents . All recommended COVID-19 PPE should be worn during care of residents under observation or in Transmission Based Precautions, which includes use of a NIOSH approved N95 or higher-level respirator, eye protection . gloves and gown. Place a resident with suspected or confirmed (COVID-19) infection in a single-person room. The door should be kept closed (if safe to do so) . If co-horting, only residents with the same respiratory pathogen should be housed in the same room . facilities could consider designating entire units within the facility, with dedicated (Healthcare providers), to care for residents . A review of the facility policy titled, Multi Route Transmission Based Precautions, dated 10/30/2020 and revised 8/17/2021 provided, Transmission-based precautions are the second tier of basic infection control and are to be used in addition to standard precautions for guests/residents who may be infected or colonized with infectious agents for which additional precautions are needed to prevent infection transmission . There are three categories of Transmission-Based Precautions: Contact Precautions, Droplet Precautions, and Airborne Precautions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Enteral nutrition (nutrition through a feeding tube into the stomach or intestines) formula was provided as ordered for one resident (Resident #89) of 2 residents reviewed for enteral nutrition, resulting in Resident #89 not receiving the appropriate amount of Enteral formula. Findings Include: Resident #89: Tube Feeding: A review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #89 was admitted to the facility on [DATE] with diagnoses: Dysphagia (difficulty swallowing) following a stroke, hypertension, chronic kidney disease, and weakness. The MDS assessment dated [DATE] indicated Resident #89 had full cognitive abilities and needed assistance with all care. The MDS assessment section K Swallowing/Nutritional Status: Nutrition via a feeding tube. On 12/06/20 22 at 9:09 AM, Resident #89 was observed with an electronic pump for Tube feeding on a pole next to the bed. A bottle of enteral formula was hanging on the pole with the pump and it was not running. The pump was turned off. The resident said it was supposed to run until 10:00 AM and it had been off awhile. There was no reading on the pump to indicate how much had infused or how long it was supposed to run. On 12/06/2022 at 9:15 AM, Nurse P was interviewed, she said Resident #89's tube feeding was supposed to be stopped at 10:00 AM and restarted at 2:00 PM. Nurse P said she did not know how long the resident's tube feeding had been turned off. On 12/6/2022 at 10:16 AM, a bag of tube feeding of tube feeding was hanging on the pole and it was directly connected to the resident's feeding tube in his stomach. It was not connected through the electronic pump and was running via gravity. The tube feeding was dripping very quickly into the tubing. At 10:16 AM, on 12/6/2022 Nurse P was asked if the tube feeding was running by gravity, as the pump was not on. She said it was running by gravity because she didn't have the right tubing to connect the bottle of tube feeding through the pump. The nurse said she was more familiar with a different brand of electronic pump specifically designed for tube feeding; She stated, This is not like that. During the interview with Nurse P on 12/6/2022 at 10:16 AM, she said the resident had told her the tube feeding had been down awhile and she didn't know how long that meant. She said she was worried about him not receiving nutrition. The Nurse was asked at what rate the tube feeding was supposed to be set at and she said it should run at 75 cc/ml an hour. Nurse P was asked if she knew how fast it was running via gravity and she said she didn't know. She said the nurse prior did not tell her in report about the tubing or that the tube feeding was down. She said the resident told her it had been down a while and she didn't know how long that meant, but it was at least since before her shift started. On 12/6/2022 at 10:17 AM Nurse P, disconnected the tube feeding. She said she would restart it when she found the correct tubing to use the pump. 1 On 12/6/2022 at 10:22 AM, Nurse P held up a package of tubing and a full tube feeding bottle, she said she found it in the medication room. She said she would reconnect it after the resident's bath. The Nurse was asked if she received education on the use of the tube feeding pump and supplies. She said she had not. A review of the physician orders for Resident #89 revealed the following: Nothing by mouth diet . start date 10/31/2022. Enteral feed order: every day shift for Tube feeding; Jevity 1.5 at 75 ml/hour x 20 hours. TF (Tube feeding) off from 10:00 AM to 2:00 PM. A review of the Care plans for Resident #89 identified the following: (Resident #89) unable to tolerate nutritionally adequate food and/or fluids by mouth requiring the use of a feeding tube related to:, date created 10/31/2022 and revised 11/1/2022 with Interventions: Administer tube feeding as ordered, date initiated 11/11/2022. (Resident #89) is at risk for impaired skin integrity/pressure injury . date initiated 10/31/2022 with Interventions: Provide diet as ordered . date initiated 11/15/2022. (Resident #89) has an ADL (activities of daily living) self care performance deficit and requires assistance . date initiated 10/3/2022 with Interventions: Eating: NPO (nothing by mouth), Tube feeding, date initiated 11/11/2022. (Resident #89) is at risk for fluctuation in blood sugar levels related to DM (diabetes), created on 11/2/2022 with Intervention: Provide diet as ordered, date initiated 11/2/2022. On 12/7/22 at 4:12 PM, the Registered Dietitian G was asked if he was aware that Resident #89 had not received the ordered amount of nutrition on 12/6/2022, he stated I do the tube feeding rate, nothing else. I don't do anything with the pump; that's nursing. On 12/8/2022 at 11:00 AM, the Director of Nursing was asked about the tube feeding for Resident #89, she said she was aware. A review of the progress notes indicated there was no mention of the resident not receiving the required amount of enteral nutrition. A review of the facility policy titled, Enteral Nutrition, date effective 6/24/2022 provided, Guests/residents maintain acceptable parameters of nutritional status . Each guest/resident is provided with sufficient fluid intake . Guests/residents who are unable to feed themselves receive the necessary services to maintain good nutrition, including at times, enteral nutrition. Enteral feedings are typically indicated for the guest/resident who cannot eat normally . A guest/resident who is fed by nasogastric, dobhoff, gastrostomy or jejunostomy tube receives the appropriate treatment and services .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure sanitary storage of respiratory equipment for two residents (Resident #39 and Resident #94)) and ensure that oxygen was ordered and care planned for one resident (Resident #94) of 2 residents reviewed for respiratory care, resulting in the potential for exposure to infectious organisms for Resident #39 and Resident #94 and inappropriate treatment with respiratory decline for Resident #94. Findings Include: Resident #94: A review of the Face sheet and MDS assessment for Resident #94 indicated an admission date of 6/24/2022 with diagnoses: Paranoid Schizophrenia, depression, anxiety, hypertension, atrial fibrillation, chronic kidney disease, and COPD (Chronic Obstructive Pulmonary Disease). The MDS dated [DATE] identified mild cognitive loss with a BIMS score of 12/15 and needed assistance with all care. The MDS dated [DATE] also indicated Resident #94 was receiving oxygen therapy. Respiratory Care On 12/5/22 at 3:40 PM, Resident was observed with oxygen flowing via nasal cannula (nc). The oxygen rate via concentrator was set at 5 liters a minute. The resident said he had been on oxygen a while. A Nebulizer machine was on the bedside stand. The mouthpiece was lying uncovered on top of various items on the bedside stand. The nebulizer mouthpiece was still connected to the tubing and had not been cleaned after use; observed on 12/5/22 and 12/6/22. A review of the physician orders identified the following: Albuterol sulfate nebulization solution 1.25 mg/3ml: 3 ml inhale orally via nebulizer four times a day for wheezing related to Chronic Obstructive Pulmonary Disease with acute exacerbation, start date 12/1/22. There was no physician order for oxygen to be administered. A provider note dated 11/7/2022 by Nurse Practitioner Q revealed . COPD on 3 to 4L of oxygen, atrial fibrillation on Eliquis, Crohn's disease hypertension, Covid-19 infections, Parkinson's disease kidney cancer history, status post resection, anxiety, depression . Respiratory: supplemental oxygen, wheezing on both anterior lungs . Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation: Lungs were wheezing. 02 sat is 97% on oxygen. Continue 02 as ordered Notify provider for any new changes. On 11/23/22 at 6:10 AM, a progress note written by Nurse R provided, Resident called 911 . Resident complained of not being able to breathe . There was no mention of oxygen administration. A review of the Care plans for Resident #94 revealed the following: (Resident #94) has a potential for difficulty breathing and risk for respiratory complications related to: COPD, date initiated 6/24/2022 on 12/8/2022 the Care plan was updated to include Requires the use of O2 (oxygen). There was no intervention for oxygen listed on the care plan or breathing treatments and the care of the respiratory equipment. On 12/07/22 at 3:06 PM, Resident #94 was observed to have oxygen on via nasal cannula at 5 liters/minute. The resident said he was having difficulty breathing and felt short of breath when getting out of bed to use the restroom. On 12/07/22 at 3:14 PM, Nurse P was interviewed related to Resident #94's use of oxygen she said he was supposed to receive the oxygen but could not find an order for oxygen in the medical record. Nurse P brought her Unit Manager B to also look at the physician orders and they could not find an order for the oxygen. Both nurses said the resident was supposed to receive oxygen. Reviewed with them the oxygen was set at 5 liters, which is a higher rate and would require monitoring. On 12/07/22 at 3:47 PM, the Director of Nursing/ DON was interviewed, she said the nurses had contacted her about the oxygen order for Resident #94. She said she found an old order from March 2022 that was discontinued. She told them to contact the doctor for an order. A review of the policy titled, Use of oxygen, dated effective and revised 8/17/2021 provided, To promote guest/resident safety in administering oxygen . the O2 (oxygen) equipment should be cleaned regularly . A review of the facility Nebulizer protocol titled, Nebulizer Therapy, small volume, dated reviewed 7/29/2022 revealed, Nebulizer therapy is an established component of respiratory care that aids bronchial hygiene . Rinse the nebulizer with sterile water and allow it to air dry, or discard it after the treatment . Resident 39: According to admission face sheet, Resident #39 was a [AGE] year old female admitted to the facility on [DATE], readmitted on [DATE], with diagnoses that included: Chronic Obstructive Pulmonary Disease, Cardiac, Peripheral Vascular Disease, High Lipids, Diabetes, Morbid Obesity, and other complications. According to Minimum Data Set (MDS) dated [DATE], Resident #39 scored a 15 out of 15 on the Cognition Assessment, indicating no cognition impairment. The MDS coded Resident #39 as requiring extensive 2 person assist for Bed Mobility, Toileting and Transfers. Observation of Resident #39 on 12/5/22, reflected Resident #39 resting in her bed. The head of the bed was up in high fowler's position, but Resident #39 was positioned down in the bed, with her head bent forward towards her chest. Resident #39 was receiving oxygen. Resident #39 was asked if she was comfortable and indicated no, she was not, and wanted to be pulled up in bed and indicated it helps with her breathing. Further observation reflected the trapeze bar over the head of the bed, was hung up high around the bar and out of reach. Additional observation in Resident #39's room reflected an oxygen concentrator in use, with tubing extending from the concentrator to Resident #39, and delivering oxygen via nasal cannula to Resident. Observation of the long oxygen tubing reflected there was no label or dating on the tubing anywhere from resident to the concentrator. Resident #39 said they are suppose to change the tubing on Thursday. Also observed, was a Single Volume Nebulizer (SVN) mask that was laying across the top of the night stand, next to the bed. There was an Nebulizer machine present, and a clear plastic bag on the nite stand, for the SVN mask to be placed in when not in use. The SVN mask was not placed in the bag, but was laying on top of the bag crossways. During initial screening of Resident #39 on 12/5/22, Resident #39 was asked about the care she received in the facility. Resident #39 verbalized that she was not receiving the help she needed from staff. Surveyor asked Resident #39 what she meant by that. Resident #39 said that when she puts her call light on to be repositioned in bed, or if she needs care, she has to wait a long time. Resident #39 went on to say that staffing was a problem on the unit. Resident #39 said that most of the time there is only one Aid assigned to the unit, and that she requires two persons to help move her, or get her up, or for most care. Resident #39 verbalized that if there are 2 Aids assigned, one gets pulled to help on other floors, but usually only one Aid is assigned. On 12/6/22, and 12/7/22, observation of the SVN mask reflected it was laying in the same position on the nite stand and not in the bag. Resident #39 was asked if the SVN mask had been cleaned or touched and verbalized, No, it is in the same position as the first day you seen it. The oxygen tubing was still undated. Resident #39 said it is supposed to be change tomorrow. Review of Resident #39's current active physician orders reflected orders for: Continuous Oxygen 2 Liters via Nasal Cannula every shift for COPD (Chronic Obstructive Pulmonary Disease). Change oxygen tubing weekly and date. Albuterol Sulfate Nebulizer Solution (2.5 MG/ML) 3 ml inhale orally via nebulizer every 6 hours as needed for Shortness of Breath. On 12/08/22, an interview with Director of Nursing (DON) was asked about the oxygen tubing being undated/unlabeled, and indicated that the tubing should be labeled weekly with every tubing change. The DON was asked how the SVN mask should be stored and verbalized the mask should be in a plastic bag when not being used. Review of Policy Use of Oxygen' dated as revised 08/17/21, documented: To promote guest/resident safety in oxygen administration, the following guidelines will be observed in administering oxygen: The O2 cannula or mask should be changed weekly and dated. It should be changed when soiled or dirty. The tubing should be kept off the floor. O2 cannula or mask should be stored in a clean plastic bag when not in use. Bags should be changed weekly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #23 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #23 was admitted to the facility on [DATE] with diagnoses: Dementia, diabetes, chronic kidney disease, dependence on renal dialysis, depression, anxiety, hypertension, arthritis, history of falls, neuropathy, and weakness. The MDS assessment dated [DATE] revealed Resident #23 had severe cognitive decline with a Brief Interview for Mental Status (BIMS) score of 3/15 and the resident needed assistance with all care. A review of the facility policy titled, Hemodialysis, dated effective 10/14/2021 revealed, . Hemodialysis is a potentially life-saving procedure that removes blood from the body and circulates it through a purifying dialyzer, then returns the blood to the body. It is used for guests/residents with acute reversible renal failure, or long term for chronic end-stage renal disease . On 12/06/22 at 10:40 AM, Resident #23 was observed sitting in the dayroom with his head in his hands. Nurse P said the resident left for dialysis about 4:45 AM, He leaves early, and had just returned. The nurse was asked if paperwork was sent with the resident when he went to dialysis and she stated, Yes, a book is sent with dialysis forms and then dialysis sends it back. That is before I get here, but I have to assess him when he comes back. A review of the physician orders provided the following: 12/15/2021: Hemodialysis on T (Tuesday), TH (Thursday), SAT (Saturday) . P/U (Pick up) 4:15 AM, chair time 5:30 AM-9:15 AM . (via ambulance). 7/13/2021: Complete dialysis form, notify doctor if refuses two times a day every Tues, Thu, Sat for dialysis. On 12/07/22 at 3:24 PM, the dialysis communication book for Resident #23 was observed at the nurses desk. There were four Hemodialysis Communication Forms dated 11/29/2022, 12/1/2022, 12/3/2022 and one undated form. The forms were divided into three sections: Completed by the facility before departure; Completed at the Dialysis Unit; Completed by the Facility Upon Return. Each of the four forms was incomplete and missing assessment information. The Hemodialysis Communication Form dated 11/29/2022 was blank for the Completed at the Dialysis Unit and Completed by the Facility Upon Return. The Hemodialysis Communication Form dated 12/1/2022 was blank in the section titled, Completed at the Dialysis Unit. The Hemodialysis Communication Form dated 12/3/2022 was blank in the sections titled, Completed at the Dialysis Unit and Completed by the Facility Upon Return. The undated Hemodialysis Communication Form was also blank in the sections titled, Completed at the Dialysis Unit and Completed by the Facility Upon Return. A review of the Hemodialysis Communication Forms scanned into the electronic medical record/emr for 11/1/2022 to 11/26/2022 revealed the following incomplete forms: 11/26/2022, 11/19/2022, 11/17/2022, 11/12/22, 11/8/2022, and 11/1/22. A review of the Care plans for Resident #23 provided the following: (Resident #23) is at risk from complications related to needs hemodialysis due to End Stage Renal Disease, created on 8/16/2018 and revised 12/8/2021 with Interventions: For Hemodialysis: Facility will utilize the Dialysis Communication form to communicate with the dialysis center. Send the dialysis communication book to the dialysis center with each appointment. Upon return from the dialysis center review the communication book including any progress notes. Provide an update to the physician and any staff member/disciplines as needed, date created and initiated 5/30/2019. Based on observation, interview, and record review, the facility failed to communicate with the Dialysis Center, and ensure that Dialysis assessments were completed consistently and correctly by the facility, and the Dialysis Center, for two residents (Resident #23 and Resident #111), resulting in missed documented communication, incomplete and inaccurate Dialysis communication sheets, lack of coordination of care, inaccurate assessments, and the potential for missed complications and unmet needs. Findings include: According to admission face sheet, Resident #111 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: End Stage Renal Disease, Diabetes, High Blood Pressure, Oxygen dependant, on Hemodialysis, and other complications. According to Minimum Data Set (MDS) dated [DATE], Resident #111 scored a 15 out of 15 on the Cognition Assessment, indicating no cognition impairment. The MDS coded Resident #111 as requiring extensive 2 person assist for Bed Mobility, Toileting and Transfers. Review of Resident #111's current active physician orders reflected an order in place for: Dialysis at (gave name) T/TH/Sat (Tuesday, Thursday, and Saturday) at 5 am, requires stretcher and assist of x 1. The facility was asked to provide the Dialysis Communication forms that go to and from Dialysis with the resident on her Dialysis days. The facility provided a book that had Dialysis Communication sheets specific for Resident #111. Review of 'Hemodialysis Communication Form' reflected areas of information to be completed by the facility before Resident #111 goes to Dialysis such as: VS (vital signs), Mental Status, Medications before Dialysis, Medication changes, Pertinent Labs, Condition of shunt, Special Instructions to Dialysis unit, and other things to include on the assessment along with nurse signature. On the form was also an area for the Dialysis Center to complete such as: Pre-Dialysis Weight, Mental Status, Medications during Dialysis, Medication changes recommended, Diet changes needed, Complications during Dialysis, Pertinent Labs, Additional comments, Vital Signs, Post-Dialysis Weight, Dialysis signature. At the bottom of the form was information to be completed by the Facility upon return such as: Vital Signs, Mental Status, Condition of Access site and nurse signature. Review of Dialysis Communication Forms reflected a period of 11/5/22 through 12/6/22, on multiple Forms were not filled out or completed by Dialysis center and/or the Facility. Hemodialysis Form dated 11/05/22, reflected that the Dialysis Center did not document an assessment nor did the facility perform a post Dialysis assessment upon return. Hemodialysis Form dated 11/08/22, reflected that the Dialysis Center did not document a complete assessment. They only documented a Pre-dialysis weight. Vital signs were entered on the form, but were crossed off. The facility also did not perform a post Dialysis assessment upon return. Also there was no Resident name documented on the form. Hemodialysis Form dated 11/15/22, reflected that the facility did not perform a post Dialysis assessment upon return. Hemodialysis Form dated 11/17/22, reflected that the Dialysis Center facility did not document an assessment performed, nor did the facility upon return. Hemodialysis Form dated 11/19/22, reflected that the Dialysis Center did not document an assessment performed. In the vital sign section was only a blood pressure entered as the only piece of assessment completed by the Dialysis Center. There was no pre-Dialysis weight or post-Dialysis weight documented. Hemodialysis Form dated 11/22/22, reflected that the facility did not document an assessment performed upon return to the facility. Hemodialysis Form dated 11/29/22, reflected that the Dialysis Center did not perform or document an assessment on the communication form. The facility also left areas blank on their section of the form and did not document an assessment performed upon return to the facility. Hemodialysis Form dated 12/1/22, reflected that the Dialysis Center did not perform or document an assessment on the Communication form. There were vital signs documented in the section, but were crossed out. There was no pre-Dialysis or post-Dialysis weight documented. On one of the Forms, there was no date as to know when Resident #111 went to Dialysis. The Hemodialysis Form was blank. The DON and Administrator were aware of the incomplete data by Dialysis and by the Facility. The DON was asked who was responsible to complete the form and indicated the nurse who is in care of the resident on Dialysis days and the nurse in care upon return, and the Dialysis Center is supposed to complete their section. Review of Policy 'Hemodialysis' dated 10/14/21, documented: Guests/residents receiving hemodialysis will be assessed pre and post treatment and receive necessary interventions . Under 'Guidelines' number 4. The facility completes the appropriate section of the hemodialysis communication form prior to the guest receiving dialysis session and again when the guest returns . Under number 7. Guest's/residents weight will be completed at dialysis unless otherwise requested by the attending Physician .

Based on interview, and record review, the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day for seven days a week; resulting in the likelihood of inadequate coordination of emergency or routine care with negative clinical outcomes, potentially affecting all residents in the facility. Findings include: During annual survey, the Administrator was asked to provide daily staff posting sheets for 3 month period of September - November, 2022. Review of daily staff posting sheets reflected in a time period of September 2022, October 2022, and November 2022, staff posting sheets documented there were 3 dates without Registered Nurse Coverage. Review of daily posting sheets documented that on: 10/26/22, 6 am-6 PM, and 6 PM -6 am, there was no RN coverage. 11/23/22, 6 am -6 PM, and 6 PM -6 am, there was no RN coverage. 11/26/22, 6 am -6 PM, and 6 PM - 6 am, there was no RN coverage. Also noted was on 9/26/22 and 9/29/22, the census was not documented on the daily posting sheets which reflected incomplete data. Also noted was missing daily posting sheets for the dates: 10/1/22, 10/2/22, 10/8/22, 10/9/22, 10/15/22, 10/16/22, 10/17/22, 10/18/22, 10/19/22, 10/22/22, 10/23/22, 10/27/22, 10/28/22, 10/29/22, 10/30/22. The Administrator was asked were the daily postings sheets were for those dates, and indicated she was not able to find them in the schedulers office, and was not sure where they were. Those additional postings were not provided to Surveyor by end of survey. Further review of the daily posting sheets reflected inaccurate data entered on the sheets for multiple days. On the daily posting sheets listed a phone number and person to contact with concerns after hours. The Administrator's phone number was provided on the form, along with the Director of Nursing. Review of the form reflected that the old DON who was no longer employed at the facility was listed on the dates of: 11/3/22, 11/4/22, 11/7/22, 11/8/22, 11/9/22, 11/10/22, 11/14/22, 11/15/22, 11/16/22, 11/18/22, and 11/29/22. Surveyors were onsite during a time frame of 10/18/22, through 11/7/22, and the facility had an Interim DON in place during that time. The postings reflected incorrect contact information for concerns after hours. During an interview on 12/13/22, the new DON indicated she started on 11/7/22. Her name was documented on some of the postings dated: 11/11/22, 11/17/22, 11/19/22, 11/20/22, 11/21/22, 11/22/22, 11/23/22, and 11/30/22. There was no phone number provided for contact with the new DON on those daily postings. The Old DON contact information was on the other postings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a medication error for one resident (Resident #111) by failing to administer the correct dosage of Cetirizine (Zyrtec) over a 2 month time frame, resulting in the possibility of adverse consequences of the medication, exacerbation of a medical condition, and not following physician's orders for the correct dosage of medication to be administered. Findings include: Resident #111: According to admission face sheet, Resident #111 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: End Stage Renal Disease, Diabetes, High Blood Pressure, Oxygen dependant, on Hemodialysis, and other complications. According to Minimum Data Set (MDS) dated [DATE], Resident #111 scored a 15 out of 15 on the Cognition Assessment, indicating no cognition impairment. The MDS coded Resident #111 as requiring extensive 2 person assist for Bed Mobility, Toileting and Transfers. Review of Resident #111's current active orders reflected an order in place for: Cetirizine HCL tablet 5 milligrams (Zyrtec) give one tablet by mouth one time a day related to allergies. The start date for the order was documented as 10/28/22, and listed as active. During a medication pass in the facility that occurred on 12/08/22, with Licensed Practical Nurse J the following observation took place. LPN J was preparing to administer medications to Resident #111, who was getting ready to go to dialysis for treatment. LPN J pulled the scheduled medications to be administered at 9:15 AM. LPN J verbalized to Surveyor, after she pulled the medication ,popped the Zyrtec into a medication cup, double checked the orders in Point Click Care and with the medication cartridge, that she was not going to administer the Zyrtec. Surveyor asked why she was holding the medication and LPN J indicated it was the wrong dosage that was sent by pharmacy, and in the medication cart. LPN J showed Surveyor the cartridge of Zyrtec and the dosage sent was 10 milligrams and not 5 milligrams, and Surveyor verified what the order was. LPN J indicated she was going to contact the physician for clarification on the dosage to be administered due to what the order is for, and what was sent by pharmacy. The medication was held at that time. LPN J verbalized she did not realize before it was the wrong dosage to be administered. LPN J admitted that she had given that medication the day before along with all the other nurses over the past few weeks because pharmacy had sent only 10 milligrams and never sent 5 milligrams. LPN J verbalized the nurses are not allowed to cut the pills in half and pharmacy did not ever send the correct dosage of 5 milligrams. Surveyor reviewed the Medication Acceptance Record (MAR) for October, November, and December, 2022. Review of the MAR indicated that a dosage adjustment was made on 10/28/22, to administer Zyrtec 5 milligrams once a day, from 10 milligrams, a decreased to 5 milligrams. (dosage cut in half strength). The MAR reflected that the nurses signed as given 10/28/22 - 10/31/22, as administered. The MAR for November also reflected for the whole month Resident #111 received the incorrect dosage of 10 milligrams. Also in December until the 8th was receiving 10 milligrams instead of 5 milligrams, when LPN J held the dosage. The DON and Administrator was made aware of the medication error and was shown the MAR reflecting the order change for a decrease dosage, but not the correct dosage sent by pharmacy. LPN J came to Surveyor after the medication pass was completed with other nurses and informed Surveyor that she contacted the physician and obtained a new order for different medication and correct dosage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #23: Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #23 was admitted to the facility on [DATE] with diagnoses: Dementia, diabetes, chronic kidney disease, dependence on renal dialysis, depression, anxiety, hypertension, arthritis, history of falls, neuropathy, and weakness. The MDS assessment dated [DATE] revealed Resident #23 had severe cognitive decline with a Brief Interview for Mental Status (BIMS) score of 3/15 and the resident needed assistance with all care. On 12/06/22 at 10:40 AM, Resident #23 was observed sitting in the dayroom with his head in his hands. A review of the physician orders revealed the resident was receiving the following medications: Cardura, Cozaar, Hydralazine, Nifedipine heart medication; Colace for constipation; Fluticasone for allergies; Latanoprost eye drops for glaucoma; Novolin 70/30 insulin for diabetes; Phoslo capsule for kidney disease; and Zoloft for depression. A review of the monthly drug regimen reviews for Resident #23 by the facilities pharmacist, indicated recommendations on the 2/22/2022 and 10/25/2022 monthly Consultation Reports. On the 2/22/2022 pharmacy Consultation Report, the pharmacist documented, (Resident #23) is at moderate to high risk for falls and receives a medication that may cause orthostatic (postural) hypotension (low blood pressure) for hypotension: Nifedipine ER (extended release), Doxazosin (Cardura), Hydralazine. Recommendation: Please monitor orthostatic blood pressures periodically . per facility policy or procedures, and as clinically indicated. If orthostasis is noted, please consider reevaluating medications that may be contributing. References: Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. STEADI-Stopping elderly accidents, deaths and injuries. 2019 Sep. There was no response to the recommendation from the provider. The boxes for Physician Response were blank. The options were: I accept the recommendations above, please implement as written or I accept the recommendations above 'With the Following Modifications: or I decline the recommendations above and do not wish to implement any changes due to the reasons below . None of them were checked and it was not signed by the provider. A review of the medical record indicated there was no order or evidence that the facility was taking orthostatic blood pressures for Resident #23. The blood pressures are taken when the resident is lying down, then sitting up and then standing; to identify if the resident's blood pressure drops upon the change in position, which could lead to dizziness, unsteadiness and falls. Further review of the medical record indicated the resident had fallen on 11/27/2022, 11/25/2022, 11/5/2022, 10/17/2022, 8/9/2022, and 7/21/2022 with the following documentation: 11/27/22- resident had unwitnessed fall and was found crawling to bed from restroom, states he self transferred to restroom . 11/25/22- found on floor in between bed and wheelchair. pt stated that he was attempting to get in bed and slipped on to the floor . 11/5/22 with a late entry dated 11/8/22- patient was observed on the floor. no injuries, neurons started . 10/17/2022- Post Fall: Resident slid out of his chair this am . 8/9/22 Encounter note- Nursing reports that resident had an unwitnessed fall, resident slid off the toilet . 7/21/2022- Resident was observed on the floor at 2:25 am, lying supine between his bed and his roommate's bed . Resident #23 had repeated falls and the pharmacist's recommendation on 2/22/2022 was not addressed. On 12/7/22 at 12:30 PM, the Director of Nursing/DON was interviewed about the Pharmacy Recommendations, she said she would look for the reports as they were not in the medical record. 12/7/2022 at 3:30 PM, the DON found the recommendation, but it was not signed. Further review in the medical record indicated it was not addressed by the provider. A review of the facility policy titled, Timeliness of Medication Regimen Review (MRR) Reports, date effective and revised 9/30/2021 provided, The pharmacist will review and report any medication irregularities at least once a month . The consultant will provide monthly MRR reports addressed to the Medical Director, Director of Nursing, and Attending Physician within 3-5 days of completion via secure email or hard copy. The attending physician is expected to review the guest's/resident's individual MRR and document and sign that he/she has reviewed the pharmacist's identified recommendations within 14 days of receipt. If the attending Physician does not respond to the guest's/resident's MRR report within 14 days, the Director of Nursing will notify the physician of pending MRR reports . If by the 21st day, the attending physician has not yet responded . the Director of Nursing will notify the Medical Director . If the Medical Director is also the attending physician, the Director of Nursing will escalate the issue to the facility Administrator . Based on interview and record review, the facility failed to act upon recommendations regarding medication irregularities made by the pharmacist during monthly Medication Regimen Reviews (MRR) for two residents (Resident #23, and Resident #48) reviewed for MRR's, resulting in the potential for inadequate monitoring of laboratory values, missed psychotropic gradual dose reductions, medication changes, not following pharmacy recommendations and adverse side effects of medications. Findings include: Resident #48: According to admission face sheet, Resident #48 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Parkinson's, Diabetes, High Blood Pressure, Dementia, Bipolar and other complications. According to Minimum Data Set (MDS) dated [DATE], Resident #48 scored a 7 out of 15 on the Cognition Assessment, indicating moderate cognition impairment. The MDS coded Resident #48 as requiring extensive 1 person assist for Bed Mobility, Toileting and Transfers. Review of Resident #48's electronic medical record reflected the consultant pharmacist monthly review of Resident #48's Medication Regime, reflected on the dates of 7/27/22, 9/21/22, and 10/25/22, irregularities were noted. In the Progress notes for those dates indicated See Report for irregularities. The Director of Nursing was asked for the reports for the 3 documented irregularities and the response by the facility for the 3 irregularities. On 12/8/22, the DON indicated she could not find the irregularities or the responses. The DON indicated she would reach out to the Medical Group to see if they had any documented responses to the irregularities. By the end of the survey, the DON was not able to find the reports or the responses made by the facility. Resident #48 also had a diagnosis of Bipolar and Major Depression, and was receiving treatments for the diagnoses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility to obtain consents for antipsychotic usage for three residents (Resident #36, Resident #94 and Resident #114), resulting in Resident's #26, #94 and #114 being administered an antipsychotic medication without appropriate consent and risk-versus-benefit analysis of the medications explained to the resident/responsible party and the increased potential for serious side effects and adverse reactions. Findings Include: Resident #114: On 12/6/22 during initial tour Resident #114 was observed and appeared to be comfortable and was in a pleasant mood. On 12/7/22 at approximately 8:45 AM, a review was completed of Resident #114's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, Depression, Anxiety, Alcohol-Induced Persisting Dementia and Dysphagia. Resident #114 was not cognitively intact and had a guardian appointed to make all medical decisions. He additionally required assistance with his Activities of Daily Living (ADL). Further review was completed of Resident #114's records and it yielded the following results: Physician Orders: Risperdal Tablet 1 MG (milligram) started on 7/26/22 - Give 1 mg by mouth in the morning Risperdal Tablet 3 MG started on 8/30/22 - Give 3 mg by mouth every night shift Care Plan: Focus: (Resident #114) is at risk for adverse reaction and side effects r/t (related to) receiving multiple psychotropic medications . Interventions: .Administer antipsychotic medication per orders. Observe for side effects/ineffectiveness . On 12/7/22 at 12:30 PM, an interview was conducted with Social Worker F regarding process for initiating antipsychotic medications. Social Worker F expressed if it is recommended for a resident to being an antipsychotic, a consent and risk vs benefits would be completed with the resident or their responsible party prior to administration. This writer asked Social Worker F if she could locate the consent for Risperdal for Resident #114. Social Worker F perused the resident's chart and was not able to locate any progress notes or documentation indicating the guardian was aware Resident #114 was started on Risperdal and consented to it. On 12/8/22 at 8:40 AM, the DON (Director of Nursing) was asked what her expectation for residents being prescribed antipsychotic medications. The DON reported she would expect when antipsychotic's are initiated that a risk vs benefits, and consent forms are completed with the resident or responsible party. The DON was informed Resident #114 Risperdal was begun in 7/2022 and there was no consent or risk vs benefits form completed. The DON expressed understanding of the concern. On 12/13/22 at 10:00 AM, a review was completed of the facility policy entitled, Psychoactive Medication Management, revised 8/31/22. The policy stated, .5. Confirm and document that the guest/resident representative has been informed of the purpose and potential side effects of antipsychotic's, when in place using the Antipsychotic Risk Benefit Medication Evaluation form. An initial verbal notification is permissible with witness signature. An original signature from the guest/resident representative must follow Resident #36: Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #36 was admitted to the facility on [DATE] with diagnoses: Alzheimer's Dementia, dysphagia and history of liver cancer. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss and needed some assistance with all care. A record review of the physician orders identified the following medications that Resident #36 was receiving: Quetiapine fumarate (Seroquel/ an antipsychotic medication) Tablet 25 mg: Give 1 tablet by mouth two times a day for antipsychotic, start date 10/29/2022 and discontinued 11/30/2022. Quetiapine fumarate Tablet 25 mg: Give 1 tablet by mouth two times a day for antipsychotic, start date 11/30/2022. On 12/07/22 at 1:11 PM during a record review, a Risk/Benefit for psychiatric medications form for Resident #36 was dated 11/3/2022. There was no medication name on the form. It was unclear what the medication was that the Risk to benefit was referencing. The form was signed, but there was no indication for what. There was also an 11/3/2022 consent to treat for behavioral health with boxes to treat or not to treat, neither were checked but the form was signed by the responsible party. It was unclear if there was consent or no consent. Interviewed Social Worker/SW F on 12/7/2022 at 11:30 AM, she was asked about the risk to benefit form for antipsychotic medications and the consent form to treat for behavioral health, she said the forms were incomplete. Social Worker F said she was going to obtain completed forms. Resident #94: Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A review of the Face sheet and MDS assessment for Resident #94 indicated an admission date of 6/24/2022 with diagnoses: Paranoid Schizophrenia, depression, anxiety, hypertension, atrial fibrillation, chronic kidney disease, and COPD (Chronic Obstructive Pulmonary Disease). The MDS dated [DATE] identified mild cognitive loss with a BIMS score of 12/15 and needed assistance with all care. A review of the physician orders for Resident #94 revealed the following: Benztropine mesylate ( a medication used for movement disorders such as Parkinson's) tablet 2 mg: Give 2 mg by mouth one time a day related to Adjustment disorder with mixed disturbance of emotions and conduct, order date 7/28/2022. Risperdal (Risperidone) tablet 2 mg: Give 1 tablet by mouth at bedtime related to Adjustment disorder with missed disturbance of emotions and conduct, order date 8/15/2022. Risperidone tablet (Risperdal) 1 mg: Give 1 tablet by mouth two times a day related to Restlessness and agitation; In addition to 2mg at HS (bedtime) (Total 3 mg at bedtime), date ordered 11/6/2022. On 12/07/2022 at 1:58 PM, a record review revealed a Behavioral health/Psych note dated 11/2/2022. It mentioned benztropine, trazadone (an antidepressant) and Risperdal, all medications Resident #94 was receiving. A Risk vs Benefits/consent for psychotropic medications was dated 6/27/22. The form did not include the name of the medications. There was no explanation referencing what they were or what they were for. The form was signed by Resident #94 on 6/27/22. An 11/7/2022 provider note said, . recommend add risperidone 1 mg daily and risperidone 3 mg at hs 2100 . No consent for the antipsychotic medications was found in the medical record. On 12/7/22 at 3:40 PM, Social Worker F was interviewed about the antipsychotic consent form for Resident #94. The Social Worker said she could not find a consent for the Risperdal, and she was working on that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility 1) Failed to ensure that 2 of 3 Medication storage rooms were free of expired supplies and medications, and 2) Failed to ensure proper completion of 2 temperature logs for medication refrigerators, resulting in the likelihood of administration of ineffective medications, and medication storage at inappropriate temperatures. Findings Include: On [DATE] at 09:50 AM 3-North Medication Room was observed with Nurse E, LPN. A white rolling cart was examined and a bag of Covid PCR test tubes were found expired. Green tops lab tubes were found expired, and urinalysis (UA) yellow top tubes were found expired (in total of 40 tubes). Nurse E collected all in one bag and stated she will give them to the Unit Manager B. Medication room refrigerator was opened and inspected. There was an IV (intravenous) antibiotic Cefepime (piggy bag) for 3 North unit resident dated [DATE]. Medication was not administered when prescribed, bag was left in a refrigerator. When asked, Nurse E said it was not supposed to be stored here. On [DATE] at 10:15 AM during an observation of 1-North Medication Room with Nurse D, LPN, a white rolling cart was noted. On observation there were 9 green-top tubes found expired (on 9/22). During Treatment cart review, 3 wound dressings were found to be expired. Upon review of the storage shelves Zinc supplement bottle was found expired on 5/22, and 2 vitamin E 1000 mg bottles were found expired on 8/22. When asked if these supplies and medications should be in use, nurse D answered that of cause not. During the interview with DON on [DATE] at 01:00 PM, she was made aware of the expired supplies and medications that were found in medication storage rooms on the 1st and the 3rd floor. Medication management Policy was requested and reviewed. Policy effective [DATE] and revised [DATE] had the following indicated: Medications are stored, dispensed, and destroyed in a manner to ensure safety and conformance with state and federal laws. Further: 5. Medications discontinued are maintained in a secured area until returned to pharmacy or destroyed. 6. State law/guidelines are followed for destruction of medications. 11. Medications will be dated and discarded per manufactures guidelines. During a tour of the medication room on 1 North hall, with Licensed Practical Nurse D on [DATE], at 1:33 PM, the following observation occurred: In the medication room, on 1 North Unit, observation of Vaccine Storage Temperature Log for the month of December, 2022, reflected the temperature log used to monitor the temp of the refrigerator, which stores vaccines, and other medications, reflected that the nurses were not consistently completing the Vaccine monitoring sheet, located on the front of the fridge. Review of the monitoring sheet reflected on: [DATE]st, 2nd, (AM and PM shifts) were left blank with no documentation of monitoring completed by both shifts of nurses. Also on [DATE]th (PM shift) was left blank. On [DATE]th, and 7th, was also left blank. On the Vaccine monitoring sheet documented that: Vaccines must be stored between 35 degrees F and 46 degrees F, to maintain potency. Under instructions: Place a checkmark in the box that corresponds with the temperature, day of the month, and/or AM/PM for your temperature check. Then enter your initials and the time you monitored the temperature in the boxes at the top of the chart. The instructions indicated that: If the temperature is in the gray range: -store the vaccines under proper conditions as quickly as possible, -call the vaccine manufactures to determine whether the potency of the vaccine has been affected, and -Call your VFC Consultant. In the fridge was a vial of un-opened TB vaccine, stored in the fridge. LPN D seen the incomplete data. Observation on [DATE], of the North of the Medication room, with LPN J reflected the Vaccine Storage Temperature Log was not consistently being filled out as monitored per instructions. On the Dates of: [DATE]st, (AM and PM shift) not Initialed by a nurse. On [DATE], PM shift, was left blank. Observation in the fridge reflected a vial of TB solution dated [DATE], stored in the fridge. LPN J verbalized, oops, the nurses are not doing what they are supposed to. The DON was made aware of the incomplete data and lack of monitoring of Vaccine Storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide palatable food that is served at appropriate temperatures to two residents (Resident #77 and Resident #323) of 2 residents reviewed, resulting in residents voicing their dislikes of food palatability and eating cold meals. Findings Include: Resident #77: During the facility tour on 12/05/22 at 03:38 PM Resident #77 was observed in her room sitting in a wheelchair. When asked about care in a facility she stated that she was well taken care of. When asked if anything can be better or helped with, she said the food. Resident #77 continue with description of food that she does not like, and how cold meals are. When asked if she ever told anyone about her dislikes and cold food she stated, yes, they know. Resident #77's roommate added that she thought the same- food usually cold when residents get it and not many choices for breakfast. According to admission face sheet, Resident #77 was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses that included: Chronic obstructive pulmonary disease (COPD), Atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your arteries) of native coronary artery, Hypertension (elevated blood pressure), Heart failure, Atrial Fibrillation (dysrhythmia), End stage renal disease and dependence on dialysis, Anemia, Weakness, Anxiety, Major depressive disorder, and Peripheral Vascular disease. According to Minimum Data Set (MDS) dated [DATE], Resident #77 was scored 15/15 on the Cognition Assessment, indicating no cognition impairment or memory problem. According to the MDS, Resident #77 was scored as 2 staff assist with bed mobility, transfers, and toileting. Set up only assistance with eating. On 12/05/22 at 04:11 PM during interview with Dietary Manager S, breakfast food choices were discussed and how residents were able to order alternatives. Provided menus were reviewed and revealed Scrambled eggs served for breakfast every Sunday, Tuesday, Thursday, and cheesy scrambled eggs on Saturday. Manager S stated that she often responds to Resident council and addresses complaints of food. She was not aware of residents being served cold eggs. She said that menus are composed and distributed by corporate office. On 12/06/22 at 09:25 AM (Tuesday after breakfast) during facility tour two other residents confirmed that their breakfasts were cold, especially scrambled eggs. Several residents in a Confidential group also mentioned being served cold food, especially during breakfasts. On 12/07/22 test tray was requested. On 12/07/22 at 01:25 PM two staff members began to pass trays on 2 South. Tray was picked up by surveyor at 02:02 PM after majority of the trays went to the residents (only one tray remained on a serving cart). Immediately, food was tasted. Chicken, green beans and macaroni and cheese were all lukewarm at that time. Coke was sampled, and it was room temperature, not cold. Food overall tasted palatable. Residents Rights Policy was requested and reviewed. Policy effective on 05/01/22 and revised on 04/08/22 indicated: Under Respect and Dignity- The guest/resident has a right to be treated with respect and dignity, including: 3. Reasonable Accommodation. The right to reside and receive services in the facility with reasonable accommodations of guest/resident needs and preferences except when to do so would endanger the health or safety of the guest/resident or other guest/residents. Meal service Policy was requested and reviewed. Policy effective on 11/19/21 and revised on 11/11/21, indicated: Guest/Resident meals will be distributed promptly by facility staff. Resident #323: During a tour of the facility on 12/06/22 at 9:33 AM, Resident #323 said his breakfast was, Not good. The eggs were cold and rubbery. The other meals are ok, but not breakfast. It's cold. I like scrambled eggs, but not cold eggs. A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #323 indicated an admission to the facility on [DATE] with diagnoses: Pneumonia, bipolar disorder, hypertension, history of pulmonary embolism, arthritis, weakness, and kidney failure. A review of the physician orders for Resident #323 provided, Diet: No added salt diet, Level 3 Advanced (Mechanical soft) texture, Thin consistency, date initiated 11/16/2022. On 12/7/22 at 3:55 PM, Registered Dietitian/RD G was interviewed about the resident's complaints of cold food. He said there had been some complaints. He said the facility was not using the steam tables because not all staff were trained on them and they didn't want to try to use them and then trained floor staff were not available to use them. The RD was asked if the residents were able to express their concerns about the food and he said they could file a grievance form. The RD was asked if the facility had a meeting specific to food and the dining experience where they could provide suggestions or relay concerns that they had. The RD said No, there wasn't a meeting like that, but they could discuss it in the monthly resident council meetings. A review of the Care plans for Resident #323 provided the following: Resident is at risk for Nutritional decline, date initiated 11/16/2022 with Interventions: Provide Meals per MD orders, date initiated 11/16/2022. (Resident #323) has alteration in nutritional and/or hydration status Date initiated 11/16/2022 with Interventions: Provide diet as ordered: NAS (no added salt) diet, regular texture, thin consistency, date initiated 11/16/2022; Obtain and honor food preferences within dietary parameters, date initiated 11/16/2022. The resident's Care plan said regular texture diet and the physician orders said Mechanical soft texture. There was a discrepancy. A review of the facility policy titled, Meal Service, effective 11/19/2021 revealed, It is the policy of this facility to provide a dining experience that is conducive to meal acceptance, which includes a quiet, pleasant room, positive staff attitudes, and attractive meal presentation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow evidence-based practices for Infection Control, including analysis and investigation of surveillance data to identify trends and patterns of signs and symptoms of illness to aid in preventing the spread of infection, which could result in infectious illness and death. Findings Include: APIC (Association for Professionals in Infection Control and Epidemiology): APIC TEXT: Surveillance, published October 2, 2014 and revised September 20, 2020, ' . Surveillance can be defined as a comprehensive method of measuring outcomes and related processes of care, analyzing the data . Surveillance is an essential component of an effective infection prevention and control program . Surveillance can be used for the following purposes: . Determine baseline and endemic rates of occurrence of a disease or event; Detect and investigate clusters or outbreaks . detect and report notifiable diseases to the health department . identify organisms and diseases of epidemiological importance .' APIC TEXT: General Principals of Epidemiology, published November 15, 2022, ' . Epidemiology is the study of the distribution and determinants of disease and other conditions in the human populations . The primary purpose of Epidemiology is to aid in the understanding of the cause of disease by knowing its distribution; determinants in terms of person, place, and time . ' APIC TEXT: Outbreak Investigations, published October 2, 2014 and revised April 6, 2020, ' . Outbreaks in healthcare settings are suspected when healthcare-associated infections (HAI's) or adverse events occur above the background rate or when an unusual microbe or adverse event is recognized . Investigations of outbreaks are required to be conducted in a standardized way . The goal of any outbreak investigation is to control the outbreak by identifying and modifying contributing factors . Recognition of a potential outbreak: Epidemics or outbreaks are defined as an increase over the expected occurrence of an event. In some instances, small outbreaks are referred to as clusters, both outbreaks and clusters require prompt investigation . Infection Control O 12/08/20 22 at 3:00 PM, the Infection Control Practitioner A was interviewed during review of Infection Surveillance. The ICP had provided an infection surveillance document that listed 8 residents with diarrhea and all symptoms had started on 12/5/2022. The document indicated all residents were tested for Covid-19 on 12/5/2022 via rapid/Point of care/POC testing and all were negative. The document also said PCR (Polymerase Chain Reaction/ lab testing) results were not yet available for the 8 residents. In addition, the residents were all placed in Isolation on 12/5/2022. Six of the residents resided on the 200 hall in rooms 201-213; the other two residents were on the 3rd floor 300 hall room [ROOM NUMBER]. During the interview with the ICP on 12/8/2022 at 3:00 PM, the ICP was asked about the residents with diarrhea. She said the residents were tested for Covid-19 and were negative. When asked if she had investigated the episodes of diarrhea to determine if they could be caused by something other than Covid-19, the ICP said she thought some of the residents might have been on a stool softener and maybe some of it was possibly food related. The ICP was asked if she had begun an investigation to aid in identifying a potential cause and she said she had not. She did not have a written investigative report. The ICP was asked if there were residents that had experienced gastrointestinal (GI) symptoms other than diarrhea. She did not have additional surveillance data. The ICP was asked if additional testing had been performed to aid in identification and she said there was no additional testing. The ICP was asked if she had contacted the local Health Department to report a potential outbreak and she said she had not. Michigan Department of Health and Human Services-Bureau of Laboratories-Bureau of Infectious Disease Prevention, Rev. 12/2021: 2022 Reportable Diseases in Michigan-By Condition: A Guide for Physicians, Health Care Providers and Laboratories . Report the unusual occurrence, outbreak or epidemic of any disease or condition, including healthcare-associated infections . On 12/12/22 at 11:00 AM, the ICP provided additional infection surveillance documents, one for resident's and one based on identification of Covid-19 for staff. The additional infection surveillance for Residents identified 3 residents with vomiting: 2 on the first floor 100 hall (11/28/2022 and 12/4/2022) and one on the 2nd floor (12/4/2022); all 3 were negative for Covid-19. 3 residents had a fever (100 hall, 200 hall, 300 hall); One resident on the 300 hall tested positive for Covid-19 on 12/6/2022. The remaining 2 were negative. There were 4 staff with either diarrhea, head ache, nausea or vomiting from 11/17/2022- 12/5/2022. One of the staff with GI symptoms tested positive for Covid-19 on 11/25/2022. The remaining did not. The last staff member to report diarrhea was on 12/5/2022. On 12/12/2022 at 2:45 PM, the ICP was interviewed about the cases of staff and residents with GI symptoms. She was asked if she had looked to see where the staff worked (which halls) and when and where the residents were located to aid in identifying a trend. She said she was tracking/contact tracing where positive Covid-19 cases were located for residents and staff. She was not investigating other potential causes of illness. The ICP said the resident's had not been tested for Influenza or investigated for GI illnesses such as Norovirus. On 12/12/2022 at 3:45 PM, the facility Administrator was interviewed related to the lack of analysis and investigation of potential outbreak. She said the ICP was new. A review of the Facility Assessment, dated 10/7/2022, . Describe how you evaluate if your infection prevention and control program includes effective systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals, that follow national standards: The infection control & prevention program uses a variety of systems . to ensure that infectious individuals are speedily identified and effectively managed. County services are utilized in the event of an outbreak . The Infection prevention RN (Registered Nurse) is certified. Infection issues are addressed immediately . The IPC nurse was not a Registered Nurse, and she was not certified; she had received a certificate of completion from a training course for infection control. A review of the facility policy titled, Infection Prevention Program Overview: Infection Prevention Program, effective 10/14/2022 and last revised 9/9/2022 revealed, Mission of Program: The infection prevention and control program (IPCP) must include, at a minimum, the following elements: The facility establishes a program under which it: Investigates, identifies, prevents, reports and controls infections and communicable diseases for all guests/residents, staff, contractors, consultants, volunteers, visitors and others . Is based upon facility assessment; follows accepted standards of practice . The major activities of the program are: Surveillance of infections . There is on-going monitoring to identify possible communicable diseases or infections . Preventing infections . Outbreak investigation . Systems are in place to facilitate recognition of increases in infections as well as clusters and outbreaks .

Based on observation, interview and record review, the facility failed to provide assistance to multiple residents in a dignified manner during mealtime, resulting in meals not being served timely and to all residents at the same time, residents waiting for their food while watching other residents eating, and the potential for a negative psychosocial outcome for residents. Findings Include: On 12/07/22 at 01:12 PM during observation on 2 North three staff members were noted passing lunch trays. By 01:23 PM all trays were passed to the residents and those residents who needed assistance were attended to. On 12/07/22 at 01:25 PM the tray cart was delivered to 2 South unit. There were 2 staff members (nurse aids) who started to pass trays. Five residents were observed in a large dining/activity room next door to the social work office. One resident was waiting in a wheelchair in a hall next to the tray cart. One resident was waiting in a recliner chair next to the nurses' station. Five other residents were observed in a smaller lounge/dining area. Staff proceeded to distribute trays to the residents who were dining in their rooms first. After that, staff began delivering lunch trays to the residents in both lounges who required assistance with eating. One additional staff member, who did not assist with trays distribution, proceeded to assist one resident with the meal. Lunch that day consisted of BBQ chicken, green beans and macaroni and cheese. The appetizing smell of BBQ chicken quickly filled the hallway and dining rooms. Observation was made of a small table, in a smaller dining area, with one resident being assisted with lunch, other resident sitting in a wheelchair across the table with food tray in front of her and waiting for assistance. The third resident had her head down on a table, next to the lunch tray, waiting, licking her lips, and watching other resident eating. This continued for 20 minutes while only 2 staff members were assisting multiple other residents and passing trays as soon as they could. One resident was sitting in a recliner chair next to the nursing station across from the small dining area and was watching other residents eating. Nurse returned to the Unit at 01:53 PM. She did not help with tray distribution to the residents or assisting with feeding. At 01:56 PM there were 2 lunch trays waiting on a food cart (two residents did not receive their meals yet). At 2:00 PM staff member had a chance to assist the residents who were sharing a table with the resident who started her meal 30 minutes prior. By this time mostly all of the residents in rooms finished their meals. A final tray was noted on a food cart at 02:02 PM. It was yet to be delivered to the resident (47 minutes later after first resident had been served lunch). On 12/08/22 at 12:56 PM during the interview with the facility scheduler K, she was asked how many nurse aids and nurses usually scheduled to work 2 South Unit. She responded that usually she will assign 3 aids and one nurse. When scheduler was asked about day shift on 12/07/22 she responded that one aid called in and did not come to work, so only 2 aids were working that day. On 12/13/22 at 12:20 PM during phone interview with DON she was queried if staff shared any information with her regarding difficulty of passing food trays timely with only 2 staff members on 2 South and no additional help. DON responded that she did not hear anything about it. Moreover, she stated, Unit manager was always there to help as well as the nurse on duty. When it was shared with DON that unit manager wasn't there on 12/07/22 during lunch time and nurse was not present for the most of the residents' lunch time and did not help with trays distribution, DON stated that the nurse should have stayed and helped. Review of the facility's provided staffing sheets revealed 2 Nurse aids scheduled for day and afternoon shifts on 2 South (with 1 additional aid providing one on one care for an assigned resident) for the dates of 12/09/22, 12/10/22, 12/11/22 and 12/12/22. Residents Rights Policy was requested and reviewed. Policy effective on 05/01/22 and revised on 04/08/22 indicated: Under Respect and Dignity- The guest/resident has a right to be treated with respect and dignity, including: 3. Reasonable Accommodation. The right to reside and receive services in the facility with reasonable accommodations of guest/resident needs and preferences except when to do so would endanger the health or safety of the guest/resident or other guest/residents. Meal service Policy was requested and reviewed. Policy effective on 11/19/21 and revised on 11/11/21, indicated: 5. Guest/Resident will be assisted to the Dinning Room, as needed, by the facility staff. Positioning and assistance at mealtime will be appropriate for the guests'/residents' needs and is responsibility of the Nursing staff. 6. Guest/Resident meals will be distributed promptly by facility staff. 7. At least one Nursing staff member will be stationed in the Dining Room during meal services to assist guests/residents with eating, to handle any emergency that might arise, and to monitor guest/resident meal acceptance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to review and revise care plans with residents' changes, to ensure that interventions necessary for care and appropriate care services were provided for four residents (Resident #23, Resident #94, Resident #104, and Resident #120) of 27 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #104: On 12/07/22 at 11:20 PM Resident #104 was interviewed in his room. During interview resident shared that he had a procedure done couple weeks ago on his right shoulder. He shared that he had a frozen shoulder and he had to undergo manipulation under anesthesia to fix it. After his (resident's)return from the hospital, he had a new prescription for Oxycodone (prescribed by his surgeon) to manage his pain. Resident #104 stated that he was in constant pain, which was about 6 or 7 out of 10 without pain medications, and around 3 to 4 out of 10 with pain killers. There were no days that he does not feel pain, she said because he also suffers from back pain. Resident #104 shared that he had back pain for a long time now and usually Ibuprofen 800 mg takes care of it, but not for the shoulder. After that procedure his right shoulder is constantly hurting. When asked if nursing staff assesses him for pain regularly, he answered that is it hit or miss, depends on who is working and what shift. According to admission face sheet, Resident #104 was a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses that included: Chronic obstructive pulmonary disease (COPD), Myocardial infarction (heart attack), Atherosclerosis (condition that develops when a sticky substance called plaque builds up inside your arteries) of coronary artery with bypass graft (heart surgery), Hypertension (elevated blood pressure), Wernicke's encephalopathy (a life-threatening illness caused by thiamine deficiency, which primarily affects the peripheral and central nervous systems), Weakness, Low back pain, Anxiety, Major depressive disorder, Insomnia. According to Minimum Data Set (MDS) dated [DATE], Resident #104 was scored 15/15 on the Cognition Assessment, indicating no cognition impairment or memory problem. According to the MDS, Resident #104 was scored as independent for bed mobility, transfers, care, and toileting. On 12/08/22 at 02:00 PM review of the Resident #104 electronic medical records revealed that resident had the shoulder manipulation done on 11/21/22. There also was a physician's order: Oxycodone HCl Capsule 5 MG Give 1 tablet by mouth every 6 hours related to pain in a right shoulder. Start date: 11/21/22 at 06:00 PM. Resident #104's Care Plan revealed the following: Focus: Resident #104 is at risk for pain related to diagnosis of lower back pain. Date Initiated: 12/01/2021. Created on: 12/01/2021. Revision on: 06/09/2022. Goal: (Resident #104) will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Date Initiated: 12/01/2021. Created on: 12/01/2021. Revision on: 12/06/2021. Interventions: - Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding to the physician. Date Initiated: 12/01/2021. Created on: 12/01/2021 - Encourage/Provide Non-Pharmacological interventions to prevent/manage pain as needed such as Positioning devices, Relaxation techniques such as deep breathing, meditation, prayer, shower. Distraction such as music, television, activities of choice. Date Initiated: 12/01/2021 Created on: 12/01/2021. Revision on: 12/01/2021 - Evaluate characteristics of pain on a scale of 0-10 or on a Verbal description scale: Mild, Moderate, Severe, Very Severe, Horrible. Date Initiated: 12/01/2021. Created on: 12/01/2021. Revision on: 12/01/2021 - Evaluate the effectiveness of pain interventions as given. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition as needed. Date Initiated: 12/01/2021. Created on: 12/01/2021 - Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Date Initiated: 12/01/2021 Created on: 12/01/2021 - Observe for pain presence Q shift as needed. Date Initiated: 12/01/2021. Created on: 12/01/2021. Revision on: 12/01/2021 - Observe for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Date Initiated: 12/01/2021. Created on: 12/01/2021 - Provide resident with reassurance that pain is time limited. Date Initiated: 12/01/2021 Created on: 12/01/2021. Revision on: 12/01/2021 - Refer to therapy as needed Date Initiated: 12/01/2021. Created on: 12/01/2021. Resident #104's Care Plan was not updated after his surgical procedure on 11/21/22 and increased ongoing shoulder pain was not addressed in a Focus area or Interventions. Resident #120: On 12/06/22 10:40 AM Resident #120 was observed in his room lying in bed. During room observation wheelchair was noted close to resident's bed. Resident #120 was asked if he was able to get up on his own, and he said yes. He then proceeded to get up from his bed and insisted on demonstrating how he transfers himself. He stated that he has ongoing knee and back pain due to the accident that happened sometime ago. Resident also shared that his knees sometimes give in, and he can't use his walker anymore, now he has to use a wheelchair. While continuing conversation, Resident #120 stated that when he leaves facility and goes out to smoke or to a gas station near by wheelchair works better for him, even though sidewalks are narrow, and he got stuck several times in a past month. When asked how often he goes outside, resident said that he goes at least 3 times a day. He stated he will try to quit smoking in January. On 12/07/22 at 08:32 AM Resident #120 was seen leaving facility in a wheelchair, dressed appropriately for the weather. After leaving the building he lighted up his cigarette on a corner of the building and proceeded to smoke it. According to admission face sheet, Resident #120 was a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses that included: Atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your arteries) of native coronary artery, Hypertension (elevated blood pressure), Type 2 Diabetes with diabetic neuropathy (nerve damage that is caused by diabetes), Muscle weakness, Difficulty walking, Major depressive disorder, Insomnia. According to Minimum Data Set (MDS) dated [DATE], Resident #120 was scored 14/15 on the Cognition Assessment, indicating no cognition impairment or memory problem. According to the MDS, Resident #120 required one staff assistance with bed mobility, transfers, care, and toileting. On 12/07/22 03:00 PM review of the Resident #120 Care Plan revealed the following: No Care Plan interventions were noted regarding resident's smoking status, education for smoking cessation or safety while outside the facility. Further review of Resident#120's care plan revealed the following: Focus: Resident has an ADL Self Care Performance Deficit and requires assistance with ADL's and mobility. Interventions: Transfer: Limited 1PA (person assist). Date Initiated: 11/15/2022. Created on: 11/15/2022. Revision on: 11/28/2022. Ambulation: Supervision with rolling walker. Date Initiated: 11/15/2022 Created on: 11/15/2022. Revision on: 11/15/2022. No updates in ADL Care plan were found to reflect resident's changes in ambulation ability and use of a wheelchair. On 12/07/22 at 10:41 AM copies of sign out sheets for the past 2 weeks for all residents in a facility were requested from the front desk and reviewed. During interview with nurse E, LPN on the 1st North floor (unit where Resident #120 resided), she stated she was new to the facility and was not aware about the LOA (leave of absence) folder that residents had to sign in before leaving the unit. Nurse E wasn't sure about how she can find out who is able and allowed to leave the facility, she said she would consult social worker about that information. On 12/07/22 at 12:25 PM LOA (leave of absence) folder for the 1st North floor was requested and reviewed. Resident #120's name was not on the LOA list. Resident #120's Face sheet was noted in a folder. Under the sign out tab there was a clean (not filled) sign out sheet with no dates/times or Resident 120's signature. On 12/08/22 at 12:45 PM Resident #120's smoking on facility's premises, lack of assessment for safety, lack of interventions in resident's care plan for smoking and safety while leaving the facility was discussed in detail with Administrator. Resident #23: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #23 was admitted to the facility on [DATE] with diagnoses: Dementia, diabetes, chronic kidney disease, dependence on renal dialysis, depression, anxiety, hypertension, arthritis, history of falls, neuropathy, and weakness. The MDS assessment dated [DATE] revealed Resident #23 had severe cognitive decline with a Brief Interview for Mental Status (BIMS) score of 3/15 and the resident needed assistance with all care. On 12/06/22 at 10:40 AM, Resident #23 was observed sitting in the dayroom with his head in his hands. Nurse P said the resident left for dialysis about 4:45 AM, He leaves early, and had just returned. The resident was asked if he already had breakfast and he stated, I don't know. I am not sure. A review of the physician orders provided the following: 3/8/2021: Renal diet-Regular texture, Thin consistency (fluids). 12/15/2021: Hemodialysis on T (Tuesday), TH (Thursday), SAT (Saturday) . P/U (Pick up) 4:15 AM, chair time 5:30 AM-9:15 AM . (via ambulance). A review of the Care plans for Resident #23 provided the following: (Resident) has potential alteration in nutritional and/or hydration status related to history of . kidney failure . diabetes. Increased nutrient needs secondary to ESRD (end stage renal disease) on (hemodialysis). Therapeutic diet in place . history of poor po (oral) intake . Date initiated 8/27/2018 and revised 11/19/2022 with Interventions: Provide and serve diet as ordered: Renal, Regular texture, Thin liquids, Monitor Intake per policy, 8/27/2018 and revised 6/4/2020. There was no mention of sending the resident breakfast bag to dialysis with him on Tuesday, Thursday and Saturday. (Resident) is at risk of complications related to diagnosis of Renal failure: End stage disease (chronic kidney disease stage 4), dated initiated and revised 2/17/2021, with Interventions: Dietary consult as needed to regulate dietary needs, date initiated 2/17/2021. There was no mention of sending the resident a breakfast to dialysis, or ensuring he received a breakfast when he returned. (Resident) is at risk for fluctuation in blood sugar levels related to: Dialysis, Diabetes, Requires daily insulin, date initiated and created 5/30/2019, with Interventions: Offer substitute for foods not eaten, date initiated 5/30/2019. There was no mention of ensuring that Resident #23 received breakfast on the days he received dialysis. An interview on 12/07/22 at 4:07 PM with Registered Dietitian (RD) G about Resident #23 going to dialysis early in the morning revealed, We have a breakfast bag for them to take. RD G was asked how often the resident was weighed and he stated, He should be weighed monthly and before and after dialysis. The RD was asked if the staff were providing the bagged breakfast on dialysis days for Resident #23 and he said he did not know. Resident #94: A review of the Face sheet and MDS assessment for Resident #94 indicated an admission date of 6/24/2022 with diagnoses: Paranoid Schizophrenia, depression, anxiety, hypertension, atrial fibrillation, chronic kidney disease, and COPD (Chronic Obstructive Pulmonary Disease). The MDS dated [DATE] identified mild cognitive loss with a BIMS score of 12/15 and needed assistance with all care. The MDS dated [DATE] also indicated Resident #94 was receiving oxygen therapy. Respiratory Care On 12/5/22 at 3:40 PM, Resident was observed with oxygen flowing via nasal cannula (nc). The oxygen rate via concentrator was set at 5 liters a minute. The resident said he had been on oxygen a while. A Nebulizer machine was on the bedside stand. The mouthpiece was lying uncovered on top of various items on the bedside stand; observed both on 12/5/22 and 12/6/22. A review of the physician orders identified the following: Albuterol sulfate nebulization solution 1.25 mg/3ml: 3 ml inhale orally via nebulizer four times a day for wheezing related to Chronic Obstructive Pulmonary Disease with acute exacerbation, start date 12/1/22. There was no physician order for oxygen to be administered. A review of the Care plans for Resident #94 revealed the following: (Resident #94) has a potential for difficulty breathing and risk for respiratory complications related to: COPD, date initiated 6/24/2022 on 12/8/2022 the Care plan was updated to include Requires the use of O2 (oxygen). There was no intervention for oxygen listed on the care plan or breathing treatments and the care of the respiratory equipment. On 12/07/22 at 3:06 PM, Resident #94 was observed to have oxygen on via nasal cannula at 5 liters/minute. The nebulizer mouthpiece was apart on a tray and cleaned. On 12/07/22 at 3:14 PM, Nurse P was interviewed related to Resident #94's use of oxygen she said he was supposed to receive the oxygen but could not find an order for oxygen in the medical record. A review of the facility policy titled, Care Planning, dated effective and last revised 6/24/2021 provided, Purpose: Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment . The care plan must be specific, resident centered, individualized and unique to each resident . It should be oriented toward preventing avoidable declines; How to manage risk factors . The care plan and resident [NAME] will be updated on Admission, Quarterly, Annually and with significant changes. This includes adding new focuses, goals, and interventions and resolving ones that are no longer applicable as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to complete timely assessments to determine the need for enabler bars, monitor residents' continued use of bedrails, obtain physicians' orders, implement care plans, and obtain consent prior to use for eight residents (Resident #34, Resident #37, Resident #53, Resident #60, Resident #70, Resident #75, Resident #96, Resident #111) reviewed for bed mobility resulting in the potential for entrapment, decline in mobility and death. Findings Include: Resident #53: During initial tour on 12/6/22, Resident #53 was observed enjoying his breakfast in bed. He had bilateral assist bars for mobility. On 12/6/22 at 12:10 PM, a review was completed of Resident #53's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Congestive Heart Failure, Diabetes, Alzheimer's, Hypertension, Adjustment disorder with anxiety. Resident #53' has a guardian for decision making. Further review of Resident #53's records yielded the following: Physician Orders: There was no order found for Resident #53 bilateral assist bars Care Plan: Interventions: .bil assist bars for increased bed mobility . date initiated 11/7/2020. Physical Device Evaluation: - 8/18/2021 - 6/8/2022 Equipment and Device Safety Log (completed by Maintenance Director every 3 months to check securement and safety of assist bars) - The log showed maintenance was informed Resident #53 had assist bars on 7/26/22. From the care plan his assist bars were installed in November 2020 and does not appear there was continued assessment and securement check completed at the appropriate intervals. It can be noted there is no clear date indicated in Resident #53's record as to when the bilateral enabler bars were initiated. On 12/7/22 at 3:38 PM, an interview was conducted with Therapy Manager M regarding facility resident's enabler bars. She reported when a new resident is admitted (and quarterly) they complete assist bar evaluation during their assessment under Bed Mobility, but it (assist bars) is not explicitly stated under that section of the assessment. Manager M stated the appropriate assessment for the assist bars is titled Physical Device Evaluation, and that is completed by nursing staff. On 12/8/22 at approximately 12:30 PM, a tour was completed of a subset of facility residents with enabler bars. From Maintenance's safety assessments there are 29 residents in the facility with enabler bars. The following 7 residents were reviewed for this usage: - Resident #34 - Resident #96 - Resident #37 - Resident #70 - Resident #75 - Resident #111 - Resident #60 On 12/8/22, a review was completed of the above 7 residents medical records, and it was found the initial documentation, consents, physician orders and continued assessments for enabler bars were inconsistent amongst the residents. All the residents did not have continued Physical Device Evaluation and the inception dates of the bars were not clear. It was concluded from the review the process to initiate and the continued use of the enabler bars lacked appropriate implementation, communication, and documentation. Resident #34: Resident #34 admitted to the facility on [DATE] with diagnoses that included Dysphagia, Hypertension and Progressive Bulbar Palsy. Resident #34 is her own responsible party. Resident #34's initial order for assist bars was initiated on 6/8/22, a consent was signed 3 weeks later, and maintenance was made aware of the assist bars on 7-26-22 (over a month later). Resident #96: Resident #96 was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder, Adjustment Disorder, Hyperlipidemia and Hypertension. The resident is her own responsible party. Resident #96's initial order for assist bars was initiated on 6/8/22, a consent was signed 3 weeks later and maintenance was made aware of the assist bars on 7-26-22 (over a month later). Resident #37: Resident #37 was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure, Dementia, Anxiety, Schizophrenia and Bipolar Disorder and is her own responsible party. Resident #37's initial order for assist bars was initiated on 11/7/2020, a consent was signed 5 months later, and maintenance began their safety evaluations in 7/2021 (8 months after placement). Resident #70: Resident #70 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Heart Disease, Hyperlipidemia and Dementia and his sister is his guardian. Resident #70's initial order for assist bars was initiated on 6/8/2022, a consent was signed on 6/29/22 and maintenance began their safety evaluations on 1-10- 22 (5 months before the physician order was entered) which indicated the resident had the assist bars 5 months before appropriate assessment and authorization was in place. Resident #75: Resident #75 was admitted to the facility on [DATE] with diagnoses Major Depressive Disorder, Adjustment Disorder, Insomnia, Alcohol Polyneuropathy and is his own responsible party. Resident #75's initial order for assist bars was initiated on 6/8/2022 and a consent was signed 3 weeks later. Maintenance began their safety evaluations on 1-10-22 (5 months before the physician order was entered) which indicated the resident had the assist bars 5 months before appropriate assessment and authorization was in place. Resident #111: Resident #111 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease, Acute Kidney Failure, Hypertension, Anemia, and Diabetes and is her own responsible party. Resident #111's initial order for assist bars was initiated on 6/8/2022 and maintenance began their safety evaluations on 4-6-2022. Resident #60: Resident #60 was admitted to the facility on [DATE] with diagnoses that included Diabetes, Hypotension, Atrial Fibrillation, Tachycardia, Spinal Stenosis, Chronic Obstructive Pulmonary Disease and is her own responsible party. Resident #60's initial order for assist bars was initiated on 6/8/2022, a consent was signed on 4-21-2021 and maintenance began their safety evaluations on 7-22-22 (over a year after the consent was signed). On 12/8/22 at 12:41 PM, Nurse J was queried on who was responsible for ongoing assessments for their residents with enabler bars. Nurse J stated the nurses are not responsible for the assessment and was not sure who was. On 12/8/22 at 12:50 PM, Nurse O was queried on who was responsible for ongoing assessments for their residents with enabler bars. Nurse O reported nursing staff does not complete the assessment but believed that therapy did. On 12/8/22 at 1:20 PM, Maintenance Director N was interviewed regarding his safety assessment for residents assist bars. Director N explained therapy will assess the resident for mobility and if they meet criteria, they input a request into their maintenance system and only then will they then install the assist bars. He continued he will only know about the assist bars through their maintenance system and he then completes quarterly audits for safety and functionality. On 12/8/22 at 2:56 PM, an interview was conducted with Administrator and DON (Director of Nursing) regarding assist bars for their residents. We discussed the inconsistencies with initial and ongoing assessment and monitoring of assist bars, how therapy , there is in no master list of residents with assist bars with their inception date and the supporting documentation (care plan, consents, physician orders, evaluations) is not consistent amongst any of the residents. It was further discussed their policy does not clearly define the entire process and is intertwined with their restraints policy. The Administrator and DON expressed understanding to the concern. On 12/13/22 at 1:00 PM, a review was completed of the facility policy entitled, Restraint Management, revised 9/9/2022. The policy stated, .Whenever a guest/resident is admitted with an order for a restraint (including side rails), the staff may accept the order for up to 72 hours pending completion of the Physical Device Evaluation .A Physical Device Evaluation will be completed prior to initiating a device by a licensed nurse or the interdisciplinary team .The guest/resident, family member or legal representative will be included in the decision process. They will be fully informed .Any guest/resident using a physical restraint or side rail must have a current, signed restraint consent in the medical record . Any guest/resident using side rails will have a current order with the following components: Type of side rails; Number of side rails to be raised; reason for use/medication symptom; Guest/resident request for use of side rails (if applicable) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate staffing to meet residents' needs, provide adequate and timely assistance with meals, transfers, and repositioning, resulting in observation of residents waiting for assistance with meals, residents voicing concerns about their safety and appropriate staffing in the facility. Findings include: On 12/07/22 at 01:25 PM the tray cart was delivered to 2 South unit. There were 2 staff members (nurse aids) who started to pass trays. One additional staff member, who did not assist with trays distribution, was assigned to assist resident with the meal. Observation was made of multiple residents sitting in a hall and dining areas waiting for their trays and watching other residents eating for 20 to 30 minutes. Nurse came to the floor at 01:53 PM. She did not help with tray distribution to the residents or assisting with feeding. At 01:56 PM there were 2 lunch trays waiting on a food cart (two more residents did not receive their trays yet). A final tray was noted on a food cart at 02:02 PM. It was yet to be delivered to the resident (47 minutes later after first resident received lunch). On 12/08/22 at 12:56 PM during the interview with the facility scheduler K she was asked how many nurse aids and nurses usually scheduled to work 2 South Unit. She responded that usually she will assign 3 aids and one nurse. When scheduler was asked about day shift on 12/07/22 she responded that one aid called in and did not come to work, so only 2 aids were working that day. On 12/13/22 at 12:20 PM during phone interview with DON she was queried if staff shared any information with her regarding difficulty of passing food trays timely with only 2 staff members on 2 South. DON responded that she did not hear anything about it. Moreover, she stated, Unit manager is always there to help as well as the nurse on duty. When it was shared with DON that unit manager wasn't there on 12/07/22 and nurse was not present for the most of the residents' lunch time and did not help with trays distribution, DON stated that the nurse should have stayed and helped. Review of the facility's provided staffing sheets revealed 2 Nurse aids scheduled for day and afternoon shifts on 2 South (with 1 additional aid providing one on one care for an assigned resident) for the dates of 12/02/22, 12/09/22, 12/10/22, 12/11/22 and 12/12/22. Meal service Policy was requested and reviewed. Policy effective on 11/19/21 and revised on 11/11/21, indicated: 5. Guest/Resident will be assisted to the Dining Room, as needed, by the facility staff. Positioning and assistance at mealtime will be appropriate for the guests'/residents' needs and is responsibility of the Nursing staff. 6. Guest/Resident meals will be distributed promptly by facility staff. 7. At least one Nursing staff member will be stationed in the Dining Room during meal services to assist guests/residents with eating, to handle any emergency that might arise, and to monitor guest/resident meal acceptance. Resident 39: According to admission face sheet, Resident #39 was a [AGE] year old female admitted to the facility on [DATE], readmitted on [DATE], with diagnoses that included: Chronic Obstructive Pulmonary Disease, Cardiac, Peripheral Vascular Disease, High Lipids, Diabetes, Morbid Obesity, and other complications. According to Minimum Data Set (MDS) dated [DATE], Resident #39 scored a 15 out of 15 on the Cognition Assessment, indicating no cognition impairment. The MDS coded Resident #39 as requiring extensive 2 person assist for Bed Mobility, Toileting and Transfers. Resident #39 was dependent on oxygen. Observation of Resident #39 on 12/5/22, reflected Resident #39 resting in her bed. The head of the bed was up in high fowler's position, but Resident #39 was positioned down in the bed, with her head bent forward towards her chest, with her chin resting on her chest. Resident #39 was receiving oxygen. Resident #39 resided on the 1 North hall. Resident #39 was asked if she was comfortable and indicated no, she was not, and wanted to be pulled up in bed and indicated it helps with her breathing. Further observation reflected the trapeze bar (assist bar) over the head of the bed, was hung up high around the bar and out of reach. An interview was conducted with Resident #39 on 12/5/22, during initial screening. Resident #39 was asked how the care was and staffing. Resident #39 said, They are short staffed. There is not enough help here. I am 2 person assist for everything except getting dressed. They only schedule one Aid on this hall. If they ever schedule 2 Aids, which is rare, they pull the Aid from this hall. I have to wait a long time for my care. I have to wait to be adjusted, and it is normally longer than 30 minutes that I wait. They just don't have enough help. The nurses do not help the Aides with repositioning and moving me. The Aides have to go get another person from another floor to get help. It takes a long time. Most of the time, they only schedule 1 Aid on the hall. (1 North). Surveyor explained to Resident that Surveyor would not leave until Resident #39 was adjusted in bed for comfort and breathing. Resident #39 activated her call light. The assigned Aide came within 3 minutes and Resident #39 verbalized she needed to be adjusted in bed for comfort. The Aide turned the call light off and told Resident #39 I have to go find someone to help me, because the nurse is off the floor, and I am the only one working on the unit. Surveyor asked the Aide where she goes to find help and verbalized I have to go to another floor and have someone come help, because this resident requires 2 person assist. The Aide promised to hurry and go find help. Surveyor asked the Aide if the nurses help with moving residents, and the Aide said, not really, they have their own stuff to do. Agency nurses only pass medications, they don't help. Once in awhile one or two good nurses will step up and help us, but most of them don't. If they are done passing med's, they go take a lunch, or a break, or leave the floor. The Aide was asked how many Aids were scheduled on the hall on 12/5/22, and said only one. The Aide was asked how are you moving the 2-person assists, and said, I have to go find another Aide to help me. The Aide left the room to get help. Resident #39 said to Surveyor, you are going to be waiting a long time. Surveyor waited with Resident #39, and the Aide came back with another Aide in 25 minutes, and the 2 Aides repositioned Resident #39 up in the bed as requested. During initial screening of other cognitively intact residents, several residents voiced complaints about lack of help and verbalized to Surveyor They are working short most of the time. The Aides tell us they are short. We know what is going on. We also know the nurses are supposed to help, but they have their own jobs and say, I did not become a Nurse to do Aide work. Some nurses will help. Agency nurses will not. They pass med's and that is about it. We get cold food a lot. If there are 2 Aides on the floor, they do all the work. The Aides call off a lot because they are tired. They have had a lot of staff just quit, and not show up for their shifts. They are stretching the Aides as far as they can stretch. We hear what they are saying and grumbling. Sometimes I am afraid they will take out the frustrations on us. They need more staff. During an interview on 12/12/22, with Director of Nursing, the DON was asked how the units are staffed and verbalized she tries to run with 5 nurses scheduled on both of the 12 hour shifts, day and night shifts. The DON was asked how many Nursing Assistants (Aides) are scheduled for the 1-North hall and said we schedule 2, but if there are call offs, we pull from that unit. The DON was asked about the 2-person assists for repositioning and transfers, on the 1 North unit and said, the nurse is there to help. The DON indicated they try and run with at least 2 Aides on 1 North, 2 North, first shift; and 2 Aides and 2 one to one on 2 south, and 3 Aides on 3 north and 3 south. Same for 2nd shift, and 2 Aides on all units 3 rd shift. An interview was done on 12/13/22, with Scheduler K related to staffing the facility. Staff K verbalized that it was challenging staffing the building. Staff K also verified that they will pull Aids to cover other call ins from the 1 North hall. Staff K indicated she staffs the building appropriately, but there are a lot of call offs by Aides that make it difficult at times to get it covered. Staff K indicated when the staff call off, she starts calling staff to come in and cover shifts. Staff K verbalized they will mandate at times. Staff K verbalized sometimes if I can't get it covered, we run with what we got and do the best we can. Staff K was asked if they use Agency for Aides and said not for Aides, but we do for nurses. Staff K said that she will come in and see what is going on in the facility and try and cover shifts with call ins. I handle Monday thru Friday and the on call nurse usually handles the weekend staffing. Staff K indicated the acuity for residents is higher on the 3rd floor and tries to schedule 3 aids. Staff K was aware that on 12/7/22, there were not 3 Aides scheduled on the 3rd floor, both sides (North and South), and said that a girl quit without telling her and they did not have 3 Aides on both sides. Review of staffing sheets was done with Staff K and the DON on 12/13/22. Facility provided staffing sheets for 11/27/22 through 12/13/22. Review of staffing with Staff K and the DON of staff assignment sheets reflected that on the dates of 12/9/22 - 12/13/22, multiple changes were made to the sheets, to address call ins, and adjustments. Review of the sheets and discussing with Staff K and the DON, reflected inaccurate data and incomplete data documented on the assignment sheets. Review of staffing reflected nurse and Aids with numerous changes made to the schedule and names crossed out, written in, and very difficult to follow and know accurately who was in the facility. On 12/11/22, 2nd shift, there were 5 documented Call ins for staff and 2 staff documented as late. On the staffing sheets were multiple documented call ins. Review of assignment sheets reflected on: 1st shift--1 North hall only one aid scheduled. A total of 13 Aides to include 2 one to one staff, and one call in leaving 10 to do resident care. On 11/28/22, 2nd shift-a 4 hour hole left to cover. making it 14.5 Aides to do care with 2 of the Aides performing one on one duties. On 12/1/22-2nd shift-a 4 hour hole with 13.5 Aides scheduled to perform care to include 2 one on one duty. On 12/2/22-a 4 hour hole on 2nd shift leaving 9 Aides to perform care. On 12/9/22- on 1 North-1 Aide assigned and a one on one for room [ROOM NUMBER]-1 assigned. On 2nd shift, 3 Aides were assigned, but only one Aide signed in as present. On 12/12/22-the assignment sheet for 2nd shift on 1 North hall, there were no resident rooms assigned, only showers and assist with feeding for one Aide. Staff K was asked about only having 7 Aides for the whole building on September 25th, and verbalized, she did not find out until the next day. Staff K said that the Aides and Nurses are supposed to sign in the signature box on the assignment sheet, but are not always doing it consistently. Review of Policy Nursing Staffing documented The nursing service department provides 24-hour nursing services. The facility ensures sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure guest/resident's safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each guest, as determined by each guest's assessments and individual plans pf care .and considering the number of acuity and diagnoses and guest/resident population in accordance with the facility assessment .

Based on observation, interview and record review, the facility failed to ensure clinical staff posting of Licensed and un-Licensed staff was completed daily, and posted in a visible area with accurate and complete data, resulting in the inability for residents and visitors to know what clinical staff were working on those days, and inaccurate contact information. Findings include: According to the State Operational Manual [SOM] reflected The facility must post the total number and actual hours worked by Licensed and un-Licensed nursing staff directly responsible for resident care per shift . to include Registered Nurses .Licensed Practical Nurses .and Certified Nursing Aids . The SOM guides that the facility must Ensure staffing information is posted in a prominent place ready accessible to resident's and visitors . The facility was asked to provide daily staff posting sheets for time frame of September, 2022 through November, 2022. Review review of the daily posting sheets reflected inaccurate data entered on the sheets for multiple days. The postings also did not have a census number of residents documented 9/26/22, and 9/29/22. Review of the postings reflected 15 missing daily posting sheets for the dates: 10/1/22, 10/2/22, 10/8/22, 10/9/22, 10/15/22, 10/16/22, 10/17/22, 10/18/22, 10/19/22, 10/22/22, 10/23/22, 10/27/22, 10/28/22, 10/29/22, 10/30/22. On the daily posting sheets listed a phone number and person to contact with concerns after hours. The Administrator's phone number was provided on the form, along with the Director of Nursing. Review of the form reflected that the old DON, who was no longer employed at the facility, was listed on the dates of: 11/3/22, 11/4/22, 11/7/22, 11/8/22, 11/9/22, 11/10/22, 11/14/22, 11/15/22, 11/16/22, 11/18/22, and 11/29/22, with a name and phone number to call for after hour concerns. Surveyors were onsite during a time frame of 10/18/22, through 11/7/22, and the facility had an Interim DON in place during that time. The previous DON was not working at the facility. The postings reflected incorrect contact information for concerns after hours. During an interview on 12/13/22, the new DON indicated she started on 11/7/22. Her name was documented on some of the postings dated: 11/11/22, 11/17/22, 11/19/22, 11/20/22, 11/21/22, 11/22/22, 11/23/22, and 11/30/22. There was no phone number provided for contact with the new DON on those daily postings. The Old DON contact information was on the other postings. The DON was made aware of the inaccurate and incomplete daily staff postings. The DON was made aware of the concerns related to inaccurate data and missing daily census postings and old contact information that was not correct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to monitor and justify the administration of an antibiotic for three residents (Resident #39, Resident #111, Resident #223), resulting in Resident #223 being ordered Augmentin for 42 days and Resident #39 and Resident #111 receiving an antibiotic without appropriate clinical rationale and the possibility of antibiotic resistance due to inappropriate usage. Findings Include: Resident #223: During initial tour on 12/5/22, Resident #223 was observed resting in bed and appeared to be in good spirits. On 12/7/22 at approximately 8:45 AM, a review was completed of Resident #223's medical records and it revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Dementia, Parkinson's, Anxiety, Hypertension and Pulmonary Embolism. Resident #223 was not cognitively intact and had a guardian appointed to make all medical decisions. He additionally required assistance with his ADL (Activities of Daily Living)'s. Further review was completed of Resident #223's records, and it yielded the following result: Physician Orders: Amoxicillin-Pot Clavulanate Tablet 500-125 MG (Milligram) - Give 1 tablet by mouth three times a day for bacterial infection for 42 days MAR (Medication Administration Record): November 2022 Amoxicillin-Pot Clavulanate Tablet 500-125 MG o Give 1 table by mouth three times a day for bacterial infection for 10 days o Ordered on 11/22/22 and Resident #223 was sent to the hospital on [DATE]. Nursing Progress Notes: 12/1/22 at 18:47: Resident returned from (hospital) on stretcher via ambulance with EMT's. Resident was put in bed by EMT's . 12/1/22 at 21:57: All medications transcribed and verified by on- call NP (Nurse Practitioner) . Care Plan: - There was nothing mentioned on Resident #223's care plan that indicated he was on an antibiotic. It can be noted Resident #223 was initially prescribed Augmentin during his first admission to the hospital in November 2022. When he returned to the facility on [DATE] the Augmentin order was in place for 10 days for bacterial infection. He was sent back to the hospital for evaluation on 11/28/22 and returned to the facility on [DATE] with the 42-day Augmentin order. There were no other specifics found regarding the justification for the antibiotic. On 12/7/22 at 10:32 AM, a review was completed of Resident #223's progress notes while at the facility. A note was reviewed from Nurse Practitioner Q on 12/2/22 (after Resident #223 was readmitted to the facility). The note did not mention anything regarding Resident's #223's need for long term antibiotic treatment, cultures that were completed or risk verse benefits statement and specially what the antibiotic was treating. During the Annual Recertification the survey team is not able to access facility medical records from their laptops and the facility provided their COW's (computer on wheels) to surveyors for the duration of the inspection. Resident specific documents are requested from the facility prior to exit and are provided. Upon review of the facility provided documents after exit there appeared to be an addition to Nurse Practitioner Q note that was not there when initially reviewed on 12/7/22 by this writer. The practitioner notes provided verbiage regarding the long-term usage of the antibiotic that was not there when initially reviewed. Resident #223's practitioner notes that were printed on 12/8/22 at 15:15 and emailed to this writer on 12/8/22 at 3:55 PM and 4:15 PM. On 12/8/22 at 10:55 AM, an interview was conducted with Nurse Practitioner Q and Infection Control Nurse A regarding Resident #223's Augmentin order for 42 days. Nurse A explained she queried Practitioner Q regarding the length of the order and actual usage as the reasoning was vague. Nurse A was informed by Nurse Practitioner Q the resident had a lung infection and he readmitted on this medication. She further stated prior to him being evaluated at the hospital he was already on Augmentin for 10 days for a UTI and was in the middle of his sequence when he was sent out. Nurse A said she spoke to Practitioner A about the length of his treatment in morning meeting and she agreed to complete a note and risk versus benefits statement regarding it. Nurse A was queried if a culture was completed on the resident, and she stated she did not have one that was completed from the hospital. Practitioner Q joined the conversation and explained Resident #223 was diagnosed with ESBL in his urine and the Augmentin was ordered for his UTI. She reported the Infectious Disease physician assessed the resident while in the hospital and ordered the Augmentin for 42 days. Practitioner Q reported the order was unusual, but the resident is recovering well. The DON (Director of Nursing) questioned the Practitioner in the presence of this writer, Nurse A and another surveyor regarding the usage of Resident #223's antibiotic. The DON expressed they spoke about this resident in morning meeting and Nurse Practitioner Q assured them the antibiotic was for his lung infection and not a UTI. Practitioner Q reiterated it was for ESBL in this urine as that was in his discharge paperwork. The DON and Infection Control Nurse A contended they were never aware it was ordered for the UTI but for a lung infection and the information being provided to the surveyors was different from what was related to them when Practitioner A spoke to them about it. The DON reported they did request a note be completed providing the clinical rationale the antibiotic usage, but it had not been documented at the time of this discussion. Review was completed of Nurse Practitioner Q progress note during report writing and the following was found in Resident #223's record: Nurse Practitioner Q Progress Note: 12/2/22 at 00:00: .Patient readmitted to the hospital due to malnutrition and UTI (Urinary Tract Infection) .Patient was seen today to follow up on malnutrition and UTI .continue to provide and encourage oral food and fluid . Extended spectrum beta lactamase (ESBL) resistance: Patient had UTI with ESBL upon hospital admission. Patient will need long term treatment of antibiotic and benefit is outweighs the risk of antibiotic due to patient's past multiple hospital involved UTI cases . All practitioner notes are timed in the chart at 00:00. It is evident the documentation Nurse Practitioner Q composed with either not relayed to the facility timely when they voiced their concerns, was added after this writer reviewed the practitioner notes on 12/7/22 and after the discussion with Infection Control Nurse A, DON, Nurse Practitioner Q and two surveyors. Hospital Discharge Records - .Cavitary lesion of lung. Ct chest shows multilobulated cavitary lesion left lower love measuring 7 cm AP by 5.5 cm transversely by adjacent ground-glass opacity .lesion could be abscess vs pneumonia vs malignancy .patient started on Augmentin 500 mg 3 times daily for 6 weeks . It can be noted there was no culture or justification located to why the antibiotic was ordered for an extended amount of time in his discharge records. The ordering physician was not an Infectious Disease physician (as stated) but a general practice doctor. There was no justification (at time of review) found in facility documents or provided by Infection Control Nurse A that gave a rationale as to why the medication was ordered for 42 days. On 12/14/22 at 3:00 PM, a review was completed of the facility policy entitled, Infection Control Antibiotic Stewardship & MDROS's, revised 9/9/2022. The policy stated, .Protocol will be developed and followed that promote health and wellness through responsible use of antimicrobials in an effort to prevent unnecessary treatment and resultant antibiotic resistance .The program will encourage appropriate prescribing .the medical director and director of nursing will use his/her influence as medical and nursing leaders to help ensure antibiotics are prescribed only when appropriate. The infection preventionist will be responsible for promoting and overseeing antibiotic stewardship activities in the facility . APIC (Association for Professionals in Infection Control and Epidemiology) TEXT: Long-Term Care, published October 2, 2014, Use of Antimicrobials in Long-Term Care Facilities: Antibiotic resistance will continue to pose a significant problem for residents in LTCF's (Long-term care facilities) because of the overuse and misuse of antibiotics. A common problem within LTCF's is the failure to distinguish infection from colonization . and the inappropriate treatment of the colonization with antibiotics. Another problem is the inappropriate selection of empiric antibiotics without culture evidence of susceptibility. LTF IP's can combat the problem of antibiotic resistance by making sure that the infection prevention and control program contains elements of prevention . procedures for correct identification of organisms . and antimicrobial stewardship . Infection Control On 12/08/2202 at 1:00 PM, the Infection Control Practitioner/ ICP nurse A was interviewed about the Infection surveillance/line list for November 8th, 2022 to December 8th, 2022. The ICP provided a line listing with 13 infections listed from 11/8/2022-12/8/2022. The line listing did not include a separate line listing for 8 residents with diarrhea or the respiratory line list that included residents with potential or confirmed signs and symptoms of COVID-19 infection. Upon review of the November 8th 2022- December 8th, 2022 infection line list there were 5 urinary tract infections/UTI; 1 clostridium difficile; 4 skin/wound; 2 others: 1 ear, 1 helicobacter pylori and 1 respiratory infection. Of the 13 infections on the line list all but one received an antibiotic, anti-fungal or antiviral treatment. Five of the infections were identified by the ICP to meet criteria (Criteria Met column on the line list) as a Healthcare associated Infection (HAI), although the ICP also classified 8 infections as HAI on the Acquired column on the line list. There was no explanation for why this occurred. On further review of the infection line list with the ICP, it was noted that room numbers were only listed for 6 of the 13 resident infections, including the c. diff infection, the respiratory infection and 3 of the UTI's; making it difficult to track the spread of infection. During the interview on 12/8/2022 at 1:00 PM with the ICP, the UTI's were reviewed. Two of the UTI's did not have a listed urine culture and sensitivity; no organism was identified. Each of the residents (#'s 39 and 111) were being treated with the antibiotic Cephalexin. The ICP was asked about the lack of identified organism to aid in ensuring an appropriate antibiotic was used and stated, There is a positive Nitrite for (Resident #39). The ICP was asked why there was no culture and sensitivity/C&S for the two residents and she did not know. Resident #39: A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #39 indicated an admission date of 1/16/2021 with diagnoses: Heart disease, diabetes, asthma, and peripheral vascular disease. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities and needed assistance with all care. Per the Face sheet the resident's room was 102 on the first floor. On review of the facility provided infection surveillance for November 8th, 2022 to December 8th 2022, it indicated Resident #39 was readmitted to the facility on [DATE] and had a UTI without an indwelling urinary catheter, with an onset date of 11/21/2022. There was no urine culture, no identified organism and the resident received Cephalexin antibiotic. Per the line list the infection resolved on 12/1/2022. Resident #111: A record review of the Face sheet and MDS assessment revealed Resident #111 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: End stage renal disease, hypertension, diabetes, anemia, GERD, and weakness. The MDS assessment dated indicated the resident had full cognitive abilities and needed assistance with care. The resident's room at the facility was 228 on the 2nd floor. A review of the infection surveillance/line list on 12/12/2022 for November 8th, 2022 to December 8th 2022 said Resident #111 had an HAI/UTI with onset date of 12/8/2022; organism unknown; Positive for Nitrite; Criteria Met false. The resident was receiving Cephalexin antibiotic. There was no urine culture and no identified organism to determine if the resident was receiving an appropriate antibiotic to treat infection, if present. On 12/12/22 at 2:45 PM, during an interview with ICP A she was asked about the November 8th, 2022 to December 8th, 2022 line list and why there were no urine c&s for Resident's #'s 39 and 111. She again said the nitrites were positive. When asked if she had culture and sensitivity results to determine if the resident was on the appropriate antibiotic to treat their infection, she said she did not have them. National Library of Medicine: Medline Plus: Nitrites in Urine, last updated August 3rd, 2022, . A test called a urinalysis checks a sample of your urine to see it it has nitrites. Nitrites in urine may be a sign of a urinary tract infection (UTI). UTI's are caused by different types of bacteria .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00124541 Based on observation, interview and record review, the facility failed to provide care and maintenance of an indwelling urinary catheter per physician's order, in a dignified manner, per standards of practice and infection control principles for two residents (Resident #103 and Resident #149) of three residents reviewed, resulting in urinary drainage tubing being maintained directly on the floor, drainage bags not having a privacy cover, catheter not secured, catheter not changed/care per physician's order, and possible complications in residents' health conditions with likelihood for re-occurring UTI infections. Findings include: Resident #103: On 10/24/22 at 03:18 PM Resident #103 was not found in his room. When staff in care was asked where the resident was, nurse aid answered that he went to the hospital around noon. Resident's room had a sign on the door Enhanced barrier precautions, and there was a personal protective equipment (PPE) cart outside the resident's door. On 10/24/22 at 04:30 PM during interview with infection control nurse A she explained the new initiative in infection control program that provided enhanced protection during care for residents with external catheters, tracheostomy's, colostomies, and tube feedings. Staff was expected to wear gown, gloves, masks, and eye protection during residents' care. Nurse A said that nursing staff was provided education about the enhanced precautions, and she was rounding floors regularly to ensure compliance. On 10/25/22 at 10:35 AM Resident #103 was observed in his room lying in bed. Breakfast tray was noted in front of the resident. Foley catheter collecting bag was noted hanging on a left side of the bed with no privacy cover on it. On 10/26/22 at 01:00 PM Resident #103 was observed in his bed. Wound care nurse K and certified nurse assistant (CENA) BBB was providing care. Both staff members were wearing gloves and masks during resident's wound care. Hand hygiene was appropriate. Wound care was performed per physician's order. Resident #103 was informed about procedure and pain was assessed by the nurse. During repositioning of the resident nurse K adjusted resident's Foley catheter and placed the collecting bag on the bed. No privacy cover was noted on the bag. After wound care procedure was completed nurse K was asked about enhanced precaution sign on the resident's door. She stated it was a new infection control process for the residents with catheters and tubes. When questioned if staff that was providing care to the resident supposed to wear full PPE she said yes, I usually do. Nurse K said she was nervous and forgot to don full PPE. CENA BBB also forgot to don full PPE before providing care to Resident #103. According to admission face sheet, Resident #103 was an [AGE] year-old male, originally admitted to the facility on [DATE], with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Hemiplegia and Hemiparesis (paralysis of one side of the body) following Cerebral Infarction (Stroke), Hypertension, Heart failure, Left hand contracture, Benign Prostatic Hyperplasia (enlarged prostate without cancer) with lower urinary symptoms, Neuromuscular dysfunction of the bladder, Iron deficiency anemia, Osteoarthritis, and Carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus (MRSA). According to Minimum Data Set (MDS) dated [DATE], Resident #103 was scored 15/15 on the Cognition Assessment, indicating no Cognition Impairment. According to the MDS, Resident #103 required full staff assistance with transfer, toileting, and bed mobility. Review of the Resident #103's record revealed the following physician's orders: 1) Change 18 Fr 10 CC Suprapubic catheter every 4-6 weeks. Order- Active. Start date 09/19/22. 2) Suprapubic Foley catheter care to include emptying drainage bag of urine every shift for skin care. Order date- 01/12/21, discontinued date 10/14/22. 3) Change SP (Suprapubic) catheter every month- 16 Fr 30 cc balloon every shift every 1 month, starting on the 1st for 1 days. Active order. Start date 03/01/22 at 07:00 PM. 4) Clean around SP site with soap and water, pat dry, apply antifungal ointment, and apply split gauze twice daily every day and night shift for Fungal rash. Order start date- 04/29/22. Discontinue date- 10/14/22. 5) Clean around SP site with wound cleanser, pat dry, apply silver nitrate around the stoma area, and apply dry dressing every day and PRN (as needed) two times a day for Suprapubic care. Order start date- 08/26/22. Discontinue date- 10/14/22. 6) Cleanse suprapubic catheter with wound cleanser and apply dry dressing every day shift for skin care. Start Date-10/15/2022 at 07:00 AM. During interview with interim DON on 11/01/22 at 02:20 PM she stated that she was not aware why Resident #103 had 2 active Suprapubic catheter change orders for different size and time of change. She also did not review Resident #103's chart recently and was not aware that several physician's ordered catheter care/task were not recorded and were not completed. Review of Medication administration record (MAR) and Treatment administration record (TAR) for Resident #103 revealed the following: Provider's Order: Suprapubic Foley catheter care to include emptying drainage bag of urine every shift for skin care. Order date- 01/12/21, discontinued date 10/14/22. Was not complete on: 08/01/22-day shift 08/01/22-night shift 08/05/22-day shift 08/05/22- night shift 08/08/22-day shift 08/10/22-day shift 09/19/22-day shift 09/23/22-day shift 10/01/22-day shift 10/06/22-day shift 10/07/22- night shift 10/13/22- night shift Provider's Order: Change SP (Suprapubic) catheter every month- 16 Fr 30 cc balloon every shift every 1 month, starting on the 1st for 1 days. Active order. Start date 03/01/22 at 07:00 PM. Was not complete on: 08/01/22 (once a month task) Provider's Order: Clean around SP site with soap and water, pat dry, apply antifungal ointment, and apply split gauze twice daily every day and night shift for Fungal rash. Order start date- 04/29/22. Discontinue date- 10/14/22. Was not complete on: 08/01/22-day shift 08/01/22-night shift 08/02/22-day shift 08/04/22-day shift 08/05/22-day shift 08/05/22-night shift 08/06/22-day shift 08/08/22-day shift 08/10/22-day shift 08/11/22-day shift 08/23/22-day shift 08/26/22-day shift 08/27/22-day shift 08/31/22-day shift 09/19/22-day shift 09/23/22-day shift 10/01/22-day shift 10/13/22-night shift Provider's Order: Clean around SP site with wound cleanser, pat dry, apply silver nitrate around the stoma area, and apply dry dressing every day and PRN (as needed) two times a day for Suprapubic care. Order start date- 08/26/22. Discontinue date- 10/14/22. Was not complete on: 08/27/22-day shift 08/29/22-day shift 08/30/22-day shift 08/31/22-day shift 09/19/22-day shift 09/23/22-day shift 10/01/22-day shift 10/08/22-night shift 10/13/22-night shift Further review of Resident #103's medical records revealed the following documentation: Laboratory results collected on 09/13/22 and reported on 9/16/22 indicated urine culture positive for Escherichia Coli, Proteus Mirabilis and Providencia stuartii. Provider note dated 09/19/22: Chief Complaint- follow up Urinary tract infection. Patient had symptom of yellow discharge from urethra and cloudy urine. Urinalysis obtained, positive urine culture. New orders given. Start IV Ertapenem Sodium solution reconstituted 1 gm every 24 hours for 10 days. Monitor adverse reaction of Ertapenem Sodium. Monitor further signs and symptoms for urinary infection. Review of the Resident #103's Care Plan revealed: Under Focus: Resident #103 is at risk for urinary tract infection and catheter-related trauma, has Suprapubic catheter related to urinary retention/neurogenic bladder, BPH (initiated on 01/29/18, revised on 02/11/19) Goal: Resident #103's catheter will remain patent and without complications through the review date (initiated on 01/29/18, revised on 02/17/21) Interventions: - 22 Fr (size) 10 cc balloon inflation (initiated 10/21/20, revised on 05/28/21) - Catheter care per policy (initiated 01/29/18, revised on 05/28/21) - Change catheter and tubing per facility policy (initiated 01/29/18, revised on 11/11/18) - Observe/document for pain/discomfort due to catheter (initiated 01/29/18, revised on 05/28/21) - Observe/record/report to MD (doctor) for signs and symptoms of UTI (urinary tract infection): pain, burning, frequency, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, foul smelling urine, fever, chills, altered mental status. Change in behavior, change in eating pattern (initiated 01/29/18, revised on 01/29/18) - Position catheter bag and tubing below the level of the bladder. Check tubing for kinks each shift (initiated 01/29/18, revised on 11/11/18) - Privacy bag on catheter for dignity (initiated on 05/28/21) No interventions were noted for monitoring Lab work, or measure and record intake and output for Resident #149 per physician's order. No updates were made to Care plan for a change in catheter size per physician's order. Further, after antibiotic was ordered on 9/19/22 for UTI treatment via IV (intravenous therapy) no updates were noted to Resident #103's Care Plan in regard to therapy, IV site care/maintenance/dressing changes, monitoring for IV occlusions, and side effects of antibiotic therapy. Resident #149: On 11/01/22 at 10:55 AM Resident #149 was observed lying in bed, scooted to the left, with his head pressing onto the bed rail. Right heal protection boot was off the resident's foot and on the floor. Tube feeding pump was beeping. Foley catheter tubing was observed draining milky urine and was touching the floor. Catheter collecting bag did not have a privacy cover on, catheter was not secured. On 11/02/22 at 09:23 AM second observation was made of Resident #149. He was in his room, lying in bed. Tube feeding was infusing. Foley catheter tube was draining milky colored urine and was observed directly on the floor. Catheter collecting bag was observed hanging on the bed frame. It was not covered with privacy cover. During further observation catheter was not secured (to the resident's leg). Nurse in care, LPN CCC was asked to come in the room and confirm observations. When questioned, she stated that catheter should be secured to prevent urethral trauma, tubing should not touch the floor, and privacy cover should be covering catheter collection bag. According to admission face sheet, Resident #149 was an [AGE] year-old male, admitted to the facility on [DATE], with diagnoses that included: Chronic Combined Systolic and Diastolic (Congestive) Heart Failure (CHF), Hypertension (elevated blood pressure), Diabetes Mellitus Type 2, Chronic Kidney disease, Atrial fibrillation, Chronic Obstructive Pulmonary Disease (COPD), History of Cerebral Infarction (Stroke) without residual deficits, Venous Insufficiency (chronic peripheral), Dementia, Bipolar disorder, Anxiety disorder, Muscle weakness, and Benign Prostatic Hyperplasia (enlargement of prostate). According to Minimum Data Set (MDS) dated [DATE], Resident #149 was not scored on the Cognition Assessment, indicating Severe Cognition Impairment. According to the MDS, Resident #149 required two staff assistance with transfers, bed mobility and toileting. Review of the Resident #149's medical record revealed that resident was hospitalized on [DATE]. Resident #149 returned to facility on 10/24/22. There was a re-admission nursing note dated 10/24/22 at 4:08 PM: Resident (#149) returned from (Hospital name). Resident returned with hospice care ordered. Hospice nurse present and did skin assessment with nurse. One skin issue noted-a pressure sore to coccyx. Patient has some general swelling and dry skin through body. PEG tube and Foley present and intact. V/S stable. Resident orientated to room. Call light in reach bed in lowest position. No concerns or pain noted at this time. Review of the Resident #149's Care Plan revealed: Under Focus: Resident #103 is at risk for urinary tract infection and catheter-related trauma, has indwelling catheter related to_ (blank), (initiated on 10/24/22, revised on 10/25/22) Goal: Resident #103's catheter will remain patent and without complications through the review date (initiated on 10/24/22) Interventions: - Change catheter and tubing per facility policy (initiated on 10/24/22) - Observe/document for pain/discomfort due to catheter (initiated on 10/24/22) - Observe/record/report to MD (doctor) for signs and symptoms of UTI (urinary tract infection): pain, burning, frequency, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, foul smelling urine, fever, chills, altered mental status. Change in behavior, change in eating pattern (initiated on 10/24/22) No interventions were noted for catheter care per facility's policy, size of the catheter, positioning catheter bag and tubing below the level of the bladder, checking tubing for kinks, maintaining catheter secured, maintaining privacy bag on catheter for dignity or applying infection control principles to catheter maintenance (keeping bag and tubing off the floor). Facility's Catheter Care was requested and reviewed (revised November 19, 2021). In Introduction portion of the Policy was the following: A nurse should follow the practitioner's orders for care for newly inserted suprapubic catheter. Care of an established catheter site includes daily cleaning. Under Documentation: Document the characteristics and volume of the patient's urine output.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00124541 Based on observation, interview and record review, the facility failed to ensure that prescribed medications were given on time and per physician's order for one resident (Resident #103) of three residents reviewed, resulting in missed medications, incomplete prescribed medical treatment, pain and suffering, and potential for preventable decline. Findings include: Resident #103: On 10/24/22 at 03:18 PM Resident #103 was not found in his room. When staff in care was asked where the resident was, nurse aid answered that he went to the hospital around noon. Resident returned from the hospital around 11:00 PM on 10/24/22. On 10/25/22 at 10:35 AM Resident #103 was observed in his room lying in bed. Breakfast tray was noted in front of the resident. When asked how he was feeling Resident #103 stated he was tired and wanted to rest. When asked if he received his pain medication this morning he stated yes, I got my Norco. When he was asked if he missed any pain medications (Norco) last week or over the weekend Resident #103 said yes, I did. When queried if he had pain that was not addressed due to Norco not given, he stated yes, I had some pain. On 10/24/2022 at 3:05 PM during interview with the Interim Director of Nursing she was asked if she was aware that Resident #103 did not receive the prescribed doses of Norco from 10/21/2022 to 10/24/2022 (Friday through Monday). She stated that she was not aware of this fact and nursing staff did not report to her any information regarding medications are not being available. According to admission face sheet, Resident #103 was an [AGE] year-old male, originally admitted to the facility on [DATE], with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Hemiplegia and Hemiparesis (paralysis of one side of the body) following Cerebral Infarction (Stroke), Hypertension, Heart failure, Left hand contracture, Benign Prostatic Hyperplasia (enlarged prostate without cancer) with lower urinary symptoms, Neuromuscular dysfunction of the bladder, Iron deficiency anemia, Osteoarthritis, and Carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus (MRSA). According to Minimum Data Set (MDS) dated [DATE], Resident #103 was scored 15/15 on the Cognition Assessment, indicating no Cognition Impairment. According to the MDS, Resident #103 required full staff assistance with transfer, toileting, and bed mobility. Review of resident #103's medical records revealed the following: Physician's order- Norco Tablet 7.5-325 mg (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours for Pain, Start Date 6/8/2021: Administration times- 6:00 AM, 2:00 PM, and 10:00 PM. Active order. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for October 2022 for Resident #103 indicated that resident did not receive his Norco doses on the following dates and times: 10/21/22 at 10:00 PM, 10/22/22 at 06:00 AM, 02:00 PM and 10:00 PM, 10/23/22 at 06:00 AM, 02:00 PM, and 10:00 PM and 10/24/22 at 06:00 AM (total of 8 doses of pain medication). A review of the progress notes for Resident #103 identified the following: Nursing progress notes from 10/21/2022 at 9:36 PM to 10/24/2022 at 5:25 AM revealed, medication on order; awaiting on delivery from pharmacy; on order will continue regimen upon arrival; medication on order and will be delivered with next delivery per pharmacy (10/24/2022). Nurses in care did not document that they did not contacted the pharmacy until 10/24/2022 at 5:25 AM. The resident had been out of his pain medication for 4 days. A review of the Care Plan for Resident #103 indicated: (Resident #103) is at risk for pain, right foot, knee, general related to his diagnosis of: osteoarthritis, neuropathy, Gout, contracture left hand, GERD, BPH (enlarged prostate), anxiety & depression. He is at risk for pain related impaired mobility. Resident states acceptable level of pain is 2-3 on verbal pain scale (0-10), Date initiated 3/7/2017 and Revised 10/27/2022 with Interventions: Administer medications as ordered Date initiated 5/11/2020; Observe and report any signs and symptoms of non-verbal pain .Mood/behavior (changes, more irritable, restless, aggressive . Report abnormal findings to physician, Date initiated 5/11/2020; Administer analgesia per physician orders. Observe for effectiveness, date initiated 1/18/2017. Review of resident #103's medical records revealed the following: Physician's orders: 1) Ertapenem Sodium solution reconstituted 1 gm. Use 1 gm intravenously in the evening for UTI for 10 days every 24 hours for 10 days. Start 09/23/22. 2) Sodium Chloride Solution 0.9 % Use 10 ml intravenously every 24 hours for flush for 10 Days Flush 10 ml' s' in PIV (peripheral IV) (Right) antecubital before and after ABT (antibiotic). Start Date-09/23/2022 at 1:15 PM. A review of the Medication Administration Record (MAR) for September and October 2022 for Resident #103 indicated that resident did not receive his prescribed antibiotic on 10/02/22, which indicated that only 9 doses were given out of 10 that was prescribed by physician. Also, prescribed Normal Saline flushes before and after antibiotic infusion were not given on 10/01/22 and 10/02/22. Review of the Resident #103's medical record revealed the following progress notes: Nursing note dated 10/01/22 at 11:50 PM: PIV (peripheral intravenous line) is infiltrated. On call provider notified and replacement order has been placed. Provider's note, signed by NP (nurse practitioner) OOO, and dated 10/04/22: As per nursing staff, patient missed one dosage of IV antibiotic. Discussed with the nursing to extend IV Ertapenem Sodium solution Reconstituted 1 gm every 24 hours per missing dosage and change the order in PCC (Point Click Care-electronic medical records program). No additional orders were found for IV antibiotic Ertapenem after 10/04/22 and Resident #103 did not complete his prescribed antibiotic therapy for UTI. During interview with the provider NP OOO on 11/03/22 at 11:24 AM, she stated that she was not aware of Resident #103 not completing his antibiotic therapy. Review of the Resident #103's Care Plan revealed no updates after IV antibiotic was prescribed, IV site was established and therapy was initiated. No goals or interventions were found for antibiotic treatment therapy, IV site care/maintenance/dressing changes, monitoring for IV occlusions/infiltrations, and side effects of antibiotic therapy. Facility's Medication Administration Policy was requested and reviewed (effective 10/14/22 and revised 9/9/22). Policy had the following guidance: Physician's Orders - Medications are administered in accordance with written orders of the attending physician. If a dose is inconsistent with the guest's/resident's age and condition or a medication order is inconsistent with the guest's/resident's current diagnosis or condition, contact the physician for clarification prior to administration of the medication. Document the interaction with the physician in the progress notes and elsewhere in the medical record, as appropriate. Under documentation: Record the dose, route, and time of medication on the Medication/Treatment Administration Record. Document if the guest/resident refused. Medication Management Policy (effective 10/14/21 and last revised 10/01/2019) indicated: Pharmacy vendor procedures are accessible at each nurse's station that contains ordering procedures, labeling requirements, emergency pharmacy processes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #103: On 10/24/22 at 03:15 PM certified nursing assistant (CENA) was observed at 3 North nurse's station (Resident #103's unit) with her surgical mask pulled down, not covering her nose and mouth. One more nurse aid was observed on a 3 North hallway with surgical mask not covering the nose and with multiple residents around in the hall and lounge. On 10/24/22 at 03:18 PM Resident #103 was not found in his room. When staff in care was asked where the resident was, nurse aid answered that he went to the hospital around noon. Nurse aid that was standing close by did not have surgical mask covering the nose. On 10/24/22 at 04:03 PM staff member was observed on 3 North hall with surgical mask not covering the nose. On 10/25/22 at 10:35 AM Resident #103 was observed in his room lying in bed. He stated he was tired and wanted to rest. On 10/26/22 at 12:55 PM on 3 North hall two staff CENA's were observed to have surgical masks on that were not covering their nose. On 10/24/22 at 04:30 PM during interview with infection control nurse A she stated that nursing staff is expected to follow facility's policy and guidelines on wearing personal protective equipment. She added that masks must be worn in resident care areas, and cover nose and mouth. Nurse A also added that she rounds often to assure staff compliance with PPE. On 11/02/22 at 09:30 AM staff CENA was observed on the 2 North floor next to the dining room with the face mask not covering the nose. Several residents were present in a dining room eating their breakfasts. According to admission face sheet, Resident #103 was an [AGE] year-old male, admitted to the facility on [DATE], with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Hemiplegia and Hemiparesis (paralysis of one side of the body) following Cerebral Infarction (Stroke), Hypertension, Heart failure, Left hand contracture, Benign Prostatic Hyperplasia (enlarged prostate without cancer) with lower urinary symptoms, Neuromuscular dysfunction of the bladder, Iron deficiency anemia, Osteoarthritis, and Carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus (MRSA). According to Minimum Data Set (MDS) dated [DATE], Resident #103 was scored 15/15 on the Cognition Assessment, indicating no Cognition Impairment. According to the MDS, Resident #103 required full staff assistance with transfer, toileting, and bed mobility. Review of intake documentation dated received on 07/03/22 for Resident #103 revealed multiple concerns related to care at the facility including lack of consistency of staff wearing face masks. The intake further detailed that on 07/2/2022, a second shift staff member did not wear a face mask for four hours while providing care to Resident #103, stating to him that it was too hot, and she could not breath. The staff member was also breathing over resident's food as she cut it up. Facility's Infection Prevention Program Policy was requested and reviewed. Policy dated effective and revised on 12/2/21 had the following under Surveillance of infections with implementation of control measures and prevention of infections: Preventing the spread of infections is accomplished by use of standard precautions and other barriers, appropriate treatment and follow up, and employee work restrictions for illness. According to the CDC guidelines Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. Standard Precautions among others include the following: 1. Hand hygiene. 2. Use of personal protective equipment (e.g., gloves, masks, eyewear). 3. Respiratory hygiene / cough etiquette. 4. Clean and disinfected environmental surfaces. Further, Centers for Disease Control and Prevention (CDC), Implement Source Control Measures: Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Corona virus Disease 2019 (COVID-19) Pandemic, Updated Sept. 23, 2022, .This interim guidance has been updated based on currently available information about COVID-19 and the current situation in the United States This guidance is applicable to all U.S. settings where healthcare is delivered (including nursing homes .) . Recommended routine Infection Prevention and Control (IPC) practices during the COVID-19 pandemic . Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing . Source Control options for HCP include: A NIOSH-approved particulate respirator with N 95 filters or higher: A respirator approved under standards used in other countries that are similar to NIOSH-approved N 95 . A well-fitting facemask . Association for Professionals in Infection Control and Epidemiology (APIC): APIC TEXT: Corona virus Disease 2019 (COVID-19), revised March 30, 2021, .CDC guidance for COVID-19 established two separate categories of IPC practice recommendations: one for routine healthcare delivery and the second for the care of persons with suspected or confirmed COVID-19 disease Recommended IPC practices for routine healthcare delivery to all patients including those with confirmed COVID-19 should be used in addition to standard IPC practices during the COVID-19 pandemic . Implement universal source control measures: Source control refers to the use of cloth face coverings (for patients) or medical face masks (for HCP) to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19 . This Citation Pertains to Intake Numbers: MI00124541 and MI00124709. Based on observation, interview and record review, the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1) Transmission Based Precautions (TBP), including appropriate use of face masks for Resident #103), 2) TBP, including Hand Hygiene and use of gloves during eye exams for Resident #113, and 3) Disinfection of ophthalmic equipment after use between each resident for Resident #113, from a census of 123 residents, resulting in the potential for spread of infection, which could cause serious illness. Findings include: Association for Professionals in Infection Control and Epidemiology (APIC): APIC TEXT: Hand Hygiene, December 10, 2021, Hand hygiene is a critical component of patient and employee safety. Effective patient safety and infection prevention and control programs require that healthcare personnel be familiar with hand hygiene recommendations and consistently adhere to them . Hands contaminated with transient bacteria pose a significant risk for transmission of infection . Hand hygiene has been accepted as the single most important measure to prevent transmission of infection and is the cornerstone of most infection prevention and control (IPC) programs . Association for Professionals in Infection Control and Epidemiology (APIC): APIC TEXT: Standard Precautions, October 2, 2014, Standard Precautions are guidelines that outline the minimum set of interventions that are required for preventing the transmission of microorganisms. They provide a foundation for infection prevention measures that are to be used for all patients in every healthcare setting. There are many factors that contribute to the consistent use of Standard Precautions within healthcare facilities . There are several key components that the Healthcare Infection Control Practices Advisory Committee identifies that constitute the Standard Precautions guidelines. Hand hygiene, respiratory hygiene and cough etiquette, appropriate use of personal protective equipment, safe work and injection practices, and environmental cleaning, as well as patient placement, are all elements essential in breaking the cycle of microorganism transmission. In today's global society, it is imperative that all facilities and settings that provide healthcare meticulously practice Standard Precautions to prevent transmission of known, as well as unknown threats of emerging pathogens protecting all persons including healthcare personnel, patients, and the community at large . Standard Precautions are intended to be utilized for the care of all patients, in all settings in which healthcare services are rendered, even in the absence of a suspected or confirmed infectious process . Standard Precautions are utilized to protect both healthcare personnel and patient(s) from infection, preventing the spread of microorganisms between hosts (person-to-person, person to environment to person) . Cleaning and disinfecting of all surfaces, equipment, and devices in patient care areas are an integral part of Standard Precautions. 1,2,3 Cleaning of all medical equipment and devices . that enter patient care areas is important to prevent transmission of infectious organisms. Noncritical patient care equipment should be cleaned and disinfected after each patient use. All soiled medical equipment and devices should be handled in a manner that prevents the transfer of microorganisms to others and the environment. Contaminated equipment that must be cleaned and disinfected must be stored in an area that is separate from clean supplies and equipment. HCP should wear gloves when handling equipment that is contaminated or visibly soiled and perform hand hygiene immediately after removal of gloves . On 11/1/2022 at 12:30 PM, Optometrist OO was observed on the 2nd floor, entering resident rooms to perform eye exams with eye drops for dilation and viewing the eyes with a Tonometer. The doctor did not perform hand hygiene, or wear gloves. He was observed taking the same eye medication vials room to room/resident to resident. The Tonometer was taken room to room and was not cleaned or disinfected. The doctor was observed to have a carry case with his equipment on top of a push cart. There were zip lock bags of eye medication/vials, in the case. The baggies appeared old and soiled. Upon review of the eye medications, some were outdated/expired from 8/2022. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #113 was admitted to the facility on [DATE] with diagnoses: Dementia, anxiety, depression, history of a head injury. The MDS assessment dated [DATE] revealed severe cognitive loss with a Brief Interview for Mental Status score of 4/15. Resident #113 was independent with ambulation and needed some assistance with activities of daily living. On 11/1/2022 at 12:35 PM, Optometrist OO was observed entering Resident #113's room, after leaving another resident's room across the hall. He did not perform hand hygiene or clean his equipment prior to entering Resident #113's room. The doctor was observed opening the resident's right eye with his bare fingers; no gloves He put eye drops, from his bag on the cart, into the resident's eye and held the Tonometer to the resident's eye. The Tonometer was observed touching the resident's eyeball. The Doctor was asked if the Tonometer touched the resident's eye and he stated, Yes, it did. When the doctor finished the examination of Resident #113, he took his equipment back to the hall and his cart and did not wash his hands. He was asked if he performed hand hygiene and he stated, I usually do, sometimes, I use hand sanitizer. He looked in his bag and stated, I think I have hand sanitizer in here. He couldn't find any. There was hand sanitizer on the wall in the hall, he made no attempt to use it nor wash hands with soap and water. Each resident room had a sink. He took a small alcohol pad and wiped off the Tonometer eye lens and set in in his case- which appeared soiled. The doctor did not disinfect the Tonometer or medication vials that he put into the zip lock bags. The doctor was asked if he usually wore gloves when holding a resident's eye open and he stated, I didn't actually touch his eye (eyeball). Confirmed with the doctor that he touched the skin on the resident's upper and lower eye lids, very close to the resident's eye. On 11/2/2022 at 9:15 AM, during an interview with the Infection Prevention and Control (IPC) Nurse A and Corporate Nurse L, they were asked if they had observed Optometrist OO when he examined the residents, both said they had not observed him. Reviewed with the IPC A and Corporate Nurse L that the Optometrist was observed examining residents with uncleaned/not disinfected equipment, not performing hand hygiene between seeing each resident and not wearing gloves when touching the residents skin around their eyes, while holding the eye open for the examination. Corporate Nurse L said, We will take care of that. That is not acceptable. A review of the facility policy titled, Infection Prevention Program Review, dated effective 12/1/2021 provided, . The facility establishes a program under which it: Investigates, identifies, prevents, reports and controls infections and communicable diseases . The facility must require staff to clean their hands after each direct guest/resident contact using the most appropriate hand hygiene professional practices .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Facility Reported Incident (FRI) intake documentation initially submitted on 1/17/22 revealed, Incident Summary (Resident #110) pushed (Resident #111) out of their wheelchair and they fell . Resident #110: On 10/26/22 at 3:20 PM, Resident #110 was observed in their room. The Resident was in bed, laying on their right side, on top of their blankets with bare feet. A visibly soiled brief was present on the floor directly next to the right side of the Resident's bed. When spoke to, Resident #110 opened their eyes but did not provide responses to questions. An interview was conducted with CNA BB on 10/26/22 at 3:28 PM. When queried regarding Resident #110, CNA BB revealed the Resident is quiet most of the time. When asked if they had observed any altercations between Resident #110 and other Residents, CNA BB indicated they had gotten into it with another Resident. CNA BB was then queried regarding the CNA to Resident ratio in the facility and replied, Two aides for 32 Residents. When asked if it was typical staffing to have 16 Residents per CNA, CNA BB stated, Happens quite a bit. CNA BB was then asked if that staffing level is adequate to monitor and provide care to the Residents based on their needs. CNA BB replied, No. Record review revealed Resident #110 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included epilepsy, adjustment disorder with anxiety, bipolar disorder, repeated falls, and vascular dementia with agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, required limited to extensive assistance to complete Activities of Daily Living (ADL's), and displayed no verbal or physical behaviors. Review of Resident #110's care plans revealed a care plan entitled, (Resident #110) have the potential for fluctuations in mood R/T (related to): DX (diagnosis): Bipolar DO (disorder), Psychotic Disorder, Adjustment/Anxiety Disorder (Initiated: 1/16/19; Revised: 1/14/22). Care plan interventions included: - Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding to the physician (Initiated: 1/16/19) - Approach in a calm, quiet manner. Maintain appropriate body language during interactions such as maintaining eye contact and sitting in a relaxed position (Initiated: 1/16/19) - Behavior Management/RAR (Resident at Risk) per facility protocol (Initiated: 1/16/19; Revised: 1/25/19) - Behavioral health/psych consults as needed and follow recommendations as Indicated (Initiated: 1/16/19) - (Resident #110) requires extensive supervision with no more than 1:4 staff/resident ratio (Initiated: 12/2/20; Revised: 3/4/21) - Encourage resident to verbalize feelings as needed (Initiated: 1/16/19) - Observe and report to SW (Social Worker) and/or physician prn acute changes in mood or behavior; feelings or sadness; increased anxiety/agitation, depression, withdrawal/loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills; how resident interacts with others (Initiated: 1/16/19) - Observe for signs and symptoms of psychosis, mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation, delusions, hallucinations or hyperactivity and report to SW/physician as indicated (Initiated: 1/16/19) Another care plan entitled, (Resident #110) has a actual behavior problem R/T used racial slurs towards other residents . do not always get along with roommates of a different race than my own. (Resident #110) become verbally aggressive . have the potential to put food and utensils into the toilet . was observed having a small food fight with another resident. (Resident #110) was going thru roommate belongings (Initiated: 1/10/20; Revised: 8/12/22) was noted in the Resident's Electronic Medical Record (EMR). This care plan included the following interventions: - Anticipate and meet (Resident) needs (Initiated: 1/10/20; Revised: 2/24/21) - Approach in a calm manner (1/10/20) - Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and move to an alternate location as needed (Initiated: 3/13/21; Revised: 12/15/21) - Observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes (Initiated: 3/13/21) - Psych consult as needed (Initiated: 3/13/21) Review of Resident #110's progress notes revealed the Resident had a history of behaviors towards others. The documentation included: - 7/26/19: Resident At Risk . IDT team discussed residents contact exchange to roommate . Resident does no longer have that roommate, no further behaviors noted . - 5/9/20: Behavior Note . Resident angry tonight on 2nd shift after 8pm, not sure way, came out and said room was cold, very rude to nurse . told (Resident #110) it will be take care of, (Resident) got angry and hit to pole next to the nursing station . around 1130 pm (Resident) came out to the desk yelling I can't find my shoes, asked (Resident) did you look around bed . got very irate and yelled I told you I can't find my shoes, went in (room) . and shoes were next to bed . - 11/29/20: Nurses Notes . patient alert and oriented. patient was observed having behaviors with another patient by which (other resident) had the cordless phone in their hand and (Resident #110) went charging towards (other Resident) stating that was their phone and grabbed (other resident) arm without any injuries noted . - 11/19/20: Resident At Risk . resident is being discussed with IDT for recent behaviors. Resident continues to be unpredictable with physical altercations with other residents. medication has been assessed . Action Taken: SW is working on d/c plan to accommodate the needs of the resident . - 3/13/21: Behavior Note . resident became visibly upset when roommate was screaming and cursing at staff. resident yelled at roommate and when roommate quieted, resident immediately relaxed, sat back in his bed and was cooperative with staff . - 4/20/21: Nurses Notes .the nurse was notified that resident's roommate attempted to throw the side table at them but with the quick intervention of aid who was in the room at the time and caught the table . only hit the resident bed. resident was startled . - 12/5/21 at 1:30 PM: Nurses Notes . Verbal and food exchange with another resident. 15 min checks initiated. Social work and house supervisor aware. - 12/5/21 at 2:02 PM: Social Services Note . SW (Social Worker) was called . for verbal altercation between (Resident #110) and fellow resident. When SW inquired what happened, (Resident #110) said 'I am fine, (Resident #124) just lost control mentally and physically, like they got confused.' SW asked if they threw food at (Resident #124) or hit them, (Resident #110) said 'no, (Resident #124) just yelled and I kept eating'. SW asked if they were hit at all, (Resident #124) reported 'No, nothing happened (Resident #124) just got confused and started yelling but I'm fine.' Resident was put on 15 Minute checks until IDT can review. Admin is aware. - 12/6/21 at 4:48 PM: Social Services Note . Follow up: Resident was observed laying in assigned bed. Resident appeared to be resting . appeared to be in no distress. Resident reported no concerns and reports . feels safe in the facility. Writer has no concerns at this time . - 12/7/21 at 5:54 PM: Social Services Note . Follow up: Resident was observed resting in assigned bed. Resident appeared to be sleeping and in no distress. SW did not disturb. No behaviors were noted . - 12/8/21 at 6:45 PM: Social Services Note . Resident was observed resting in bed and appeared to be watching TV. Resident reported was doing great and appeared to be in a good mood with no distress noted . - 1/13/22 at 3:05 PM: Social Services Note . Resident was observed sleeping in assign bed. SW was informed that resident had altercation with previous roommate yesterday. BSC psych doctor to follow up with resident. SW to follow up with resident. No behaviors being noted. - 1/14/22 at 12:24 PM: Social Services Note . Resident was observed resting in assign bed. Resident appear to be in good mood no distress noted. SW reviewed and updated behavior care plan. Resident is being follow by BCS psych services . Resident #111: Review of Resident #111's EMR revealed the Resident was originally admitted to the facility on [DATE] with diagnoses which included repeated falls, mental disorders, anxiety, auditory hallucinations, and dementia with agitation. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to extensive assistance to complete ADL's. On 10/26/22 at 3:25 PM, Resident #111 was observed in their room. The Resident was laying in bed with their eyes closed. An interview was completed with CNA BB on 10/26/22 at 3:39 PM. When queried regarding Resident #111 including any behaviors and/or altercations with other Residents, CNA BB stated, (Resident #111) talks a lot but no behaviors. When queried regarding any incidents between Resident #111 and Resident #110, CNA BB revealed they were unaware of the altercation. Review of Resident #111's care plan revealed a care plan entitled, (Resident #111) has the potential to demonstrate physical, verbal aggression R/T: Dementia, Hallucinations, Mental Illness . will go through my roommates' closets when I am up in my chair and this will agitate them. I have in the past been known to hit staff when providing care . (Initiated: 1/27/21; Revised: 5/20/22). The care plan included the following interventions: - Assess (Resident) understanding of the situation. Allow time for the resident to express self and feelings towards the situation, including antecedents, effective calming strategies etc . (Initiated: 1/27/21) - Assess and anticipate (Resident) needs: food, thirst. toileting needs, comfort level, body positioning, need for sleep, pain etc. as needed (Initiated: 1/27/21) - Assess (Resident #124) understanding of the situation. Allow time for the resident to express self and feelings towards the situation, including antecedents, effective calming strategies etc . (Initiated: 1/27/21) - Avoid changes in environment and confrontation. Reapproach when non-compliant (Initiated: 5/20/22) - Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated (Initiated: 1/27/21) - Continue to maintain consistency in daily routine and care (Initiated: 5/20/20) - Give (Resident #111) as many choices as possible about care and activities (Initiated: 1/27/21) - Observe key times, places, circumstances, triggers, and what de-escalates behavior. Adjust plan of care to reduce incidents of aggression where possible (Initiated: 1/27/21) - When (Resident #111) becomes agitated Intervene before agitation escalates; Guide away from source of distress; Engage calmly and/or (Specify [blank]) past successful (interventions [none indicated]) as needed (Initiated: 1/27/21) - Psychiatric consult as indicated (Initiated: 1/27/21) Review of documentation in Resident #111's EMR revealed the following: - 1/11/22 at 10:00 AM: eINTERACT SBAR Summary for Providers . Situation . Falls . Behavioral Status Evaluation: Other behavioral symptoms (not specified) . New Intervention Orders: (Blank) . - 1/11/22 at 10:21 AM: Nurses Notes . at 10 pm (Resident #111) was pushed put (sic) of wheelchair by roommate (Resident #110). 2nd shift CNA says that they walked in (Residents) room because heard arguing from the hallway and as was walking in the door (Resident #110) was pushing (Resident #111) out of their wheelchair. (Resident #110) is saying (Resident #111) was in their closet. I attempted to find an empty room on the unit to separate the two but there is none. Vitals are within normal range and no complaints of pain. There were no injuries, and they are both in bed sleeping right now. Provider, DON and guardian notified . - 1/13/22 at 1:41 PM: Social Services Note . SW was informed that resident had altercation with roommate yesterday. Resident was observed in the day room watching television appear to be in good mood no distress noted. Resident stated previous roommate push wheelchair because they thought .was going thru closet. Resident stated, 'I told them that this closet belongs to me also.' Resident report feel safe . no concerns . - 1/14/22 at 4:48 PM: Social Services Note . Follow up: Resident was observed resting in bed and appeared to be in no distress . expressed no concerns and just wanted to rest . reported feels safe. This writer has no concerns. SW and psych to follow. Review of facility provided Investigation documentation pertaining to the incident between Resident #110 and Resident #111 included the following: - Typed document titled, 5 Day Investigation Results (no date or time). The document contained a section labeled, Interviews which detailed the following: (Resident #110) . denies pushing anyone out of their wheelchair . states feels safe in the facility . did not want to participate in the interview and requested to be left alone (no date/time and/or signature) . - (Resident #111) states (Resident #110) just pushed them for no reason . didn't do anything to (Resident #110) . denies going through (Resident #110's) items . feels safe in the facility (no date/time and/or signature) . - CNA GG states as was walking by the room . heard (Resident #110) saying 'stay out of my stuff' . as went into the room to see . observed (Resident #110 ) behind (Resident #111's) wheelchair and observed (Resident #111) on the floor . states did not witness (Resident #110) push or pull (Resident #111) as their back was facing them . (Resident #110) kept saying, 'I'm tired of you in my stuff . always in my stuff' (Resident #111) was cursing calling (Resident #110) a mother f*cker . - Actions Taken . The Administrator, Director of Nursing (DON), Responsible Party, and Police were all notified . (Resident #110) and (Resident #111's) plan of care reviewed and updated as needed. Nurse assessed residents and no injury was noted. Social Worker and Activity monitored residents for any psychosocial changes . room change was conducted . - In conclusion, the facility completed a thorough investigation and was unable to substantiate abuse. (Resident #110) has no recollection of the alleged incident. (Resident #111) denies going through (Resident #110's) items . could be attributed to their diagnoses . - Resident #111 Skin & Wound - Total Body Assessment, dated 1/11/22 at 10:18 AM, indicating no new wounds. - Incident and Accident Report . 1/11/22 . 1:00 PM . (Resident #111) . Location: (Resident Room) . on the floor at foot of (their bed in room) . had an altercation with (Resident #110) and (Resident #110) was witnessed pushing (Resident #111) out of wheelchair . The report form section for Administrator and Physician signatures were blank. - Face sheets for both Resident #110 and Resident #111 - Activities Progress notes dated 1/12/22, 1/13/22, and 1/14/22 for Resident #110 and Resident #111 - Social Services Progress notes dated 1/13/22 and 1/14/22 for Resident #110 and Resident #111 - Behavior Health Nurse Practitioner (NP) note dated 1/17/22 for Resident #111. The note detailed, HPI . SW requested visit due to an altercation with roommate . During the exam, the patient was hard to engage . agreed to interview, then declined to answer many questions .did not remember the altercation . memory . impaired . - Behavior Health Nurse Practitioner (NP) note dated 1/17/22 for Resident #111. The note detailed, HPI . SW requested visit due to an altercation with roommate . has now switched rooms . Inquired about the altercation . denied any knowledge or memory . The provided investigation documentation did not include an Incident and Accident Report for Resident #110, any verification documentation of Police notification, description of what, if any, updates were made to either Resident's care plans, staff schedules, description of any other resident/staff witnesses, and/or written, signed, and/or dated witness/interview statements. Review of Census documentation revealed Resident #110 was moved to a different room on 1/12/22. CNA GG was not included on the facility provided employee phone list. CNA GG's phone number/contact information was requested from the facility Administrator during an interview completed on 10/26/22 at 9:14 AM but not received by the conclusion of the survey. On 10/27/22 at 10:00 AM, an interview was completed with the Assistant Administrator. The Assistant Administrator was queried regarding incident and investigations involving Resident #110 and Resident #111 on 1/11/22. When queried if Resident #110 pushed Resident #111 out of their wheelchair, the Assistant Administrator replied, Yes, it was witnessed. When queried if the Resident's had prior altercations and/or disagreements, the Assistant Administrator indicated they were not aware of any. When asked why the facility did not substantiate the allegation when Resident #110 purposely pushed Resident #111 out of their wheelchair, the Assistant Administrator revealed Resident #110 denied pushing Resident #111 but did not elaborate further. Pertains to Intake # MI00132006. Resident #134: A review of a Facility Reported Incident indicated an incident occurred on 7/19/2022 when Resident #134 was observed on camera play-back, hitting Resident #133 in the back of the head and shoulder. Resident #133 stated, He just sucker punched me. Certified Nursing Assistant AA observed the two residents immediately after the incident and heard Resident #133 say he had been hit. Certified Nursing Assistant AA said she heard yelling and looked into the hallway. Residents #133 and #134 were facing each other and standing closely. She told Resident #133 to be nice and he stated, What do you mean to be nice? He just sucker punched me! Certified Nursing Assistant AA observed Resident #134 with clenched fists and visibly shaking. When the Administrator and Assistant Administrator viewed the video footage of the incident. It revealed Resident #134 approach Resident #133 from behind, raise his hand over his head and lower it contacting Resident #133 in the back of the head. They said Resident #134 appeared to repeat this motion contacting Resident #133 on the back of his right shoulder; as Resident #133 begins to turn, Certified Nursing Assistant AA entered the picture. A review of the facility policy titled, Abuse Prohibition Policy, dated 7/2019 revealed, Policy: Each resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse . All facility staff and volunteers shall be in-serviced upon first employment and at least annually thereafter regarding Resident's Rights, including freedom from abuse, neglect, mistreatment, and misappropriation of property . To assure residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the residents . Resident #133 On 10/19/2022 at 2:30 PM, Resident #133 was observed slowly walking in the hallway near his room and the nurses desk. He was quiet without talking to or bothering any other residents. He stopped when asked how he was doing and he stated, I'm ok. A record review of the Facesheet and Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #133 was transferred to the facility on 5/26/2022 from another nursing home with diagnoses: Dementia, depression, anxiety, delusional disorder, and history of seizures. The MDS assessment revealed Resident #133 had severe cognitive decline with a Brief interview for Mental Status (BIMS) score of 3/15 and needed some assistance with all care. The MDS assessments dated 6/1/22 and 9/1/22 each identified the resident as needing supervision with ambulation. A review of the progress notes revealed the following: 7/19/2022 at 1:40 PM, a nurses note by Nurse F, Resident heard yelling, Resident stated, 'He just sucker punched me.' Referring to another resident on the unit. No witnesses present at the time . does not appear to have any injuries. Will continue to monitor. 7/19/2022 8:12 PM, a nurses note by Nurse Y . patient was ambulating with CNA (Certified Nursing Assistant) to bathroom and hit head on corner of wall turning into the bathroom. No s/s of injury noted . 7/20/2022 untimed provider note by Nurse Practitioner EE, . Nurse reports that patient was ambulating and? bumped his head on the wall? Mentation remains at baseline . Continue medications as directed. Provide supportive environment. Provide safety and fall precautions. Continue consistent daily routine. Avoid changes in environment. Monitor for changes . There was no mention of the resident being hit in the back of the head by another resident. 7/21/2022 at 8:13 PM, a nurses note by Nurse FF, Resident observed by aide starting convulsion while sitting on the couch in the dayroom . No injuries observed . Doctor notified. X-ray for right arm, shoulder and hand ordered. Right arm weakness observed 7/20 (2022) . COC (change of condition) noticed. He has not ambulated since convulsion and is very tired. He has been asleep since incident. 7/21/2022 untimed, by Nurse Practitioner HH, Call received from nurse stating that patient had a seizure around 2015 that resolved on its own after about two minutes . noticed that patient is not moving his right arm. Right hand is slightly swollen. States it was first noticed yesterday . There was no mention of the resident being hit in the head and right shoulder on 7/19/2022 by another resident. 7/22/2022 untimed, by Nurse Practitioner EE, . seizures: Breakthrough activity . abrasion above left eyebrow . Provide safety . 7/27/2022 at 5:57 PM, a nurses note by Nurse II Resident had a seizure, witnessed hitting his head on the floor 911 called, patient transported to (hospital). A record review of the Care Plans for Resident #133 revealed there was no mention of the resident being hit in the head by another resident. There was no plan for monitoring or aid in preventing future incidents. A Care Plan titled, (Resident #133) has the potential to demonstrate physical, verbal aggression related to: Anger, Delusions . dementia . Date initiated 6/10/2022 and revised 8/16/2022 with Interventions all dated 6/10/2022 except for one intervention dated 8/11/2022, Approach and redirect in a calm manner. A Care Plan titled, (Resident #133) has an ADL (activity of daily living) Self Care Performance Deficit and requires assistance with ADL's and mobility related to: Confusion, Date initiated and Revised 6/2/2022 with all Interventions dated 6/2/2022 including Ambulation: 'Supervision One Person.' A Care Plan titled, (Resident #133) is at risk for elopement and or wandering related to: Disoriented to place, Impaired safety awareness, Resident wanders aimlessly, Date initiated 5/31/22 and Revised 6/22/2022 with all Interventions dated 5/31/2022 except for Wander guard that was referenced twice 5/31/2022 and 9/8/2022. An intervention dated 5/31/2022 revealed, Provide structured activities, toileting, walking inside and outside with supervision as needed. Per the MDS and ADL Care Plan Resident #133 needed supervision with ambulation. He was observed during the survey on multiple occasions walking the hallways by himself, with no staff in view. On the day he was hit in the head by Resident #134 on 7/19/2022, he was observed unsupervised at the nurse's desk on the video surveillance camera, by staff members. On 11/1/2022 at 11:30 AM, Resident #133 was observed sitting in his room watching TV. When asked to speak with him, he was polite and offered a seat in his room. The resident was asked about the incident with Resident #134 on July 19, 2022, but he was unable to recall that it occurred. Resident #134 A record review of the Facesheet and Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #134 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, psychotic disturbance, mood disturbance, anxiety, delusional disorder, hypothyroidism, Parkinson's, and hypertension. The MDS assessment revealed Resident #134 had a BIMS score of 7/15 and needed some assist with all care, including 1-assist with ambulation. A record review of the progress notes identified the following: 7/18/22 at 5:00 PM, a nurses note written by Nurse F, . no falls this shift, however resident required frequent monitoring and redirecting throughout the shift. Resident had multiple near misses . impulsive and has safety awareness deficit .Would greatly benefit from a 1:1; sitter . 7/19/22 at 11:08 AM, a nurses note written by Nurse F, Found on floor in hallway at approx. 10am . laying on his right side . combative and refused vs (vital signs) for neuro checks . impulsive and poor safety awareness, combative with staff and unable to redirect . Resident agitated, 'I don't want to hurt you. I like to fight. Resident charging at another resident threatening to throw her over the edge. At this time resident requires constant monitoring . 7/19/22 at 1:36 PM, a nurses note by Nurse F, IM Ativan 1 mg one time dose ordered, given in right deltoid remains at nurse's station . continues to make attempts to stand up and ambulate. Will continue to monitor. 7/19/22 at 1:44 PM, a nurses note by Nurse F, Resident allegedly punched another resident. No witnesses present. 7/19/22 at 1:46 PM, a nurses note by Nurse F, Resident unable to redirect . has made multiple attempts to independently ambulate resulting in 2 falls. Resident Combative with staff and other residents . 7/19/22 at 4:28 PM, an assessment SBAR for Provider by Nurse F, . Behavioral status eval. Physical aggression danger to self and others . unable to redirect . 7/20/22 untimed, a note by Nurse Practitioner EE, . Recommend 1:1 supervision until patient calms downs, nurse states additional staff are unavailable. Patient placed at nursing station for increased observation . Consult received from Behavioral healthcare service with no new recommendations . 7/20/22 at 11:58 AM, (Interdisciplinary Team) IDT note, . reviewed multiple falls . also noted with aggressive and violent behavior at times . There was no mention of interventions for aggressive behavior. 7/22/22 untimed provider note for Nurse Practitioner EE, Review of records from patient's prior facility . same issues: recurrent falls, impulsiveness, paranoid delusional thought processes and aggressiveness with staff . 7/22/22 1140 on floor . pain right shoulder and hip . sent to hosp. A record review of the Care Plans for Resident #134 provided the following: (Resident #134) is at risk for elopement and/or wandering related to: Dementia with behavioral disturbance, Delusional Disorders, and Adjustment disorder with mixed anxiety and depressed mood, Date Initiated and Revised 7/11/2022 with Interventions: All dated 7/11/2022, including 'Provide structured activities, toileting, walking inside and outside with supervision as needed. (Resident #134) has actual behavior problem related to: Delusional Disorder, Dysthymic Disorder, Dementia . had a physical altercation with a fellow resident where he hit another fellow resident in the head . Dated initiated 7/11/2022 and Revised 7/27/2022 with Interventions: Monitor and document . dated 7/27/2022. Supervision of the resident was not addressed after multiple incidents of threats to staff and other residents, then actually physically hitting Resident #133 in the head and shoulder. On 11/1/2022 at 11:55 AM, Resident #134 was observed sitting in the dining room with a staff member, who said she was providing 1:1 sitter care for the resident. When asked how long this had been in effect, she said she did not know. The resident was not able to answer questions. When asked why the staff member was providing 1:1 sitter care for the resident, the staff member did not know. During an interview with the Assistant Administrator CC on 11/1/2022 at 1:44 PM, related to the incident between Residents #'s 133 and 134 on 7/19/2022, she said she watched it on the camera. She said both residents were located on the Dementia unit 2 south. When asked if Resident #134 had any prior history or incidents related to hitting and abuse, the Assistant Administrator CC said Resident #134 was an interesting case with behaviors, when he first came to the facility, he walked to the desk, went blank, fell over. She said he also had prior behaviors, including aggression, before admission. She said on the video of the 7/19/2022 incident between Resident's #'s 133 and 133, Resident #134 was observed walking down the hall and turned around towards the nursing station. Resident #133 came out of the doorway and Resident #134 raised his arms and they come down; kind of a fist, It looked like he made contact. She said Resident #133 was asked about the incident and stated, There's not much you can do when somebody sneaks up on you; when he comes up back here on you. During the interview with the Assistant Administrator CC on 11/1/2022 at 1:44 PM, she was asked what interventions were in place to prevent future incidents. The Assistant Administrator said, Frequent checks on both residents. When asked for further information, she said Resident #134 now had a 1:1 sitter. She was asked what the reason was for the sitter and said she thought that it was not for this incident, but wasn't sure. The Assistant Administrator CC was asked if there had been additional incidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Intake MI00126560 revealed the Facility Reported Incident (FRI) was initially submitted to the State agency via online submission on 12/5/21 at 3:58 PM. The FRI was related to a Resident-to-Resident altercation. The five-day investigation report was not submitted to the State agency until 12/17/21 at 6:32 PM. Review of Intake MI00127659 revealed a FRI related to a Resident-to-Resident altercation where one Resident was pushed out of their wheelchair. The initial report was submitted to the State on 1/17/22 at 2:09 PM and the five-day investigation report was not submitted until 1/25/22 at 7:04 PM. Review of Intake MI00128034 revealed a FRI was initially submitted to the State on 3/4/22 at 4:14 PM related to a Resident to Resident altercation with physical contact. The five-day investigation was not submitted to the State until 3/14/22 at 7:15 PM. Review of Intake MI00125816 revealed a FRI related to a Resident-to-Resident altercation. The initial report was submitted to the State on 11/29/21 at 6:29 PM and the five-day investigation was not submitted to the State until 12/10/21 at 3:37 PM. Review of Intake MI00128129 revealed the Facility Reported Incident (FRI) was initially submitted to the State agency via online submission on 3/25/22 at 5:51 PM. The FRI was related to a misappropriation of property. The five-day investigation report was not submitted to the State agency until 4/5/22 at 7:09 PM. Review of Intake MI00131997 revealed the Facility Reported Incident (FRI) related to misappropriation of property. The initial report was submitted to the State agency via online submission on 7/11/22 at 5:00 PM. The five-day investigation report was not submitted to the State agency until 7/19/22 at 5:07 PM. Review of Intake MI00132030 revealed the Facility Reported Incident (FRI) was initially submitted to the State agency via online submission on 8/18/22 at 5:58 PM. The FRI was related to a Resident-to-Resident altercation. The five-day investigation report was not submitted to the State agency until 8/26/22 at 7:33 PM. Review of Intake MI00132118 revealed a FRI was initially submitted to the State on 10/18/22 at 5:57 PM related to a Resident to Resident altercation and misappropriation of property. On 11/1/22, the facility had not yet submitted their five-day investigation. This Citation Pertains to Intake Numbers: MI00124734, MI00127659, MI00127614, MI00128034, MI00128129, MI00131892, MI00131997, MI00132027, MI00132028, MI00132030, MI00132036, and MI00132118. Based on interview and record review, the facility failed to report timely to the State Agency and the Administrator allegations of Abuse for Resident's #101, #102, #106, #110, #117, #118, #126, #127, #138, #139, #147, and #148) in a total sample of 49 residents reviewed, resulting in a delay in notification of incidents involving resident-to-resident interactions and abuse and a delay in notification of incidents per reporting guidelines and facility policy. Findings include: Review of facility 'Abuse Prohibition Policy' revised 9/9/22, documented Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion, and any physical chemical restraint imposed for the purposes of punishment . All facility staff and volunteers shall be in-serviced upon first employment and at least annually thereafter regarding guest resident rights, including freedom from abuse, neglect, mistreatment, exploitation and misappropriation of property . To assure guests/residents are free from abuse .the facility shall monitor guests/resident's care and treatment on an ongoing basis. It is the responsibility of all staff to provide a safe environment . Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment, shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative . Staff members, volunteers, family members, and others shall immediately report incidents of abuse and suspected abuse, and should be assured that they will be protected against repercussions. Abuse can be resident to resident, staff to resident, family to resident, visitor to resident . The definition of Physical Abuse includes: hitting, slapping, pinching, and kicking . Misappropriation of resident's property: deliberate misplacement, exploitation, wrongful, temporary or permanent use of resident's belongings or money without the guest/resident's consent . Mistreatment means inappropriate treatment or exploitation of guest/resident . Staff will report any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown origin, to the Administrator and Director of Nursing immediately . The Administrator or designee will notify the guest's/resident's representative. Also, any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegations or serious injury, all other not later than 24 hours). At the conclusion of the investigation, and no later then 5 working days of the incident, the facility must report the results of the investigation and if the alleged violation is verified, take corrective action . MI00131892 Review of a Facility Reported Incident dated 9/26/22, documented an incident between Resident #101 (perpetrator) and Resident #102 (victim). The 24 hour report was submitted on 9/26/22. Review of the Incident/Accident Investigation Form documented an incident that occurred on 9/26/22, in room [ROOM NUMBER]/208 bathroom, involving Resident #101 and #102. Under description: Resident #102 (gave name) reported that Resident #101 (gave name) threw her off the toilet. Resident #102 reported to the nurse on 9/26/22 at 12:25 PM. Further review of the 5 day investigation reflected the submission date to the State Agency related resident to resident altercation was submitted on 10/3/22, this was 9 days after the initial submission, and reflected a delay in reporting to the SA. Resident #101 According to admission face sheet, Resident #101 was an [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Dementia, Psychotic Disorder, Anxiety, Diabetes, and other complications. According to Minimum Data Set (MDS) dated [DATE], Resident #101 scored a 6 out of 15 on the Cognition Assessment, indicating moderate cognition impairment. The MDS also coded Resident #101 as limited assist with Activities of Daily Living (ADL) care to include ambulation, toileting and transfers. The MDS also coded Resident #101 as 'yes' for behaviors towards others. Resident #102 According to admission face sheet, Resident #102 was an [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Bipolar, High Blood Pressure, Depression and other complications. According to Minimum Data Set (MDS) dated [DATE], Resident #102 scored a 14 out of 15 on the Cognition Assessment, indicating minimal cognition impairment. The MDS also coded Resident #102 as limited assist with Activities of Daily Living (ADL) care to include ambulation, toileting and transfers. MI00127614 Review of a Facility Reported Incident reflected and investigation into allegations of abuse with no identified perpetrator, and Resident #124. The facility submitted a 24 hour report on 1/31/22, at 1:57 PM, with a five day investigation to follow. Review of the 5 day submission of the report, after an investigation was conducted for allegations of abuse, reflected the submission was sent on 2/8/22, at 6:02 PM. (9 days after the reported incident.) Resident #124 According to admission face sheet, Resident #124 was an [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Cardiac, Respiratory Failure, Kidney Failure and other complications. MI00124734 Review of Facility Reported Incident reflected a resident to resident altercation that occurred on 11/17/21, between Resident's #117 and #118, resulting in scratches and verbal abuse between the residents. Review of the 24 submission reflected a submission date of 11/17/21, and the 5 day submission was done on 11/30/21. (13 days of the initial submission). Resident #117 According to admission face sheet, Resident #117 was an [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Bipolar, Dementia, Psychotic Disturbance, anxiety, Schizophrenia, and other complications. Resident #118 According to admission face sheet, Resident #118 was an [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Parkinson's, delusions, Anxiety, Anemia, Psychotic Disturbances and other complications. An interview was conducted on 10/31/22, with the Administrator as to the late submission to the SA. The Administrator verbalized it was because it happened on a weekend and during a Holiday. MI00132038 The Facility Reported an incident of employee to resident abuse, involving Resident #142. The 24 submission report was sent on 9/7/22 at 8:01 AM, with the 5 day investigation submitted on 9/16/22. (9 days after the investigation.) Resident #142 According to admission face sheet, Resident #142 was an [AGE] year old male admitted to the facility on [DATE], with diagnoses that included: Peripheral Vascular Disease, High Blood Pressure, Cardiac, and other complications MI00132036 Resident #138 According to admission face sheet, Resident #118 was an [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Parkinson's, Delusions, Anxiety, Anemia, Psychotic Disturbances and other complications. Resident #139 According to admission face sheet, Resident #139 was an [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Sarcopenia, Vascular Dementia, Anxiety, Chronic Kidney Disease, Diabetes, and other complications. Review of a Facility Reported incident involving resident altercation between Resident #138 and Resident #139, occurring on 5/27/22, reflected the facility submitted a 24 hour report on 5/27/22, and a 5 day report submitted to the SA on 6/6/22. (10 days after the altercation.) MI00132027 Resident #139 According to admission face sheet, Resident #139 was an [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Sarcopenia, Vascular Dementia, Anxiety, Chronic Kidney Disease, Diabetes, and other complications. Review of an incident report documented an incident that occurred on 8/29/22, of a physical abuse allegation, involving Resident #139, and an employee. The facility started an investigation on 8/31/22, due to staff member failing to report the possible allegation of abuse timely on 8/29/22, and waited over 24 hours to tell a nurse. After informing the nurse, who reported to the Administrator, an investigation was started. The facility was not able to substantiate that abuse had occurred, due to inconsistencies with the staff member reporting, and changes in the information shared. The facility submitted a 24 hour report to the SA, related to suspected abuse on 8/31/22. (2 days after the alleged incident. The 5 day report was submitted on 9/9/22. 10 days after the incident.) An interview was conducted on 10/31/22, with Assistant Administrator CC who indicated the delay in initial reporting, was that Nursing Assistant I waited almost 2 days to report it to the nurse. Assistant Administrator CC indicated there were several inconsistencies that came out during the investigation, and abuse was not substantiated. Assistant Administrator CC verbalized the suspected perp had been suspended pending the investigation. She also verbalized that Nursing Assistant I received education on timely reporting any/all allegations of possible abuse immediately without delay. An interview was conducted with Nursing Assistant I related to suspected abuse against another staff member. NA I verbalized she did wait almost 2 days to tell anyone because she did not find her nurse, left her shift, then reported the allegation on her next working day 2 days later.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Numbers MI00127659, MI00128034, MI00128129, MI00131997, MI00132004, MI00132030, MI00132033, and MI00132118. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure thorough, systematic investigations of abuse and misappropriation allegations for seven residents (#'s 106, 110, 111, 122, 124, 129, and 132) of 35 residents reviewed, resulting in lack of completion and documentation of detailed investigations including observation, interviews, record review and the likelihood for unidentified and continued abuse, misappropriation of property, lack of root cause analysis, and subsequent potential for additional occurrences with the likelihood of psychosocial distress and physical injury. Findings include: Review of Facility Reported Intake (FRI) documentation dated received 12/5/21 and facility investigation report received 12/17/21 revealed, (Resident #124) was trying to get food off of (Resident #110's) plate and (Resident #110) hit (Resident #124's) arm. Resident #110 On 10/26/22 at 3:20 PM, Resident #110 was observed in their room. The Resident was in bed, laying on their right side, on top of their blankets with bare feet. A visibly soiled brief was present on the floor directly next to the right side of the Resident's bed. When spoke to, Resident #110 opened their eyes but did not provide responses to questions. An interview was conducted with CNA BB on 10/26/22 at 3:28 PM. When queried regarding Resident #110, CNA BB revealed the Resident is quiet most of the time. When asked if they had observed any altercations between Resident #110 and other Residents, CNA BB replied, (Resident #110) and (Resident #124) got into it one day. (Resident #110) flipped (Resident #124) off. When asked if they witnessed an altercation between the Resident's on 12/5/22, CNA BB revealed they did not. CNA BB was then queried regarding the CNA to Resident ratio in the facility and replied, Two aides for 32 Residents. When asked if it was typical staffing to have 16 Residents per CNA, CNA BB stated, Happens quite a bit. CNA BB was then asked if that staffing level is adequate to monitor and provide care to the Residents based on their needs. CNA BB replied, No. Record review revealed Resident #110 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included epilepsy, adjustment disorder with anxiety, bipolar disorder, repeated falls, and vascular dementia with agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, required limited to extensive assistance to complete Activities of Daily Living (ADL's), and displayed no verbal or physical behaviors. Review of Resident #110's care plans revealed a care plan entitled, (Resident #110) have the potential for fluctuations in mood R/T (related to): DX (diagnosis): Bipolar DO (disorder), Psychotic Disorder, Adjustment/Anxiety Disorder (Initiated: 1/16/19; Revised: 1/14/22). Care plan interventions included: - Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding to the physician (Initiated: 1/16/19) - Approach in a calm, quiet manner. Maintain appropriate body language during interactions such as maintaining eye contact and sitting in a relaxed position (Initiated: 1/16/19) - Behavior Management/RAR (Resident at Risk) per facility protocol (Initiated: 1/16/19; Revised: 1/25/19) - Behavioral health/psych consults as needed and follow recommendations as Indicated (Initiated: 1/16/19) - (Resident #110) requires extensive supervision with no more than 1:4 staff/resident ratio (Initiated: 12/2/20; Revised: 3/4/21) - Encourage resident to verbalize feelings as needed (Initiated: 1/16/19) - Observe and report to SW (Social Worker) and/or physician prn acute changes in mood or behavior; feelings or sadness; increased anxiety/agitation, depression, withdrawal/loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills; how resident interacts with others (Initiated: 1/16/19) - Observe for signs and symptoms of psychosis, mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation, delusions, hallucinations or hyperactivity and report to SW/physician as indicated (Initiated: 1/16/19) Another care plan entitled, (Resident #110) has a actual behavior problem R/T used racial slurs towards other residents . do not always get along with roommates of a different race than my own. (Resident #110) become verbally aggressive . have the potential to put food and utensils into the toilet . was observed having a small food fight with another resident. (Resident #110) was going thru roommate belongings (Initiated: 1/10/20; Revised: 8/12/22) was noted in the Resident's Electronic Medical Record (EMR). This care plan included the following interventions: - Anticipate and meet (Resident) needs (Initiated: 1/10/20; Revised: 2/24/21) - Approach in a calm manner (1/10/20) - Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and move to an alternate location as needed (Initiated: 3/13/21; Revised: 12/15/21) - Observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes (Initiated: 3/13/21) - Psych consult as needed (Initiated: 3/13/21) Review of Resident #110's progress notes revealed the Resident had a history of behaviors towards others. The documentation included: - 7/26/19: Resident At Risk . IDT team discussed residents contact exchange to roommate . Resident does no longer have that roommate, no further behaviors noted . - 5/9/20: Behavior Note . Resident angry tonight on 2nd shift after 8pm, not sure way, came out and said room was cold, very rude to nurse . told (Resident #110) it will be take care of, (Resident) got angry and hit to pole next to the nursing station . around 1130 pm (Resident) came out to the desk yelling I can't find my shoes, asked (Resident) did you look around bed . got very irate and yelled I told you I can't find my shoes, went in (room) . and shoes were next to bed . - 11/29/20: Nurses Notes . patient alert and oriented. patient was observed having behaviors with another patient by which (other resident) had the cordless phone in their hand and (Resident #110) went charging towards (other Resident) stating that was their phone and grabbed (other resident) arm without any injuries noted . - 11/19/20: Resident At Risk . resident is being discussed with IDT for recent behaviors. Resident continues to be unpredictable with physical altercations with other residents. medication has been assessed . Action Taken: SW is working on d/c plan to accommodate the needs of the resident . - 3/13/21: Behavior Note . resident became visibly upset when roommate was screaming and cursing at staff. resident yelled at roommate and when roommate quieted, resident immediately relaxed, sat back in his bed and was cooperative with staff . - 4/20/21: Nurses Notes .the nurse was notified that resident's roommate attempted to throw the side table at them but with the quick intervention of aid who was in the room at the time and caught the table . only hit the resident bed. resident was startled . - 12/5/21 at 1:30 PM: Nurses Notes . Verbal and food exchange with another resident. 15 min checks initiated. Social work and house supervisor aware. - 12/5/21 at 2:02 PM: Social Services Note . SW (Social Worker) was called . for verbal altercation between (Resident #110) and fellow resident. When SW inquired what happened, (Resident #110) said 'I am fine, (Resident #124) just lost control mentally and physically, like they got confused.' SW asked if they threw food at (Resident #124) or hit them, (Resident #110) said 'no, (Resident #124) just yelled and I kept eating'. SW asked if they were hit at all, (Resident #124) reported 'No, nothing happened (Resident #124) just got confused and started yelling but I'm fine.' Resident was put on 15 Minute checks until IDT can review. Admin is aware. - 12/6/21 at 4:48 PM: Social Services Note . Follow up: Resident was observed laying in assigned bed. Resident appeared to be resting . appeared to be in no distress. Resident reported no concerns and reports . feels safe in the facility. Writer has no concerns at this time . - 12/7/21 at 5:54 PM: Social Services Note . Follow up: Resident was observed resting in assigned bed. Resident appeared to be sleeping and in no distress. SW did not disturb. No behaviors were noted . - 12/8/21 at 6:45 PM: Social Services Note . Resident was observed resting in bed and appeared to be watching TV. Resident reported was doing great and appeared to be in a good mood with no distress noted . - 1/13/22 at 3:05 PM: Social Services Note . Resident was observed sleeping in assign bed. SW was informed that resident had altercation with previous roommate yesterday. BSC psych doctor to follow up with resident. SW to follow up with resident. No behaviors being noted. - 1/14/22 at 12:24 PM: Social Services Note . Resident was observed resting in assign bed. Resident appear to be in good mood no distress noted. SW reviewed and updated behavior care plan. Resident is being follow by BCS psych services . Resident #124 An interview was completed with Resident #124 on 10/26/22 at 3:35 PM. Resident #124 was soft spoken, calm, and pleasantly confused. The Resident did not recall having any altercations and indicated they liked everyone. At 3:37 PM on 10/26/22, an interview was conducted with Certified Nursing Assistant BB. When queried regarding Resident #124, CNA BB indicated the Resident's mood changes frequently. CNA BB stated Resident #124 will cuss you out if they are upset about something. Record review revealed Resident #124 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included aphasia (difficulty with comprehension and communication) following cerebral infarction (stroke), dysphagia (difficulty swallowing), difficulty walking and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired, required limited to extensive assistance to complete ADL's, and displayed physical and verbal behaviors towards others. On 10/26/22 at 3:15 PM, Resident #124 was observed sitting in their wheelchair using the phone at the nurses' station. Review of Resident #124's EMR revealed a care plan entitled, (Resident #124) has a actual behavior problem R/T: Major Depressive Disorder, Anxiety, Insomnia, Dementia . has verbal behaviors symptoms directed toward other episodes of yelling/screaming out/cursing. Physical behavioral symptoms directed towards others hitting. I will often think people are talking to me and get aggressive if I do not like what they said or what I think they said. I often go through my roommate's belongings and am found to sometimes be wearing their clothes and have their belongings in my possession (Initiated: 12/16/21; Revised: 5/4/22). Care plan interventions included: - Administer medication as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician (Initiated: 12/16/21) - Anticipate and meet (Resident) needs (Initiated: 12/16/21) - Approach in a calm manner (Initiated: 12/16/21) - Assess for possible triggers such as: Noise, pain, fatigue, or changes in environment (Initiated: 5/4/22) - Assist to develop more appropriate methods of coping and interacting (Specify:). Encourage resident to express feelings appropriately (Initiated: 12/16/21) - Avoid increased daytime sleeping and avoid increased environmental stress/stimuli (Initiated: 2/25/22) - Continue supportive environment and monitor for changes in depression and document (Initiated: 2/25/22) - Continue to reassure the patient and validate feelings (Initiated: 5/4/22) - Document behaviors, and resident response to interventions (Initiated: 12/16/21) - Encourage Socialization and participation in meaningful activities (Initiated: 5/4/22) - Explain all procedures . before starting and allow resident (X minutes) to adjust to changes (Initiated: 12/16/21) - If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident (Initiated: 12/16/21) - Maintain a supportive environment (Initiated: 5/4/22) - Observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes (Initiated: 12/16/21) - Offer reassurance, support, redirection, and diversionary activities as needed (Initiated: 5/4/22) - Psych consult as needed (Initiated: 12/16/21) - RAR per protocol (Initiated: 12/16/21) - Review concerns as needed (Initiated: 12/16/21) - Staff to monitor and report any changes in mood and/or behavior; and document (Initiated: 5/4/22) A second care plan titled, (Resident #124) has the potential to demonstrate verbal/physical aggression R/T: Dementia, Depression. (Resident #124) have behaviors of yelling/cursing at staff and residents . sometimes will kick at staff when upset . had an incident where (Resident #124) hit a resident and was yelling at them, although often forget things quickly, due to diagnosis: Dementia . at times become verbally/physicality combative when feel residents are looking at them . attempted to take some food off another resident tray, and smacked resident arm during incident . grabbed and attempted to twist another residents arm because was agitated by the sound they were making (Initiated: 8/30/19; Revised: 9/30/22). Care plan interventions included: - Continue to monitor for psychosis and change in mood and behavior (Initiated: 2/25/22) - Give (Resident #124) as many choices as possible about care and activities (Initiated: 12/16/21) - (Resident #124) had room change to deescalate the situation (Initiated: 9/3/21; Revised: 12/16/21) - Observe key times, places, circumstances, triggers, and what de-escalates behavior. Adjust plan of care to reduce incidents of aggression where possible (Initiated: 8/30/19) Review of Resident #124's EMR revealed the following progress note documentation: - 11/8/21 at 6:38 AM: Behavior Note . Patient was carrying bag of soiled briefs the aid took garbage the patient began hitting kicking the staff nurse redirected patient as (Resident) was repeating was going to beat their ass and tear it up aid also assisting with emotional support - 12/5/21 at 1:33 PM: Nurses Notes . Verbal exchange with another resident. 15 min checks implemented. House supervisor and social work aware - 12/5/21 at 1:54 PM: Social Services Note . SW was called to (unit) for a verbal altercation between the resident and a fellow resident. When SW inquired what happened. Resident reported . was hungry and was trying to get some food by taking it off the other residents tray . reported (Resident #124) looked at them crazy and then swatted their arm. Resident reported (they) smacked their arm after (Resident #124) threw mash potatoes at them . when SW asked CNA that was there. CNA reported (they saw) the other resident throw mash potatoes at (Resident #124) and (Resident #110) threw a salad at (them). However, the CNA did not witness anyone hitting one another. Resident was put on 15 Minute check until further discussion with the IDT team and Admin is aware - 12/6/21 at 3:30 PM: Social Services Note . Resident was observed in the hallway . report is doing well appear to be in good mood but was confused about their assign room. SW redirected resident to . room. Resident report no concerns at this time. BCS psych nurse/SW to follow up with resident regarding verbal altercation resident had with (other) resident on previous assign floor. SW reviewed care plan . - 12/7/21 at 8:58 AM: Total Body Skin Assessment Late Entry . Number of new skin conditions: 0 . - 12/7/21 at 1:53 PM: Social Services Note .Resident was observed at the nurse station assigned unit. Resident appear to be in good mood, no distress noted. Resident report no concerns at this time. No behaviors being noted this morning . - 12/8/21 at 1:48 PM: Social Services Note . Resident was observed in the hallway on assign floor unit. Resident appear to be in good mood no distress noted. No behaviors being noted. Resident report no concerns at this time. - 2/14/22 at 5:30 AM: Nurses Notes . Resident was heard cursing out another resident. The resident was separated by taking to . room to calm down - 2/23/22 at 12:15 PM: Nurses Notes . This morning I overheard (Resident #124) screaming at roommate. When I entered the room [NAME] was near (other) bed 3 yelling telling other resident to get out of their room. (Resident #124) was brought out of room to eat in the dining room. After redirection everything seems fine and has not done this again . - 9/15/22 at 6:56 PM: Nurses Notes . (Resident #124) got upset because another resident was making loud noises and grinding their teeth, grabbed their arm and twisted it. No injuries noted. Supervisor notified, provider notified . - 10/3/22 at 12:09 PM: Nurses Notes . Resident attempting to get out of bed, pointing to the door, states is going 'out there'. Writer asked resident if would like to get up in WC (wheelchair), resident declined. Resident using abusive language when writer attempted to help resident back in bed. Resident kicking and slapping at writer . Review of facility provided Investigation documentation pertaining to the incident between Resident #110 and Resident #124 included the following: - Typed document titled, 5 Day Investigation Results (no date or time). The document contained a section labeled, Interviews which detailed the following: (Resident #110) . 'I am fine, (Resident #124) just lost control mentally and physically like they got confused.' (Resident #110) denies hitting (Resident #124) . denies that (Resident #124) hit them . denies throwing food at (Resident #124) and denies (Resident #124) threw food at them (no date/time and/or signature) . (Resident #124) . states they were hungry and took food off of (Resident #110's) plate. (Resident #124) states (Resident #110) swatted at their arm and they swatted back at (Resident #110) . denies threw salad at (Resident #124) (no date/time and/or signature) . (CNA DD): States while passing trays (Resident #110's) tray came first, as they were getting other trays, and heard (Resident #124) yelling 'food fight.' States when they turned around, saw (Resident #110) throwing mashed potatoes at (Resident #124), and as they were walking over to get them, (Resident #124) threw a salad at (Resident #110) . stated did not witness any physical contact . removed (Resident #110) (no date/time and/or signature) . (Resident #111) . states didn't see anything happen between the residents . (the form did not indicate Resident #111's location when the altercation occurred and/or cognition) (no date/time and/or signature) . Actions Taken: The Administrator, Director of Nursing (DON), Responsible Party, and Police were all notified . (Resident #110) and (Resident #124's) plan of care reviewed and updated as needed. Nurse assessed residents and no injury was noted. Social Worker and Activity monitored residents for any psychosocial changes . In conclusion, the facility completed a thorough investigation and was unable to substantiate abuse. (Resident #110) denies swatting (Resident #124's) arm and denies being hit. (Resident #124) denies throwing food. The facility did not substantiate abuse occurred. (Resident #110) has no recollection of the alleged incident . - Face sheets for both Resident #110 and Resident #124 - Activities Progress notes dated 12/6/21, 12/7/21, and 12/9/21 for Resident #110 - Activities Progress notes dated 12/6/21 and 12/7/21 for Resident #124 - Social Services Progress notes dated 12/5/21, 12/6/22, 12/7/21, and 12/8/22 for Resident #110 - Social Services Progress notes dated 12/5/21, 12/6/22, 12/7/21, 12/8/22, and 12/13/21 for Resident #124 - Behavior Health Nurse Practitioner (NP) note dated 12/7/21 for Resident #110. The note detailed, HPI (History of Present Illness) . psychiatric history of bipolar, psychosis with delusions, anxiety, insomnia, and dementia . currently receiving anti-psychotic medication for delusions/psychosis . last seen . 10/7/21 . GDR (Gradual Dose Reduction) of Seroquel (anti-psychotic medication) . SW has requesting this NP to see the patient today due to an altercation with another resident. The other resident reported there was hitting between the two; however, per SW documentation on 12/5/21, 'SW was called . for verbal altercation between resident and fellow resident .' When asked about the incident today, the patient could not recall any details . Exam . Grooming: Disheveled . Eye contact: Poor . kept eyes closed . - Behavior Health Nurse Practitioner (NP) note dated 12/7/21 for Resident #124. The note detailed, HPI . seen in hallway, alert with forgetfulness . SW asked this NP to evaluate again due to reports of having a physical altercation with another resident . was not actually witnessed . When SW inquired what happened. Resident reported that they were hungry and were trying to get some food by taking it off the other resident's tray. (Resident #124) reported (Resident #110) looked at them 'crazy' and then swatted their arm. Resident reported they smacked (Resident #110's) arm after they threw mashed potatoes at them, When SW asked CNA that was there, CNA reported that the see (Resident #110) throw mash potatoes at (Resident #124) and (Resident #124) threw a salad at the other resident. However, the CNA did not witness anyone hitting one another' . Today . patient does not recall any aspect of the incident . On previous visit, this NP recommended an increase in Namenda. Reviewed the medical record, it has not yet been implemented . - Incident and Accident Report . 12/5/21 . 1:00 PM . (Resident #124) . Location: Dining Room . Verbal and food exchange with another resident. Denies any pain or injury. Couldn't recall what happened. 15-minute checks initiated The report form section for Director of Nursing (DON), Administrator, and Physician signatures were blank. The provided investigation documentation did not include an Incident and Accident Report for Resident #110, any verification documentation of Police notification, description of what, if any, updates were made to either Resident's care plans, skin assessment documentation, video camera footage review, staff schedules, description of any other residents/staff in the dining room at the time of the incident, and/or written, signed, and/or dated witness/interview statements. Upon request, the Incident and Accident Report for Resident #110 was received and reviewed. The report specified, 12/5/21 . 1:00 PM . Location: Dining Room . Verbal and food exchange with another resident. (No) injury. 15-minute checks initiated . couldn't recall what was said or what food was thrown . The report form section for Director of Nursing (DON), Administrator, and Physician signatures were blank. Upon review of Resident #124 and Resident #110's Electronic Medical Records (EMR's), no documentation of 15-minute checks following the altercation on 12/5/22 were noted. A second FRI involving Resident #110 was reviewed. The intake documentation was dated as received on 1/17/22 and included, Incident Summary . (Resident #110) pushed (Resident #111) out of their wheelchair and they fell . no injuries. (Resident #110) denies . (Resident #111) states did. Residents were roommates and a room change was done . Resident #111 Review of Resident #111's EMR revealed the Resident was originally admitted to the facility on [DATE] with diagnoses which included repeated falls, mental disorders, anxiety, auditory hallucinations, and dementia with agitation. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to extensive assistance to complete ADL's. On 10/26/22 at 3:25 PM, Resident #111 was observed in their room. The Resident was laying in bed with their eyes closed. An interview was completed with CNA BB on 10/26/22 at 3:39 PM. When queried regarding Resident #111 including any behaviors and/or altercations with other Residents, CNA BB stated, (Resident #111) talks a lot but no behaviors. When queried regarding any incidents between Resident #111 and Resident #110, CNA BB revealed they were unaware of the altercation. Review of Resident #111's care plan revealed a care plan entitled, (Resident #111) has the potential to demonstrate physical, verbal aggression R/T: Dementia, Hallucinations, Mental Illness . will go through my roommates' closets when I am up in my chair and this will agitate them. I have in the past been known to hit staff when providing care . (Initiated: 1/27/21; Revised: 5/20/22). The care plan included the following interventions: - Assess (Resident) understanding of the situation. Allow time for the resident to express self and feelings towards the situation, including antecedents, effective calming strategies etc . (Initiated: 1/27/21) - Assess and anticipate (Resident) needs: food, thirst. toileting needs, comfort level, body positioning, need for sleep, pain etc. as needed (Initiated: 1/27/21) - Assess (Resident #124) understanding of the situation. Allow time for the resident to express self and feelings towards the situation, including antecedents, effective calming strategies etc . (Initiated: 1/27/21) - Avoid changes in environment and confrontation. Reapproach when non-compliant (Initiated: 5/20/22) - Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated (Initiated: 1/27/21) - Continue to maintain consistency in daily routine and care (Initiated: 5/20/20) - Give (Resident #111) as many choices as possible about care and activities (Initiated: 1/27/21) - Observe key times, places, circumstances, triggers, and what de-escalates behavior. Adjust plan of care to reduce incidents of aggression where possible (Initiated: 1/27/21) - When (Resident #111) becomes agitated Intervene before agitation escalates; Guide away from source of distress; Engage calmly and/or (Specify [blank]) past successful (interventions [none indicated]) as needed (Initiated: 1/27/21) - Psychiatric consult as indicated (Initiated: 1/27/21) Review of documentation in Resident #111's EMR revealed the following: - 1/11/22 at 10:00 AM: eINTERACT SBAR Summary for Providers . Situation . Falls . Behavioral Status Evaluation: Other behavioral symptoms (not specified) . New Intervention Orders: (Blank) . - 1/11/22 at 10:21 AM: Nurses Notes . at 10 pm (Resident #111) was pushed put (sic) of wheelchair by roommate (Resident #110). 2nd shift CNA says that they walked in (Residents) room because heard arguing from the hallway and as was walking in the door (Resident #110) was pushing (Resident #111) out of their wheelchair. (Resident #110) is saying (Resident #111) was in their closet. I attempted to find an empty room on the unit to separate the two but there is none. Vitals are within normal range and no complaints of pain. There were no injuries, and they are both in bed sleeping right now. Provider, DON and guardian notified . - 1/13/22 at 1:41 PM: Social Services Note . SW was informed that resident had altercation with roommate yesterday. Resident was observed in the day room watching television appear to be in good mood no distress noted. Resident stated previous roommate push wheelchair because they thought .was going thru closet. Resident stated, 'I told them that this closet belongs to me also.' Resident report feel safe . no concerns . - 1/14/22 at 4:48 PM: Social Services Note . Follow up: Resident was observed resting in bed and appeared to be in no distress . expressed no concerns and just wanted to rest . reported feels safe. This writer has no concerns. SW and psych to follow. Review of facility provided Investigation documentation pertaining to the incident between Resident #110 and Resident #111 included the following: - Typed document titled, 5 Day Investigation Results (no date or time). The document contained a section labeled, Interviews which detailed the following: (Resident #110) . denies pushing anyone out of their wheelchair . states feels safe in the facility . did not want to participate in the interview and requested to be left alone (no date/time and/or signature) . - (Resident #111) states (Resident #110) just pushed them for no reason . didn't do anything to (Resident #110) . denies going through (Resident #110's) items . feels safe in the facility (no date/time and/or signature) . - CNA GG states as was walking by the room . heard (Resident #110) saying 'stay out of my stuff' . as went into the room to see . observed (Resident #110 ) behind (Resident #111's) wheelchair and observed (Resident #111) on the floor . states did not witness (Resident #110) push or pull (Resident #111) as their back was facing them . (Resident #110) kept saying, 'I'm tired of you in my stuff . always in my stuff' (Resident #111) was cursing calling (Resident #110) a mother f*cker . - Actions Taken . The Administrator, Director of Nursing (DON), Responsible Party, and Police were all notified . (Resident #110) and (Resident #111's) plan of care reviewed and updated as needed. Nurse assessed residents and no injury was noted. Social Worker and Activity monitored residents for any psychosocial changes . room change was conducted . - In conclusion, the facility completed a thorough investigation and was unable to substantiate abuse. (Resident #110) has no recollec[TRUNCATED]

Based on interview and record review, the facility failed to ensure that nursing staff received annual trainings, (Abuse, Dementia, Resident Rights), Competencies/Performance Evaluations, and orientation skill's checks offs for 5 nurses and 4 nursing assistants out of 12 staff reviewed for education, trainings, and yearly competencies; resulting in nursing staff lacking the necessary qualifications and trainings to adequately care for the needs of all residents. Findings include: During an extended survey on 11/1/22, it was noted that out of 12 files reviewed for nursing staff (nurses and nursing assistants), the staff did not have completed Performance Appraisals/yearly Competencies, skills checked off, by an evaluator as being competent with job skills. On 11/1/22 review of staff files with Human Resource staff ZZ it was noted that out of 6 nurses files reviewed, 5 nurses lacked appropriate educations, evaluations and training's. Review of LPN N education/evaluations reflected the last Performance Evaluation was completed on 5/8/21, which was greater than 17 months. Further review reflected there was no current Abuse or Dementia training as completed within past year. The last Resident Rights was completed 7/21/22. Review of LPN YY education as provided by the facility, reflected there was no proof of Dementia training as being completed. Review of RN C education as provided by the facility reflected there was no proof of Abuse and Dementia training as being completed. Review of LPN T education and training's reflected she had no Orientation skills check off completed, and did not have any Abuse, Dementia, or Resident's Rights training completed prior to working with residents. Review of 6 Nursing Assistant files done with HR staff ZZ reflected the following: Nursing Assistant AAA did not receive Resident Rights, Abuse, or Dementia training. Also her orientation skills check off did not have an Evaluator signature, as verified by HR ZZ. Review of Nursing Assistant BB reflected no Abuse, Resident Rights or Dementia training. The CNA competency had the signature of the evaluator whited out and signed over. HR ZZ was asked if she was able to identify who the signature belong to and verbalized she could not. Review of Nursing Assistant JJ reflected the last Competency skill check was completed 12/10/20, (almost 24 months), and the facility was not able to provide proof of Abuse and Resident Rights training. Review of Nursing Assistant WW reflected the last Competency skills check was completed on 12/14/20, and Abuse training was done 4/12/21, Resident Rights on 5/1/21, which was greater than 12 months. Review of CNA Competency Evaluation form reflected some of the training topics as: Abdominal thrust, Bathing, Bed Pan/Urinal, Catheter Care, Feeding a resident, Hand washing, Mechanical Lift. This was not all the trainings listed. AN interview with HR ZZ reflected the facility did not have a Facility Educator in place currently and the previous one who had been doing the education and evaluations was not doing it anymore. HR ZZ was offered the opportunity to search for any additional trainings for the staff reviewed and to provide to Surveyor by the end of the survey, and was not able to provide any additional information. According to the Code of Ethics for Nurses (American Nurse Association, 2001, pg 14) the nurse's primary commitment is to health, well-being, and safety of the patient. The nurse must take appropriate action regarding any instances of incompetent, unethical, or impaired practices by any member of the health care team. The Code of Ethics for Nurses (pg. 17) states the nurse is accountable to the quality of nursing care given to patients and the delegation of nursing care activities of other health care workers. The nurse is responsible for monitoring the activities of those individuals and evaluating the quality of care provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Numbers MI00124734 and MI00132036. Based on observation, interview, and record review, the facility failed to consistently monitor for aggressive behaviors for five residents (Resident #101, Resident #107 Resident #117, Resident #118, and Resident #139) of 49 residents reviewed, resulting in increased behaviors and resident-to-resident altercations, lack of interventions to manage behaviors, and incomplete documented behaviors. Findings include: Resident #101: According to admission face sheet, Resident #101 was an [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Dementia, Psychotic Disorder, Anxiety, Diabetes, and other complications. According to Minimum Data Set (MDS) dated [DATE], Resident #101 scored a 6 out of 15 on the Cognition Assessment, indicating moderate cognition impairment. The MDS also coded Resident #101 as limited assist with Activities of Daily Living (ADL) care to include ambulation, toileting and transfers. The MDS also coded Resident #101 as 'yes' for behaviors towards others. Resident #101 was involved in a resident to resident altercation on 9/26/22. Resident #101 had been displaying aggressive behaviors as documented in Progress notes on 9/19/22, and 9/20/22, and staff failed to documented those behaviors and inform the Social Service Director of the aggressive behaviors. After the third incident on 9/26/22, Resident #101 was moved to a different room on a different floor, after throwing the resident in the adjacent room off the toilet. Resident #107: According to admission face sheet, Resident #107 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Dementia with behavioral disturbances, Bipolar, Anxiety, Psychotic disorder, Depression, and other complications. Review of medical record reflected Resident #107 was referred for Psych Services on 9/8/21 after a physical alteration with another resident. Resident #107 was also receiving the antipsychotic medication Seroquel. Review of a Facility Reported Incident documented an altercation with another resident that occurred on 2/4/22, and was witnessed. The incident was documented as hitting and scratching another resident. Resident #107 was involved in a 2nd incident on 2/15/22, involving the same resident as previous incident. The Social Service Director was asked to provide proof of behavioral monitoring, and provided Behavioral monitoring completed by Nursing Assistants. Review of Tasks Behavioral Monitoring for the months of January, February, and March of 2022, reflected multiple holes in the documentation for all three months, and not done consistently on all three shifts for that time frame. The Social Service Director H was asked about behavioral monitoring documentation for residents with behaviors and verbalized she was aware of inconsistencies in documenting behaviors by staff, and that it had been an ongoing problem. Staff H was asked what she was doing to correct the problem and indicated some education was done. Resident #117: According to admission face sheet, Resident #117 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Bipolar, Dementia, Psychotic Disturbance, anxiety, Schizophrenia, and other complications. Review of behavioral monitoring documentation reflected for the months of October, November and December 2021, incomplete documentation by staff, as evidence by multiple holes in the documentation on all shifts. Resident #117 was involved in a resident to resident altercation in November 2021, resulting in scratches and verbal abuse to another resident. Resident #118: According to admission face sheet, Resident #118 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Parkinson's, delusions, Anxiety, Anemia, Psychotic Disturbances and other complications. Review of behavioral monitoring by staff reflected incomplete documentation for behavioral monitoring for the months of October, November, and December of 2021. Resident #118 was involved on a resident to resident altercation as evidenced by pulling another residents shirt and hair. Resident #138: According to admission face sheet, Resident #138 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included: Parkinson's, delusions, Anxiety, Anemia, Psychotic Disturbances and other complications. Review of behavioral monitoring was reviewed for the months of April. May and June, 2022, which reflected incomplete behavioral monitoring for Resident #138, who was involved with 2 Resident to Resident altercations. Review of Facility Policy 'Behavior Management' documented The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize behaviors . Guests/Residents with behavioral symptoms or those receiving psychoactive medications are evaluated, monitored, and managed by an interdisciplinary behavior management team including facility clinical staff,(nursing staff, social worker, social service staff, and activity staff), physician and pharmacists .