**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake numbers: MI00152521 and MI00152424. Based on observation, interview, and record review, the facility failed to thoroughly and accurately conduct an investigation of a fall that sustained a left hip fracture for one Resident (R#501) of four (4) sampled residents reviewed for fall. Findings include: Resident #501 (R501) On 5/1/25 at 10:27 AM, Resident 501 (R501) was observed grimacing and complaining of severe, unbearable pain in bed. R501 revealed she fell and broke her hip, but could not recall how it happened or when it happened. R501 attempted to get up and indicated she wanted me to stay until she returned. She said she was going to the bathroom when asked where she was going. R501's call light was not within reach during the observation. However, R501 was observed holding the wall lamp metal chain cord and was pressing on the metal bell at the tip of the metal string. Like she was pressing a call light button. R501, during a brief interview, was observed to be very confused and expressed that she was in extreme pain. A review of R501's Electronic Medical Record (EMR) conducted on 5/1/25 revealed R501 was [AGE] years old, admitted on [DATE] with the diagnosis of Dementia, Difficulty Walking, Schizophrenia, and Type II Diabetes in addition to other diagnoses. On 4/17/25, R501 fell twice and was sent to the hospital the following day on 4/18/25. R501 returned on 4/23/25 with an additional diagnosis of Displaced Interthrochanteric Fracture of the left Femur, subsequent encounter for closed fracture with routine healing, and an encounter for other orthopedic aftercare. The Minimum Data Set, dated [DATE] indicated that R501's Brief Interview of Mental Status (BIMS) Score was 10/15. A score of 10 for BIMS indicates moderate cognitive impairment. R501's Care Plan for Safety was Ambulation, which requires assistance from (1) staff to walk with a walker daily. Locomotion: R501 is independent for locomotion in a manual wheelchair, and Transfers require assistance by (2) to move between surfaces with a 2-wheeled walker. Description of the 2 Fall incidents: Incident Report Fall #1 dated 4/17/25 at 4:00 PM was reviewed on 5/1/25 at 1:45 PM. It revealed that R501 was found on the floor in the hallway with a wheelchair in front of her. R501 was unable to give a description. Although the resident was described to be alert, her mental status was described to be oriented to person and place but not to situation or time. Post-fall, the pain level was left blank, and the level of consciousness, mental status, mobility, and other predisposing factors were all left blank. When the facility was asked for the Witness or direct care staff statements. The Director of Nursing (DON) on 5/1/25 at 3:45 PM, indicated that the incident report is the nurse's statement. They did not obtain a written narrative statement from the nurse. The DON also stated that she did not get a statement from the CNA D assigned because she was not involved in the incident, because she was not there, and that the fall was unwitnessed. According to Nurse K on May 1, 2025, at 11:20 AM, and the DON on May 2, 2025, at 3:45 PM, Fall Incident# 1 on 4/17/25 at 4:00 PM was an unwitnessed fall. Incident Report Fall #2 dated 4/17/25 at 4:35 PM was reviewed on 5/1/25 at 2:00 PM. It revealed, R501 got out of bed and started to push her wheelchair and fell on the floor in front of her room door.R501 was unable to give a descriptiondescription. Staff gotR501 back into bed, assessed resident-appeared at baseline, Did not hit head, Vital Signs WNL (Within Normal Limits). No injuries observed Post Incident. Resident Taken to Hospital? Y (Yes). The date and time of the incident report written was unknown or not specified. Several boxes were not answered or marked for assessment such as Level of Pain, Level of consciousness and Mobility status did not have an entry or check mark. Staff involved was not identified. An interview with Nurse K was conducted on 5/1/25 at 11:00 AM. She stated that there were two falls on 4/17/25. One was unwitnessed in the hallway when the resident (R501) yelled for help. And the second fall happened on 4/17/25 at approximately 4:35 when she self-ambulated in her room. When Nurse K was asked about the incomplete incident report, she stated that the resident was at her baseline, so there was nothing to write. When asked about the resident's baseline? Nurse K said, She was not in pain, but I did not indicate that there was zero pain at the time of assessment. Nurse K also indicated that R501 cognition/mental status and mobility remained the same, so there was nothing to write. She stated that there was another form that was handwritten. No witness statement was obtained from the nursing assistant (CNA) because she was not there to witness both falls. The Electronic Incident report did not contain a risk analysis and a thorough summary to conclude how the resident's fall resulted in fracture and surgery at the nearby hospital. There was no root-cause analysis, and no risk management and interventions were implemented to minimize or prevent further minor or major injuries caused by falls. There were no evidence of monitoring R601 for pain, nuerovital signs and change in condition from the last fall recorded at 16:35(4:35 PM) on 4/17/25 until the following morning approximately 16 hours later when R601 complained of unbearable pain and had difficulty moving and obvious left hip deformity observed by the morning staff the following day while in bed. A Nursing Checklist to Complete with Every Fall form was reviewed. The dates were initially written as 4/16/25 but were written over to reflect 4/17/25 at 16:30 (4:30 PM). The second Form, Nursing Checklist to Complete with Every Fall, was initially written on 4/18/25, but someone wrote over to reflect 4/17/25 at 16:32 (4:32 PM). The fall time did not match any of the dates and times of Fall #1 and #2 on 4/17/25. When Nurse K was asked, she did not respond. Two nursing assistants, CNA G and CNA D, were interviewed on 5/2/25 at 2:27 PM and 2:45 PM. They were assigned to R501 on the day of the two falls on 4/17/25 and post-fall on 4/18/25. They both stated that they did not give their statements, nor were asked to provide a statement, until today, 5/2/25, for the event that occurred on 4/17/25. The DON revealed on 5/1/25 at 3:45 PM that the Charge Nurse's (Nurse K) Incident Report was considered her statement. When the DON was asked about the accuracy of the written over and missed entries in the electronic incident report and the post-fall forms, the DON did not reply. The DON did not have a summary of the investigation to conclude that the investigation was deemed not reportable to the state, despite the actual Fracture, Hospital admission, and surgical intervention post fall. During an interview on May 1, 2025, at 3:45 PM, the DON stated that there is no need to check those boxes if there are no abnormal findings. She further explained that no documentation is required if abnormal findings are found. The DON revealed that they are part EMR and part handwritten. The staff writes everything in the Post Fall Form. The don revealed that there is no need to complete the Incident Report (IR) in PCC if the Post-Fall Form is complete. It is not necessary. The DON admitted that she did not have statements from the direct caregivers, CNA G and CNA D, because they were not involved in the fall and did not witness it. She also did not have a statement from the Charge Nurse (Nurse K) who had seen Fall #1 and was the first responder and witness Fall #2 on 4/17/25. After a thorough discussion on the Reporting Process with the DON on 5/1/25 at approximately 3:45 PM, the DON stated the following: 1. The check marks in the IR were missing, therefore incomplete. 2. NO neurovitals were taken despite the IR stating an unwitnessed fall, and R501 could not verbalize what happened during the fall. BIMS Score=10. 3. The DON could not identify or know who the CNAs assigned to residents were because they were not involved in the fall. The DON revealed the investigation process: The charge nurse interviewed the resident and staff, and the nurse wrote a summary in the report. When asked for the Falls summary on 4/17/25, the DON indicated none. When asked who the CNAs were, the DON could not say their names, and no staff names were written because the fall was unwitnessed and they were not involved. The Facility Fall Program, which was reviewed in 1/2024, indicated that its purpose was to provide a safe environment for residents, modify risk factors, and reduce the risk of fall-related injuries. A Facility Incident Report Policy was requested on May 2, 2025. The Abuse Policy revised date of 1/2023 revealed, POLICY Abuse, neglect, exploitation, and misappropriation of any kind against residents, by any person, is strictly prohibited. This includes, but is not limited to: facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. All allegations of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property will be reported to the State Agency, law enforcement, and other agencies as required by current regulations and investigated by facility management. Findings of all investigations are documented and reported as required. Elder Justice Act - It is the responsibility of the facility to ensure that all staff are aware of reporting requirements and to support an environment in which covered individuals report a reasonable suspicion of a crime, and staff and others report all alleged violations of mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. REPORTING Facility employees who become aware of abuse or neglect shall ensure the resident's safety and IMMEDIATELY report the matter to the facility Administrator and/or Director of Nursing. Facility must report alleged violations- If the event results in serious bodily injury, the suspicion will be reported immediately, but not more than two hours after the individual first suspects a crime has occurred. Suppose the event does not result in serious bodily injury. In that case, the suspicion will be reported immediately but not more than twenty-four hours after the individual first suspects that a crime has occurred . DEFINITION .Neglect failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake numbers: MI00152521 and MI00152424. Based on observation, interview, and record review, the facility failed to thoroughly assess and monitor for pain and neurologic assessment after two falls (unwithnessed and witnessed) that sustained a left hip fracture for one Resident (R#501) of four (4) sampled residents reviewed for fall resulting in delay in treatment, increased experience in physical distress and worsening of pain. Findings include: Resident 501 (R501) On 5/1/25 at 10:27 AM, Resident 601 (R601) was observed grimacing and complaining of severe, unbearable pain in bed. R501 revealed she fell and broke her hip but could not recall how it happened or when it happened. R501, during a brief interview, was observed to be very confused and expressed that she was in extreme pain. A review of R501's Electronic Medical Record (EMR) conducted on 5/1/25 at 10:45 AM revealed R501 was [AGE] years old, admitted on [DATE] with the diagnosis of Dementia, Difficulty Walking, Schizophrenia, and Type II Diabetes in addition to other diagnoses. On 4/17/25, R501 fell twice and was sent to the hospital the following day on 4/18/25. R501 returned on 4/23/25 with an additional diagnosis of Displaced Intertrochanteric Fracture of the left Femur, subsequent encounter for closed fracture with routine healing, and an encounter for other orthopedic aftercare. The Minimum Data Set, dated [DATE] indicated that R501's Brief Interview of Mental Status (BIMS) Score was 10/15. A score of 10 for BIMS indicates moderate cognitive impairment. R501's Care Plan for Safety was Ambulation, which requires assistance from 1 staff member to walk with a walker daily. Locomotion: R501 is independent for locomotion in a manual wheelchair, and Transfers require assistance by (2) to move between surfaces with a 2-wheeled walker. Fall #1: Unwitness Fall 4/17/25 at 4:00 PM Incident Report Fall #1 dated 4/17/25 at 4:00 PM was reviewed on 5/1/25 at 1:45 PM. It was revealed that R501 was found on the floor in the hallway with a wheelchair in front of her. R501 was unable to give a description. Although R501 was alert, her mental status was oriented to person and place only. However, she was assessed as not oriented to the situation or time. Post-fall, the pain level was left blank, and the level of consciousness, mental status, mobility, and other predisposing factors were all left blank. When the Director of Nursing (DON) was asked for witness statements. The Director of Nursing (DON) on May 1, 2025, at 3:45 PM, indicated that Nurse K failed to report to the oncoming nurse of the two incident reports, and one fall was unwitnessed. If the fall was unwitnessed, they automatically get neurovital signs monitoring. When the DON was asked for the frequency of the neurovitals checked, she revealed that it was not done immediately after the fall #1. The neurovitals started after 8:00 AM the following day on 4/18/25. According to Nurse K on May 1, 2025, at 11:20 AM, and the DON on May 2, 2025, at 3:45 PM, Fall Incident# 1 on 4/17/25 at 4:00 PM was an unwitnessed fall. Nurse K admitted she did not start a neurovitals and told the oncoming nurse that R501 fell, but did not go into the details that there were two falls and one was unwitnessed. I forgot to report to the oncoming nurse; I should have started it immediately when she was found in the hallway the first time she fell on 4/17/25. Fall #2: Witnessed Fall #2 dated 4/17/25 at 4:35 PM The Fall #2 incident report on 4/17/25 at 4:35 PM was reviewed on 5/1/25 at 2:00 PM. It revealed that Nurse K was at the scene when R501 fell the second time on 4/17/25. R501 could not describe what happened. Staff got her up and put her back in bed. Denies pain. The DON revealed on 5/1/25 at 3:45 PM that if any unwitnessed fall occurred, especially when the resident could not describe how the fall occurred, the nurses automatically required neurovital signs monitoring. The DON explained the process for the nurses to follow: Neurological Assessments are monitored every 15 minutes X 4, (from the date and time of the incident), then every 30 minutes. X 4, then every hour X 4, and every 4 hours X 4. A neurological assessment form was reviewed for R501 on 4/17/25 at 16:30. There was no entered neurological assessments after 4/17/25 after 4:30 PM until T;00 AM the following day (4/18/25), approximately 15 hours later. The assessment did not include any description of the pain level. The following Neurological Assessment record was noted: 4/17/25 at 16:30 No entries found from 16:30 to 4/18/25 at 7:00 AM and 4/18/25 at 11:00 AM. Only 3 entries of assessment were entered. The entry dated 4/18/25 at 13:00 noted that R501 was out at the hospital. The assessment did not include any description of pain level. After a thorough discussion on the Fall Process with the DON on 5/1/25 at approximately 3:45 PM, the DON stated the following: 1. The check marks in the IR were missing, therefore incomplete. 2. NO neurovitals were taken despite the IR stating an unwitnessed fall, and R501 could not verbalize what happened during the fall. BIMS Score=10. 3. The DON could not identify or know who the CNAs assigned to residents were because they were not involved in the fall. Nurse F was the Day shift Nurse coming in on 4/18/25 at 7:00 AM On 5/2/25 at 1:30 PM, she revealed that when she went in that day, the outgoing nurse gave a report and mentioned her fall. Nurse F noticed that there was no neuro sheet. The aide alerted me and reported to her that the leg was swollen and painful when being moved. R501's pain level was 8/10. Tramadol for pain was administered, and the neurologic assessment started right away since nothing was found. Nurse F stated, There was no handoff from the outgoing nurse. R501 told me she fell, and the staff member got her back in bed. Nurse F described that R501's left leg was displaced. It was very unusual, CNA G and nurse F observed that she was in pain. CNA G got me because she wanted me to see the leg. Nurse F got hold of the Nurse Practitioner right away. At first, the doctor ordered an X-ray. But because of the condition of the leg and the pain level, the Nurse Practitioner changed her mind and sent her to the hospital instead for further evaluation and treatment. Nurse Practitioner (NP E) was interviewed on the phone on 5/2/25 at 1:48 PM. She said she came to the facility between 9 AM and 12 PM. NP E revealed that she assessed R501 and observed a significant change in her pain level and left leg. NP E observed that R501's left leg was externally rotated, with discoloration and severe pain. There was a notable change in range of motion (ROM) on the lower left extremity. At first, an X-ray was ordered, but then we decided to send her out to the hospital for further evaluation and treatment, and rule out a fracture on the left lower extremity. We did not wait for the X-ray services to arrive in-house. R501 was sent out to the emergency room. Nurse Aide G (CNA G) on 5/2/25 at 2:00 PM stated that she did not get to write a statement until now, so she dated it now (5/2/25) related to R501's broken leg found on 4/18/25. CNA G explained she was in another room when the fall on 4/17 happened. I wrote the statement that she was acting differently. Sometimes she would act a little out of the ordinary. But on that day, she did not touch her breakfast. CNA G recalled pulling her pants, and R501 must have yelled, and her leg was big and swollen. R501's leg was bigger on one side than the other. It was significantly big. R501 did not get up or eat breakfast, and she wanted to lie back down. That's when CNA G stated that she was not herself. R501 yelled a little bit when she was repositioned. Usually, she would be out of bed to go downstairs for breakfast, back and forth, and everywhere. CNA G emphasized by saying, It was obvious, you can tell there was something wrong with the R501 (R501's name mentioned). Progress notes were reviewed on 5/2/25 at 3:30 PM: > On 4/17/25 at 17:40 (5:40 PM)Nurses Notes entered: I heard the resident yelling for help and looked down the hall and noticed the resident on the floor by her room, the resident stated she didn't know how she fell and wants to lie down. The Resident lying in bed. will continue to monitor. > On 4/17/25 at 19:02 (7:02 PM) Note Text: Resident yelling and screaming getting into her chair in her room, resident then nose dived into the wall in her bathroom. The resident is now lying back in bed. will continue to monitor. > On 4/18/25, the following entry was from the Nurse Practitioner NPE who examined R501 between 9:00 AM and 12:00 PM per NP E. R501 was sent to the hospital at approximately noon. No assessment and monitoring notes related to Pain Level and Neurological Assessment were found all night from 4/17/25 at 7:02 PM until 7:00 AM. The morning shift nurse entered a neurological assessment in the Neurovitals Assessment Form on 4/18/25. Medication Administration Record (MAR) for April 2025 revealed that R501 has a routine order to receive Acetaminophen 500 mg, two tablets are ordered twice a day for pain, scheduled at 0900 AM and 1700 (5:00 PM). The resident's MAR indicated the number 12 and the nurse's initials. There was no number 12 among the codes supplied by the facility for use. Code 12 was unknown, and it was not related to pain level or the effectiveness of Acetaminophen, which was marked on the MAR on 4/17/25. It was not confirmed if R501 received any pain medication between 4/17/25 at 0900 AM and 4/17/25 at 1700 (5:00 PM). According to the MAR on 4/18/25 at 11:22 AM, R501 had a pain level of 8 and was given a PRN Tramadol HCL Tablet 50 mg, one tablet needed for moderate and severe pain. R501 did not receive pain control relief from 4/17/25 at 5:00 PM up to 4/18/25 at 11:22 AM. No pain assessment was recorded throughout 4/17 until 4/18/25, but pain relief was not administered until 4/18/25. The Facility Neurological Assessment Monitoring Policy and Pain Management Policy were requested on 5/2/25 at 10:28 AM. No policy was submitted to the surveyor upon exit on 5/2/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake numbers: MI00152521 and MI00152424. Based of interview and record review, the facility failed to timely revise/update care plans for one resident (R#501) of four residents reviewed for care plan revision resulting in care plans not being revised as the status and needs of the residents changed related to pain and post surgical site skin care. Findings include: Resident #501 (R501) A review of R501's Electronic Medical Record (EMR) conducted on 5/1/25 at 10:45 AM revealed R501 was [AGE] years old, admitted on [DATE] with the diagnosis of Dementia, Difficulty Walking, Schizophrenia, and Type II Diabetes in addition to other diagnoses. On 4/17/25, R501 fell twice and was sent to the hospital the following day on 4/18/25. R501 returned on 4/23/25 with an additional diagnosis of Displaced Intertrochanteric Fracture of the left Femur, subsequent encounter for closed fracture with routine healing, and an encounter for other orthopedic aftercare. The Minimum Data Set, dated [DATE] indicated that R501's Brief Interview of Mental Status (BIMS) Score was 10/15. A score of 10 for BIMS indicates moderate cognitive impairment. R501 was hospitalized on [DATE] and underwent surgical repair of a displaced intertrochanteric Fracture of the Left Femur after subsequent falls on 4/17/25. R501's Care Plan was reviewed for pain and skin care (post-operative surgical site). According to the review of records, R501's skin care plan was reviewed on 5/2/25 at 10:00 AM. R501's pain care plan was reviewed on 5/2/25 at 10:05 AM R501's Pain Care Plan was last revised 3/17/25. Focus: I am at risk for pain related to scoliosis, general discomfort. On 3/17/25 at 4:00 and 4:35 PM, R501 fell and sustained a fracture on the left femur requiring surgery. New medications were ordered post-operatively upon readmission on [DATE], but no care plan revision was noted. New pain control regimen was noted upon return from the hospital: A new prescription was ordered, such as Norco every 4 hours, tramadol was discontinued, and the doctor examined R501 on 5/1/25 to ensure pain management was good since 4/23/25 readmission. R501's Skin Care Plan was reviewed on 5/2/25 at 10:10 AM. R501's altered skin integrity care plan was last updated on 2/24/2025. No additional interventions were planned for the post-operative surgical site skin care, monitoring, or treatments in place. The current change in condition since readmission on [DATE], such as surgical site care and infection prevention, was not put in place. An interview with the Director of Nursing (DON) was conducted on 5/2/25 at 12:00 PM. The DON explained that they currently do not have an MDS nurse in the building and that she will try her best to answer any questions about MDS assessments and care plans. R501 care plan was reviewed with the DON. The DON agreed that R501 previously had pain and a skin care plan. It was not revised according to the recent post-surgical site care, and for a higher level of pain. The facility's policy for care plan update and revision was requested on 5/2/25 at 11:00 AM. No Care Plan Update and Revision Policy was provided during the exit conference on 5/2/25 at 3:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide necessary care and services to ensure a resident's abilities in activities of daily living (ADL) did not diminish in two (Resident #20 and Resident #24 ) of two residents reviewed for comprehensive care planning, resulting in increased levels of assistance provided by staff with ADL care. Findings Include: Resident #20 (R20) Review of the medical record reflected R20 was an initial admission to the facility on [DATE] and readmitted on [DATE]. Diagnoses of Spinal stenosis, Lumbar region without neurogenic claudication (narrowing of the spinal canal of the lower back), Lumbosacral plexus disorders (cause a painful mixed sensorimotor disorder of the corresponding limb), abnormalities of gait and mobility, benign prostatic hyperplasia with lower urinary tract symptoms (inability to completely empty the bladder), dysphagia (difficulty swallowing), muscle weakness and chronic pain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/19/2025 revealed R20 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R20 required 1 person assistance for all care. During an interview and observation on 04/14/25 at 10:10 AM, R20 stated he was scheduled to receive two shower/baths a week, on Wednesdays and Saturday's afternoons. Observation of facial hair was more than a week's growth per R20. Record review revealed he has had three bed bathes in the last month, 03/16/25, 03/17/25 and 04/02/25. During an interview on 04/15/25 at 10:22 AM, DON B stated it would be documented where the CNAs were providing the shower/bath that was preferred or as to why R20 did not receive his shower/bath. DON B also stated the CNAs document as to how many times they asked R20 to shower/bath and what his response was and if the nurse had been notified. DON B stated the expectation would be that the shower/bath would have been offered by the next shift. DON B stated that would be documented in a progress note. Record review did not reveal that R20 was asked three times to take a shower/bath or that the CNAs reported that to the nurse. No supporting documentation to reflect this resident was asked, that he refused to take a shower or receive a bed bath. During an interview on 04/16/25 at 9:50 AM, DON B stated the CNAs are not documenting that the shower/bath was completed. DON stated the CNAs were providing the showers/baths but not documenting it. A document was later provided in a statement that certain CNAs provided baths on certain days during the past 30 days, however there was no documentation to support this in the electronic medical record. Resident #24 (R24) Review of the medical record reflected R24 was an initial admission to the facility on [DATE]. Diagnoses of Stroke, Intracerebral hemorrhage affecting left non-dominant side with spasms, mild cognitive impairment and other abnormalities of gait and mobility. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2024 revealed R24 had a Brief Interview of Mental Status (BIMS) of 12 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R24 is a mild to moderate assistance of all care. During an interview on 04/14/25 at 9:49 AM, R24 stated she was supposed to get a shower two times a week. R24 stated her preference was showers over bed bathes and was not receiving them. R24 also stated her preference is to have a shower daily, but at this time she was not even receiving them two times a week. R24 also stated she had not refused any showers or bathes. R24 stated that her roommate had even told her she stunk and needed a shower. Record review revealed R24 had three showers/bed bathes in the last month on 03/23/2025, 03/29/2025 and 04/10/2025. Record review did not indicate why R24 did not received showers or bathes two times a week as scheduled. Progress notes from 03/02/2025 up to this date were read and no documentation was present as to why she has not received her showers or bathes. During an interview on 04/15/25 at 1:52 PM, Certified Nursing Assistant (CNA) H stated R24 got her showers on afternoon shift, not day shift so she could not tell writer why she had not had any showers or bathes lately. During an interview on 04/15/25 at 3:41 PM, Director of Nursing (DON) B stated there should have been some documentation in the progress notes as to why R24 did not receive her showers. DON B also stated there should have been some documentation from the CNAs under task tab, as to how many times R24 was asked to take a shower and what her response was and that the CNA's notified the nurse. Record review did not reveal that R24 had been asked three times to shower/bathe or that the CNA reported the refusals to the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide for one out of one resident (Resident #6) care and services to prevent and promote healing of pressure ulcers resulting in worsening wounds. Findings Include: Resident #6 (R#6) Review of the medical record reflected R6 was an initial admission to the facility on [DATE] and readmitted on [DATE].R6 was admitted to hospice on 08/24/2024. Diagnoses of cerebral atherosclerosis, Diabetes Mellitus with neuropathy, pressure ulcer of the sacral region, stage 4, history of a stroke, benign prostatic hyperplasia with urinary symptoms and suprapubic catheter, spinal stenosis in the cervical region, left side hemiplegia and hemiparesis following the stroke and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/03/2025 revealed R6 had a Brief Interview of Mental Status (BIMS) of 08 (moderately impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R6 is dependent of all care and required a mechanical left and 2 persons to transfer from bed to chair and back to bed. R6 required 1 person to reposition him as he cannot do it independently. During an interview on 04/14/25 11:51 AM, R6 stated he had some old pressure ulcers and some new ones too. R6 stated he had pain with the pressure ulcers. Writer asked R6 for permission to observe his wound care to his pressure ulcers and he stated yes. During an interview on 04/15/25 at 7:32 AM, Registered Nurse (RN) I was informed that this writer had received permission from R6 to observe wound care on him today. During an interview and observation on 04/15/25 on 8:15 AM, R6, stated he had pain all over his body, and he reported that the pain was a little more manageable since he had his pain medications scheduled, instead of medication as needed. R6 stated the facility staff reposition him once or twice a shift, and then he stays in that position for the rest of the shift. R6 stated he went to a hospital for the suprapubic catheter to be placed a while back, after the foley catheter created a mechanical pressure ulcer (caused by unrelieved mechanical pressure in combination with friction, shearing forces and moisture) so bad it split his penis open. R6 also stated that was the most painful thing ever. R6 stated both the facility nurse and hospice nurse were currently taking care of his pressure ulcers. R6 stated the hospice nurse comes in 2 x a week, and the facility nurses do the wound care on the other days. R6 added that another nurse comes in about weekly to assess his pressure ulcers too. Observation of R6 with no heel protectors on his feet, they were observed across his room on top of a plastic container with drawers in it. A concaved low air loss mattress was on his bed. No specialty cushion on his geri chair, sitting on a pillow. Record review revealed R6 was re-admitted on [DATE] with one stage 3 pressure ulcer of the penis and one stage 4 on the sacral. Treatment to the sacral pressure ulcer dated 07/09/24 was to clean with normal saline apply gauze daily. Treatment for the stage 3 penis pressure ulcer is cleanse under the penis with wound wash, apply inter-dry every shift. Minimum Data Set (MDS) 3.0 Section M-Skin Conditions, under M0210 dated 07/19/24. Unhealed Pressure Ulcers/Injuries revealed R6 had one stage 3 pressure ulcer and one unstageable. On 07/12/24 a progress notes for wound care evaluation, follow up to penis and sacral unstageable 4.2 x 3.4, unable to determine depth. Wound care dressing order changes to using Dankins wound wash, with comfort foam apply Medi-Honey to slough area and cover with comfort foam dressing every shift. On 07/13/24 treatment for stage 4 sacral pressure ulcer wound, reads cleanse with Dankins wound wash, pack dry ¼ strength Dankins- soaked gauze and cover with comfort foam. Treatment changes for the stage 3 penis pressure ulcer to wash wound with wound wash, apply oil emulsion dressing to wound bed cover with ABD pad daily. On 07/19/24 Wound care visit, Sacral 3 x 2.4 x 6, unable to determine depth. No change in orders. Stage 3 penis pressure ulcer wound measurement 4.2cm x 2.3cm x 0.2cm (area x length x width x depth). On 07/20/24 treatment- cleanse sacral pressure ulcer with wound cleanser, pat dry, apply skin prep to peri area, Dankins wound cleanser-soaked gauze to the wound bed, cover with sacral foam dressing daily. On 07/23/24 treatment reviewed, sent guardian a request for a debridement of sacral. On 07/26/24 Stage 4 sacral pressure ulcer measurements were 5.6 x 3.8 x 4.2. Stage 3 penis pressure ulcer wound measurement 1.8cm x 1.9cm x 1.3cm. On 08/02/24 Wound care evaluation, sacral pressure ulcer measurements 5.3 x 3.2 unable to measure the depth. Stage 3 penis pressure ulcer wound measurement 4.5cm x 2.4cm x 0.2cm. On 08/06/24 R6 sent to hospital for abnormal labs and change in mental status. On 08/17/24 re-admitted from hospital stay of 10 days, Sacral pressure ulcer measurements following debridement at the hospital. 14.9 x 4.2 x 4.8. Wound vac intact and dressing changes Monday, Wednesday and Fridays. Stage 3 penis pressure ulcer wound measurement not taken. On 08/19/24 Wound care team assessment of sacral pressure ulcer wound 4.22cm x 4.7cm with large amounts of serosanguinous fluid. Stage 3 penis pressure ulcer wound measurement 4.18cm x 2.54cm x 0.1cm. On 08/24/24- admitted to hospice. On 08/26/24 Stage 4 Sacral pressure ulcer wound measured 4.95cm x 4.98cm x 4.2 cm. Continued to have large amounts of serosanguinous fluid. Wound vac was discontinued. Stage 3 penis pressure ulcer wound measurement of 2.04cm x 0.94cm x 0.1cm. On 08/27/24 Stage 4 sacral pressure ulcer wound treatment of wash wound with wound wash, pat dry, put Dankins wound wash-soaked gauze in the wound, covered with a bordered foam dressing. On 09/02/24 Stage 4 sacral pressure ulcer wound measured 3.3cm x 2.5cm, no depth reported. Stage 3 penis pressure ulcer no wound assessment or measurement not taken. 09/03/24 and 09/10/24 Interdisciplinary Team (IDT) reviewed wound interventions current and remain in place. 09/04/24 Stage 4 sacral pressure ulcer wound measured 5.3cm x 4.3cm x 3.4cm undermining (the formation of a narrow passageway or track under the skin, extending from the wound's edge into the deep tissue). Stage 3 penis pressure ulcer wound measured 2.7cm x 1.4cm, no depth. 09/09/24 Stage 4 sacral pressure ulcer wound measured 4.4cm x 4.8cm x 3.5cm undermining. Stage 3 penis pressure ulcer no wound assessment or measurement not taken. 09/16/24 Stage 4 sacral pressure ulcer wound measured 3.5cm x 4.6cm x 3.2cm x 2.1 undermining. Stage 3 penis pressure ulcer no wound assessment or measurement not taken. 09/24/24 Stage 4 sacral pressure ulcer wound measured 4.7cm x 3.5cm no depth taken. Stage 3 penis pressure ulcer no wound assessment or measurement not taken. 09/30/24 Stage 4 sacral pressure ulcer wound measured 4.5cm x 2.7cm x 2.3 undermining. Stage 3 penis pressure ulcer wound measured 2.9cm x 3.3cm x 1.2cm, no depth. 10/01/24 Treatment for stage 4 sacral pressure ulcer is wash wound bed with wound wash, pat dry, place Dermacol (wound care dressing)to wound bed, insert Dermablue (used for moderate to heavy exuding partial to full thickness) cut to fit over Dermacol, cover with sacral dressing, change daily. Stage 3 penis pressure ulcer no wound assessment or measurement not taken. 10/07/24 Stage 4 sacral pressure ulcer wound measured 4.2cm x 2.4cm x1.4cm x 1.1cm undermining. Stage 3 penis pressure ulcer no wound assessment or measurement not taken. 10/16/24 Stage 4 sacral pressure ulcer wound measured 3.3cm x 1.5cm no depth measured. Stage 3 penis pressure ulcer wound measured 2.7cm x 1.2cm, no depth measured. 10/21/24 Stage 4 sacral pressure ulcer wound measured 3.7cm x 2.6cm x1.3cm with 1cm undermining. Stage 3 penis pressure ulcer no wound assessment or measurement taken. 10/28/24 Stage 4 sacral pressure ulcer wound measured 3.0cm x 1.9cm x 1.6cm x 0.6cm undermining. Stage 3 penis pressure ulcer no wound assessment or measurements taken. 11/04/24 Stage 4 sacral pressure ulcer wound measured 2.4cm x 1.2cm x 0.8cm x 0.6 undermining. Stage 3 penis pressure ulcer no wound measured 3.3cm x 1.6cm, no depth documented. 11/11/24 Stage 4 sacral pressure ulcer wound measured 3cm x 1.5cm x 0.3cm. Stage 3 penis pressure ulcer no wound assessment or measurements taken. 11/18/24 Stage 4 sacral pressure ulcer wound measured 3cm x 1.5cm x 0.3cm. Stage 3 penis pressure ulcer no wound assessment or measurements taken. 11/25/24 Stage 4 sacral pressure ulcer wound measured 3.3cm x 2.4cm x 0.3cm. Stage 3 penis pressure ulcer wound measured 4.2cm x 1.9cm. 12/09/24 Stage 4 sacral pressure ulcer wound measured 2.4cm x 1.5cm. Stage 3 penis pressure ulcer no wound assessment or measurements taken. 12/17/24 Stage 4 sacral pressure ulcer wound measured 2.7cm x 1.3cm. Stage 3 penis pressure ulcer no wound assessment or measurements taken. 12/22/24 Rear right trochanter/hip deep tissue injury, apply comfort foam to right hip, no measurements. Per the Resident Assessment Instrument 3.0 (RAI) manual dated October 2023, version 1.18.11-page M-27, a Deep Tissue Injury (DTI) is identified by a Purple or maroon area of discolored intact skin due to damage of underlying soft tissue . The manual further revealed, Deep tissue injuries may sometimes indicate severe damage. Identification and management of deep tissue injury (DTI) is imperative. 12/24/24 Stage 4 sacral pressure ulcer wound measured 2.7cm x 1.3cm. Stage 3 penis pressure ulcer wound measured 3.3cm x 1.7cm. Deep Tissue Injury to right heel measured 2.7cm x 2.0cm in house acquired. Rear right trochanter/hip deep tissue injury, apply comfort foam to right hip, no measurements. 12/30/24 Stage 4 sacral pressure ulcer wound measured 2.2cm x 1.3cm. Stage 3 penis pressure ulcer wound measured 3.7cm x 2.0cm. Right heel deep tissue injury measuring 2.5cm x 2.1cm. Rear right trochanter/hip deep tissue injury, apply comfort foam to right hip, no measurements. 01/07/25 Stage 4 sacral pressure ulcer wound measured 2.5cm x 0.7cm. Stage 3 penis pressure ulcer no wound assessment or measurements taken. Rear right trochanter/hip deep tissue injury, apply comfort foam to right hip, no measurements. 01/13/25 Stage 4 sacral pressure ulcer wound measured 4.1cm x 3.4cm. Stage 3 penis pressure ulcer no wound assessment or measurements taken. Rear right trochanter/hip deep tissue injury, apply comfort foam to right hip, no measurements. 01/20/25 Stage 4 sacral pressure ulcer wound measured 5cm x 4.6cm. Unavoidable wound assessment completed. Stage 3 penis pressure ulcer no wound assessment or measurements taken. Rear Right Trochanter/hip with new in house acquired deep tissue injury measuring 6.6cm x 3.3cm. 01/21/25 Rear right trochanter/hip, no longer a deep tissue injury, now stage 3, clean with wound cleaner, pat dry, apply xeroform to wound bed, cover with comfort foam daily, no measurements taken. 01/21/25 Treatment to Stage 4 sacral pressure ulcer wound. Wash wound with Dankins wound wash, pat dry, place calcium alginate to fit wound bed and cover with bordered dressing daily. Stage 3 penis pressure ulcer no wound assessment or measurements taken. Stage 3 right hip pressure ulcer wound, cleanse with wound wash, pat dry, apply xeroform to wound bed, cover with comfort foam daily, no measurements taken. 01/24/25 Stage 3 rear right trochanter/ hip pressure ulcer wound, cleanse with wound wash, pat dry, apply Medi-Honey covering slough, cover with comfort foam daily, no measurements taken. 01/27/25 Stage 4 sacral pressure ulcer wound measured 3.4cm x 2.2cm. Stage 3 penis pressure ulcer no wound assessment or measurements taken. Rear right Trochanter deep tissue injury measuring 7.1cm x 3.1cm. 01/31/25 Stage 4 sacral pressure ulcer wound measured 2.7cm x 2cm. Stage 3 penis pressure ulcer no wound assessment or measurements taken. Rear right Trochanter/hip not assessed or measured. 02/11/25 Stage 4 sacral pressure ulcer wound measured 2.53cm x 2.09cm. Stage 3 penis pressure ulcer wound measurements 5.12cm x 1.41cm, no depth recorded. Rear right Trochanter/hip now unstageable measured 5.6cm x 2.87cm. Record review revealed R6 was having unmanaged pain in February 2025 due to the progression of pressure ulcers. R6 had Morphine Sulfate Solution 20mg/ml. Give 0.5ml/10mg by mouth every 4 hours as needed for pain. This medication was administered 7 different times for a pain level of 7-9 on a scale of 0-10. March 29, 2025, R6 had scheduled MS (morphine sulfate) Contin 30mg oral tab extended release. Give 1 tablet by mouth two times a day for pain, do not crush. pain level #7 to 9 recorded on the MAR. R6 was able to manage the pain much better once his pain medication was scheduled. 02/17/25 Stage 4 sacral pressure ulcer wound measured 2.52cm x 1.76cm. Stage 3 penis pressure ulcer wound measurements 2.81cm x 1.35cm, no depth recorded. Rear right Trochanter/hip measured 5.1cm x 3.08cm, not documented as unstageable. 02/19/25 01/21/25 Stage 3 rear right Trochanter/hip not assessed or measured. Treatment to clean wound with wound wash, pat dry, apply Medi-Honey to wound bed, cover with an ABD pad, secure with tape, not assessed or had measurements taken. 02/21/25 01/21/25 Stage 3 rear right trochanter/hip pressure ulcer wound, cleanse with wound wash, pat dry, apply Santyl (debridement agent) to wound bed, cover with comfort foam daily, no measurements taken. 02/26/25 Stage 4 sacral pressure ulcer wound measured 1.93cm x 1.63cm x 1.5cm depth. Stage 3 penis pressure ulcer wound measurements 3.76cm x1.88cm x0.1cm depth. Stage 3 rear right trochanter/hip measured 4.25cm x 3.56cm x 1.25cm. 02/28/25 Treatment for sacral wash with wound wash, pat dry and pack with Hydrogelon (dressing to absorb large amounts of fluids) a sponge and cover with bordered dressing daily. Stage 3 rear right trochanter/hip pressure ulcer wound, cleanse with wound wash, pat dry, apply Santyl to wound bed and pack Dankins moistened gauze over wound bed, cover with foam bordered gauze dressing daily, no measurements taken. 03/04/25 Stage 4 sacral pressure ulcer wound measured 2.09cm x 1.6cm x 2cm depth. Stage 3 penis pressure ulcer wound measurements 6.72cm x 1.68cm, no depth recorded. Stage 3 rear right trochanter/hip measured 4.85cm x 3.46cm, no depth documented. 03/07/25 Stage 4 sacral pressure ulcer wound measured 2.34cm x 1.85cm x 2.2cm depth. Stage 3 penis pressure ulcer wound measurements 4.84cm x 2.38cm, no depth recorded. Stage 3 rear right trochanter/hip measured 4.92cm x 4.05cm x 1.6cm. 03/08/25 Stage 3 rear right trochanter/hip pressure ulcer wound, cleanse with wound wash, pat dry, pack with Dankins moistened gauze, cover with foam bordered gauze daily, no measurements taken. 03/14/25 Stage 4 sacral pressure ulcer wound measured 1.9cm x 1.3cm x 1.2cm with 2.5cm undermining. Stage 3 penis pressure ulcer wound measurements 5.9cm x 2.3cm x 0.2cm. Stage3 rear right trochanter/hip measured 4.8cm x 3.3cm x 1.5cm with undermining at 3 o'clock. 03/20/25 Stage 4 sacral pressure ulcer wound measured 1.6cm x 0.7cm x 0.5cm with 3.3cm undermining. Stage 3 penis pressure ulcer wound measurements 2.3cm x 0.1cm. Stage 3 rear right trochanter/hip measured 4.23cm x 3.38cm x 2.4cm. 03/27/25 Stage 4 sacral pressure ulcer wound measured 2.35cm x 2.65cm x 1.16cm. Stage 3 penis pressure ulcer wound measurements 3.92cm x 2.07cm. Stage 3 rear right trochanter/hip measured 4.68cm x 3.9cm, no depth documented. 04/03/25 Stage 4 sacral pressure ulcer wound measured 2.9cm x 1.3cm x 1.5cm. Stage 3 penis pressure ulcer wound measurements 4.9cm x 2cm x 0.1cm. Stage 3 rear right trochanter/hip measured 4.6cm x 1.5cm, no depth documented. Record review of the Skin Management Policy, last updated on 08/14/24, stated it was in the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries.residents with pressure injuries and lower extremity ulcers will be evaluated, measured and staged weekly in accordance with practice guidelines until resolved . 04/10/25 Stage 4 sacral pressure ulcer wound measured 2.3cm x1.2cm x 0.9cm with 2.5cm undermining. Stage 3 penis pressure ulcer wound measurements 5.5cm x 2.3cm x0.1cm. Stage 3 rear right trochanter/hip measured 2.9cm x 2.4cm x 1.9cm. 04/11/25 Treatment for Stage 4 sacral pressure ulcer wound, cleanse with wound wash/normal saline, apply collagen dressing to wound bed and pack undermining at 12 o'clock with Collagen. Apply normal saline moistened gauze over wound care. Cover with bordered foam or super absorbent dressing. Unstageable rear right trochanter/ hip pressure ulcer wound washed with normal saline or wound wash, apply collagen dressing to wound bed and pack undermining with collagen. Apply saline moistened gauze over the wound area and fill wound. Cover with bordered foam or super absorbent dressing, as needed and every day shift. During an interview and observation on 04/15/25 at 9:59 AM, CNA K stated R6 didn't have anything special for a cushion on his geri chair, he was sitting on a pillow. R6 did not have his heel protectors on. During an observation on 04/15/25 at 11:13 AM, R6 was sitting up in his geri chair, in the same position, as he was when he came downstairs to the activities at 9:59 AM. His feet were dangling down and toes resting on the floors. R6 did not have his heel protector boots on. During an interview on 04/15/25 at 11:32 AM CNA K stated they reposition R6 about every 2 hours, and it should be documented under their charting in PCC. Record review revealed R6 was not on a turning/repositioning schedule. CNA's documentation reflected that R6 was only repositioned 1-2 times during a shift. Care plan also documents that R6 needs to be repositioned as he cannot do it himself, he is dependent on the facility staff to reposition him. During an interview and observation on 04/15/25 at 1:18 PM, Register Nurse (RN) I was setting up to complete wound care on R6 with the assistance of CNA K. RN I donning with a disposable gown and gloves after washing her hands. CNA K followed the same practice of washing her hands, putting on a disposable gown and gloves. CNA K assisted by holding R6 from side to side to support his body while the nurse performed wound care. 1) Right hip/trochanter- RN I removed the soiled dressings from the right hip/ trochanter and disposed of them in a trash can. RN I removed gloves, hand sanitized and put on new gloves on. Proceeded with cleaning the wound with a spray wound cleaner and a gauze dressing. RN I removed her gloves, hand sanitized and put new gloves on as she opened packages of Collagen to put down on the wound bed and in the tunneling at 4:00 and 5:00 o'clock. RN I then covered the pressure ulcer with a bordered edge dressing which was dated and initialed. RN I stated the floor nurses do not measure the wound between the wound care team Nurse Practitioner visits on Thursday unless told to. 2) RN I then removed the soiled dressing from the sacral wound pressure ulcer and threw it in the trash. RN I then washed her hands and put on new gloves. RN I then cleaned the sacral wound with a spray wound wash and a gauze dressing, then placed Collagen into wound bed, covered with sacral shaped dressing, dated and initialed. 3) Observation of a new open area behind the left hip/ gluteal area. Both RN I and CNA K stated that was a new open area, size of a dime. No care was provided to this area at this time. 4) RN I then went on to complete the wound care on his penis. RN I washed her hands, put on new gloves, his soiled dressing had fallen off in his brief, so RN I used a spray wound wash to clean the open area the length of his shaft, removed her gloves, washed her hands and put on new gloves. RN I then applied an emollient dressing to wrap around his penis and overlapped the edges to stay in place. RN I and CNA K replaced the brief under R6 and replaced it with a new brief. Record review did not reveal any documentation to support that R6 was repositioned every two hours as R6 stated he was not, and the documentation revealed this resident was repositioned 1-2 times a shift, again, not every two hours as care plan stated. Documentation did not support any non-pharmacological intervention being used. Only new intervention was the coordination of care with the hospice team and offer R6 mandarin oranges when he eats less than 50% of his meals. Documentation of an unavoidable pressure ulcer assessment was provided for stage 4 sacral pressure ulcer only. Care plan included pressure reducing mattress, chair cushion, repositioning devices, turning/repositioning/ offloading program and heels up. R6 was not turned, repositioned/offloading, and did not have his heel protectors on him all 3 days of this survey. Under wound evaluation tab, it revealed that R6's stage 3 pressure ulcer on his penis had worsened up to a negative 97%. During an observation on 04/16/25 at 7:31 AM, R6 was sleeping on his left side, heel protections were not on his feet. During a phone interview on 04/16/25 at 9:07 AM, hospice nurse L stated she made her visit late yesterday afternoon to see R6. Stated she did not do the dressing changes yesterday as the floor nurse already did them. Stated she would complete dressing changes and assessments with measurements once a week, this week would be Friday. Writer asked if she would provide care, assess and measure the wounds the day after the wound care team NP would be doing the day prior. Hospice nurse L stated she would usually try to make that visit the beginning of the week, so R6 is getting assessments and measurements of the wounds twice a week. Writer asked hospice nurse L if she had been informed that this resident had a new pressure ulcer near his left hip, she stated no. Writer asked for the prior weekly wound assessments that hospice completed, as they were not in the paper chart binder left behind the desk, or the PCC electronic medical record. Hospice nurse L stated that this writer could contact the office to gain access to whatever documents are needed. Writer called the hospice agency and requested the wound assessments, identification and measurements. Provided email address and request so they had writers contact information. During an interview on 04/16/25 at 11:28 AM, writer asked DON B if she had been alerted of the new open pressure ulcer by his left hip that was found during the dressing changes of his other pressure ulcers yesterday morning. DON B stated she was behind on her emails and was going to look. During an interview and observation on 04/16/25 at 11:30 AM, writer observed RN I, DON B and corporation nurse donning up to observe the new reported pressure ulcer by the left hip. Observation of a now stage 2 now with a dark pink closed wound bed. Writer asked RN I if the size of the new pressure ulcer near the left hip today was about the same as yesterday, she stated yes, it's the same size but was not open today like it was yesterday. DON B took a picture of the new pressure ulcer near the left hip and stated she was going to call the provider for directions. During an interview on 04/16/25 at 11:58 AM, CNA K stated she did a check and change of R6's brief at the end of her shift yesterday, she stated the new pressure ulcer by the left hip was still red and open at the end of the day as it was during the wound care yesterday afternoon at approximately 1:15PM, while assisting RN I was performing wound care. Writer asked her if she reported this new pressure ulcer to anyone yesterday and she stated no, because the nurse was there. Record review of the intervention guideline used by the facility regarding which action should be put in place based on pressure ulcers developing, recommends a turning schedule and protection boots.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the attending physician documented in the medical record the rationale for not implementing the pharmacy recommendation for one (R11) of five reviewed. Findings include: Review of the medical record revealed R11 was admitted to the facility on [DATE] with diagnoses that included vascular dementia and catatonic schizophrenia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/23/25 revealed R11 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 1/7/25 revealed an order for carbamazepine (anticonvulsant medication) 600 milligrams (mg) one time a day. R11 had been prescribed this medication since 2021. Review of the New admission Medication Review dated 12/15/24 revealed a high drug therapy problem identified was that carbamazepine requires lab monitoring. The recommended action for the provider was Recommend a baseline carbamazepine level and repeat routinely. Carbamazepine blood concentrations should be completed periodically to optimize efficacy and reduce toxicity (levels should be drawn prior to morning dose). CBC with differential, platelets, hepatic function tests, renal function and electrolytes, eye examinations (including intraocular pressure measurements) may also be completed periodically (suggest every 6 months. The action taken/comments section was blank. The physician did not sign the form. There was no indication in the medical record that the physician acknowledged this recommendation. Review of the Consultant Pharmacist Recommendation to Physician dated 1/3/25 revealed Recommend a baseline carbamazepine level and repeat routinely. Carbamazepine blood concentrations must be completed periodically to optimize efficacy and reduce toxicity (levels should be drawn prior to morning dose). CBC with differential, platelets, hepatic function tests, renal function and electrolytes, eye examinations (including intraocular pressure measurements) should also be completed periodically (suggest every 6 months. The physician/prescriber response was written as CBC, CMP [every] 6 months, opth [ophthalmology] [follow-up] routinely. The physician/prescriber signed the document on 1/8/25. R11 had the CBC, CMP and eye exam completed, but there was no documentation in the medical record as to why the carbamazepine level was not obtained per the pharmacy recommendations. In an interview on 04/16/25 at 10:08 AM, Director of Nursing (DON) B reported today she called the Nurse Practitioner who reported carbamazepine was being used for catatonic schizophrenia and not seizures, therefore a carbamazepine level was not necessary. Medical record documentation by the attending physician, explaining the rationale, was requested. On 04/16/2025 at 10:32 AM, DON B reported the rationale was not documented in the medical record. On 4/16/25 at 10:57 AM, the Nurse Practitioner made an addendum to their note dated 4/9/25 which revealed Patient does not have history of Seizures, she remains on Carbamazepine for catatonic schizophrenia as a mood stabilizer. Will continue to monitor CBC, Liver function. Carbamazepine level is not indicated for a therapeutic dosing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medication laboratory monitoring was completed for one (R46) of five reviewed. Findings include: Review of the medical record revealed R46 admitted to the facility on [DATE] with diagnoses that included borderline personality disorder, post-traumatic stress disorder, anxiety, and depression. The MDS with an ARD of 2/8/25 revealed R46 scored 14 out of 15 (cognitively intact) on the BIMS. Review of the Physician's Order dated 9/4/24 revealed an order for Depakote 125 mg by mouth two times a day for mood stabilization/borderline personality/depression. Review of the Consultant Pharmacist Recommendation to Physician dated 9/8/24 revealed This resident is taking Depakote. The recommended routine lab work includes VPA [valproic acid] level and Ammonia level. The Response was listed as Obtain scheduled lab work as follows: VPA/Ammonia [every] 6 months. The Physician signed the form, but the date was not legible. Review of R46's laboratory results for the last 12 months, revealed no VPA or ammonia levels were obtained. In an interview on 04/15/25 at 11:59 AM, DON B reported they called the laboratory to inquire if there were any results for VPA and ammonia levels for R46. DON B reported they did not have record of R46 having their VPA and ammonia levels checked.

Based on observation, interview, and record review the facility failed to provide clinical justification for the continued use of PRN (as needed basis) psychotropic medication (Lorazepam) for one resident (#16) out of five residents reviewed for the potential of unnecessary medication. Findings Included: Resident #16 (R16) Review of the medical record revealed R16 was admitted to the facility 09/16/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD) respiratory failure, asthma, dysphagia (difficulty swallowing), chronic pain, hypomagnesemia (low magnesium), myocardial infarction (heart attack), recurrent dislocation of right shoulder, venous insufficiency, persistent mood disorder, hearing loss, constipation, spinal stenosis, bipolar disorder, major depression, anxiety, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an assessment reference date of 03/20/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 8 (moderately impaired cogitation) out of 15. During observation and interview on 04/14/25 at 11:30 a.m. R16 was observed sitting up in her wheelchair at her bedside. R16 denied that she had any depression or anxiety but was observed to be tearful during the interview. Review of R16's medical record revealed a physician order, written 12/18/2024, that stated Lorazepam 0.5mg (milligram) by mouth every 6 hours as needed (PRN) for anxiety. Review of R16's Medication Administration Record (MAR) for April 2025 revealed that she had been given Lorazepam 0.5mg by mouth on 04/03/2025 and on 04/13/2025. Review of R16's MAR for March 2025 revealed that she had not received any Lorazepam for anxiety. Review of R16's MAR for February 2025 revealed that she had not received any Lorazepam for anxiety. Review of R16's medical record revealed a document entitled Note to Attending Physician/Prescriber, dated 02/20/2025, which stated CMS(Center for Medicare/Medicaid Services) guidelines limit PRN(as needed) psychotropic med order to no more than 14 days. If continuing Lorazepam PRN, indicate length of treatment, and if more than 14 days, provide rational. The above documents also demonstrated a response statement from the physician, (with a date in March that was not legible) which stated, continue longer that 14 days will tolerate and need in this anxiety. In an interview on 04/16/2025 at 08:33 a.m. Director of Nursing (DON) B explained that it was the facility practice that PRN (as needed) psychotropic medication could not be used longer than 14 days without a justification for the use of the medication which was to be provided by the physician. DON B reviewed R16's Note To Attending Physician/Prescriber document, dated 02/20/2025. DON B confirmed that the physician did not provide medical justification for the continued use of Lorazepam as an PRN order for anxiety. DON B also confirmed that the order for Lorazepam had continued unchanged to current date and time. DON B could not provide any other clinical documentation by the physician for clinical justification or the duration for the continued PRN use of Lorazepam. Review of facility policy entitled Psychoactive Medication Management, dated 07/01/2024 and last revised 08/30/2204, revealed PRN Psychotropic Medications -PRN orders for psychotropic medications (Hospice is not exempt) which are not antipsychotic medications are limited to 14 days. The attending physician/prescriber may extend the order beyond 14 days if he or she believes it is appropriate. If the attending physician extends the PRN for the psychotropic medication, the medical record must contain a documented rational and determined duration.

During a tour of lunch service, at 11:25 AM on 4/14/25, an interview with Certified Dietary Manager D found that hot food on the steam table should be 140F or above. A temperature of the plates in the plate warmer at this time were observed to be 90F when using an infra red thermometer. At 12:03 PM on 4/14/25, a test tray was plated with the main entree, and the meal tray was placed as one of the first trays on the second cart, going to the second floor. At 12:15 PM on 4/14/25, the meal cart made it to the 2nd floor and staff started to deliver resident trays. At 12:22 PM on 4/14/25, all of the hall trays on the cart had been delivered and the test tray was in the conference room with the following temperatures found: Carrots and Peas 116F, Ham and Potato casserole 108F. Based on observation, interview, and record review the facility failed to serve food at the preferred temperature for one resident (#16) of one resident reviewed for food palatability resulting in dissatisfaction during meals. Findings Included: Resident #16 (R16) Review of the medical record revealed R16 was admitted to the facility 09/16/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD) respiratory failure, asthma, dysphagia (difficulty swallowing), chronic pain, hypomagnesemia (low magnesium), myocardial infarction (heart attack), recurrent dislocation of right shoulder, venous insufficiency, persistent mood disorder, hearing loss, constipation, spinal stenosis, bipolar disorder, major depression, anxiety, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an assessment reference date of 03/20/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 8 (moderately impaired cogitation) out of 15. During observation and interview on 04/14/2025 at 11:27 a.m. R16 was observed sitting up in her wheelchair at her bedside. R16 explained that the meals at the facility were frequently cold. Review of R16's medical record demonstrated that she was to receive a Regular diet Level 3 (mechanical soft) texture, with thin consistency. In an interview on 04/15/25 at 11:10 a.m. Certified Dietary Manager (CDM) D explained that if residents consume meals in their rooms, that the food is delivered to the units by means of a food cart. CDM D explained that the nursing staff would then deliver those trays to the residents. During observation on 04/15/2025 at 11:44 a.m. the food cart was observed to arrive on the second floor. Nursing staff was observed to immediately start passing trays on the 200-hall unit. At 11:49 a.m. R16's food tray was observed to be taken into her room. R16 was observed sitting up in her wheelchair at her bedside. Her food tray was observed to be covered. R16's food tray was placed on her overbed table, and the cover was removed. It was observed that R16 had been given ground turkey with gravy, stuffing, and carrots. Certified Dietary Manager (CDM) D was asked to get a temperature of R16's food items on her food tray. CDM D was observed to obtain a temperature of 131 degrees Fahrenheit for the ground turkey with gravy, a temperature of 123 degrees Fahrenheit for the stuffing, and a temperature of 115 degrees Fahrenheit for her carrots. R16 was then observed to sample her ground turkey with gravy and stated, It is not hot enough. R16 was observed to taste the stuffing and did not have a comment. R16 was then observed to sample the carrots and stated, They are cold. CDM D offered R16 to have her food heated up or a substitution for the food obtained, she denied both offers. In an interview on 04/15/2025 at 11:56 a.m. Certified Dietary Manager (CDM) D explained that the appropriate temperatures for R16's lunch tray should have been at a temperature of 140 degrees Fahrenheit or above for the ground turkey and gravy, 140 degrees Fahrenheit or above for the stuffing, and 135 degrees Fahrenheit for the carrots. CDM D could not explain why R16's lunch meal had not been at an acceptable temperature.

Based on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During a tour of the kitchen, starting at 9:27 AM on 4/14/25, an interview with Certified Dietary Manager (CDM) D found that most potentially hazardous foods are held for three to seven days. At this time, observation inside of the walk-in cooler, found the following items: hot dogs dated 4/12 to 5/11, sliced ham dated 4/14 to 4/27, and a large chunk of ham dated 4/14 to 4/22. A follow up of the walk-in cooler, at 2:57 PM on 4/14/25, found a new container of hot dogs in the walk-in cooler dated 4/14 to 5/11. An interview with CDM D stated she is still training some new staff on proper date marking. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . During the initial tour of the kitchen, at 9:36 AM on 4/14/25, an interview with CDM D found that the facility does not cool food down to save leftovers and tries to only make what they need for service. At this time, a tour of the walk-in cooler found the following items saved from breakfast, covered, with condensation on the inside of the containers: chunks of ham, scrambled eggs, and sausage links. At this time, a temperature of the ham chunks was found to be 88F and no logging of cooling times and temperatures by staff was present. According to the 2017 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less . According to the 2017 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. During the initial tour of the kitchen, at 9:42 AM on 4/14/25, observation of the two-door arctic air unit found an increased accumulation of crumb debris on the bottom floor of the unit. During the initial tour of the kitchen, at 9:45 AM on 4/14/25, it was observed that the inside of the clean utensil drawer was found with an accumulation of cake breading among utensils in the drawer. When asked how often staff clean this area, CDM D stated weekly. During a tour of the kitchen, at 9:48 AM on 4/14/25, observation found the underside of the coffee spouts showed an accumulation of debris. During a tour of the kitchen, at 9:52 AM on 4/14/25, it was observed that the can opener was found with an increased accumulation of debris around the blade. During the initial tour of the kitchen, at 10:23 AM on 4/14/25, it was observed that a plate drying on the clean side of the dish machine was found to have an accumulation of dried scrambled eggs. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During the initial tour of the kitchen, at 9:49 AM on 4/14/25, it was observed that the air gap on the ice machine was found sunken down the drain. Air gaps require a physical gap from the drain leaving a food contact piece of equipment. During a tour of the three-compartment sink, at 9:54 AM on 4/14/25, it was observed that no air gap was present on the sanitizer drain line. The sanitizer compartment is required to be air gapped as its considered a clean and sanitary piece of equipment. At this time, the sanitizer compartment was found directly connected to the wastewater drain. When asked if she knew anything about the direct connection, CDM D stated she was new and unsure. During a tour of the third-floor pantry, at 11:00 AM on 4/14/25, it was observed that the drain coming from the ice machine was found sunken into the wastewater drain, no longer ensuring an air gap from the ice machine. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed . During a tour of the kitchen, at 9:50 AM on 4/14/25, a half full spray bottle was found with a yellow solution. No common name was labeled on the bottle and CDM D was unsure what was in the container. According to the 2022 FDA Food Code section 7-102.11 Common Name. Working containers used for storing POISONOUS OR TOXIC MATERIALS such as cleaners and SANITIZERS taken from bulk supplies shall be clearly and individually identified with the common name of the material. During a tour of the dish machine area, at 10:25 AM on 4/14/25, it was observed that the low temperature dish machine was not able to produce a residual of chlorine sanitizer when the load was complete. A review of the machines data plate found that it needs chlorine over 50 parts per million (ppm). At this time staff was cleaning the machine, and the surveyor stated he would come back to check on the machine. During a revisit to the kitchen, at 11:15 AM on 4/14/25, observation of the dish machine found that after three loads were run, neither load was able to provide indication of a chlorine residual while using the facility provided test strips. According to the 2022 FDA Food Code section 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under §7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart . A chlorine solution ranging from 50 - 100 parts per million. According to the 2022 FDA Food Code section 4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions. (B) A WAREWASHING machine's conveyor speed or automatic cycle times shall be maintained accurately timed in accordance with manufacturer's specifications. During a tour of the Second and Third floor pantries, starting at 10:55 AM on 4/14/25, it was observed that large openings were present in the walls under the sinks where access to the plumbing is located. Holes and crevices should be filled and covered to reduce the risks of pests in the facility. According to the 2022 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During a tour of the facility with Maintenance Director (MD) J, at 1:29 PM on 4/14/25, observation of the third-floor soiled utility room found the facility had removed the hopper basin but still had active water lines. When asked if these lines get flushed, MD J was unsure. During a tour of the facility with MD J, at 1:49 PM on 4/14/25, observation of the second-floor tub room found it full of equipment and the tub removed. On the far wall water lines that used to be connected to the tub were found protruding from the wall with shut of valves. When asked if the old tub lines were flushed, MD J stated he believed they were not active anymore. After moving some equipment out of the way, the surveyor was able to access the shut off valves and find the lines were active and still connected to the domestic water supply. During an interview with MD J, at 2:05 PM on 4/14/25, it was found that the facility does regularly flush vacant rooms once a week. When asked about taking free chlorine samples, MD J stated that he only takes a couple samples a year. When asked if there was a facility control limit in place for free chlorine, MD J was unsure. A record review of the facility policy entitled, Water Management Program, revised 2/1/24, found that The general principles of an effective water management program include: .Preventing water stagnation .Ensuring adequate disinfection. The document went on to state that The Facility will implement measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems . Control measures may include visible inspections, use of disinfectant, and temperature .Monitoring such controls include testing protocols for control measures, acceptable ranges, and documenting the results of testing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one out of five medication carts were locked while unattended. Findings Included: During an observation on 1/29/2025 at 12:17 PM on the second floor, a medication cart was observed at the end of the hall next to room [ROOM NUMBER] unlocked. No staff were observed to be in sight of the cart or on the hall. At 12:19 PM, no staff were observed to approach the medication cart, and the cart remained unlocked. At 12:21 PM, no staff were observed to approach the medication cart, and the cart remained unlocked. At 12:23 PM, there was no change in observation. At 12:30 PM the cart remained unlocked with no staff in attendance of the cart. At 12:35 PM the medication cart was locked by Assistant Director of Nursing (ADON) C. In an interview on 1/29/2025 at 12:40 PM, (ADON) C, who was the nurse observed to lock the cart, confirmed that Registered Nurse (RN) D was the nurse on the medication cart. ADON C said the cart was to be locked all the time including when stepping away from the cart and not in attendance. In an interview on 1/29/2025 at 12:43 PM, RN D was informed about the medication cart. RN D stated that the policy and procedure was that upon leaving a medication cart the cart was to be locked. RN D said she must have gotten distracted. In an interview on 1/29/2025 at 12:50 PM, Director of Nursing (DON) B was informed of the concern with the medication cart. DON B stated that the facility's policy and procedure was that the cart was to be locked before leaving the medication cart, and said otherwise the cart was to be in view of the nurse at all times. Review of the facility policy and procedure titled, Storage of Medications dated last October of 2024, revealed #9, Unlocked medication carts are not left unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one (Resident #359) of three reviewed. Findings include: Review of the medical record revealed Resident #359 (R359) admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, depression, history of wedge compression fracture of thoracic vertebra, anxiety, and cerebral palsy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/8/24 revealed R359 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 5/14/24 at 9:32 AM, R359 was observed lying in bed. R359 reported yesterday, she was in her chair from 2:00 PM to 5:00 PM and had to go to the bathroom. R359 reported she took herself to the bathroom because her call light was not in reach. R359 reported afterwards, she transferred herself into her bed which was not made with a sheet or blanket. R359 reported Certified Nursing Assistant (CNA) V came into her room and wanted her to transfer back out of bed since the bed was not made. R359 reported CNA V said Why the f*ck can't you get up and go to the bathroom? R359 stated she said the f word, she was literally cussing at me. R359 reported CNA V told her she was not going to change her bed if she could not get up and go to the bathroom. R359 stated I just don't like to be treated like that. That's why I'm here is because I need help with certain things. It's downgrading when someone literally swears at you and treats you like crap. R359 was tearful when recalling the incident. R359 reported her roommate (R37) was in the room at the time of the incident. R359 reported she reported the incident to Director of Nursing (DON) B this morning and DON B filled out a grievance form. On 5/16/24 at 9:56 AM, R359 reported she felt CNA V was inappropriate and that she was verbally abused. Review of R359's Complaint/Grievance Report dated 5/14/24 and completed by DON B revealed Last night I was not happy with my CNA. She was rude and used inappropriate language. The findings of investigation revealed Resident is upset. I reassured her that I would follow up with concern. The Plan to resolve complaint/grievance was Interview CNA involved today. CNA educated on asking for assist. CNA educated on approach. The Complaint/Grievance Report revealed the incident was not reportable to the State Agency. The resolution was CNA will not be assigned to care for [R359]. [R359] agrees this will resolve concern. On 5/15/24 at 1:55 PM, NHA A and DON B reported R359 had one grievance from 5/14/24 that they were investigating. NHA A and DON B reported R359 was not happy with the CNA and reported CNA V was rude and used inappropriate language with R359. DON B reported they spoke with CNA V and reassured R359 that CNA V would not take care of her. When asked what was reported, DON B reported R359 reported CNA V used the f word. DON B reported R359's roommate, R37, reported R359 and CNA V were arguing about getting out of bed. NHA A and DON B reported CNA V was educated on her approach and that it's okay to step away and reapproach. NHA A reported the allegation was not reported to the State Agency because R359 did not say she perceived the incident as abusive. NHA A reported when they followed up again today, R359 did not feel like it was anything intentional. NHA A reported the facility was investigating this incident as a resident concern. In an interview on 5/16/24 at 9:54 AM, R37 (R359's roommate) was observed lying in bed. According to the MDS with an ARD of 4/9/24, R37 scored 11 out of 15 (moderate cognitive impairment) on the BIMS. R37 had a history of stroke and had difficulty expressing speech. As questions were asked, R37 pointed to her right side indicating she had a stroke and that she would have trouble with speech. Yes and no questions were asked. R37 reported she overheard the argument between CNA V and R359. R37 reported CNA V did swear and use the f word. R37 felt CNA V was inappropriate. In an interview on 5/16/24 at 10:42 AM, NHA A and DON B reported R359 reported CNA V used the f word and said why the f*ck didn't you get up to go. NHA A reported they considered it as more of a customer service and etiquette issue. When asked if CNA V did swear and say that to R359, would that be considered abuse, NHA A and DON B did not answer the question. In a telephone interview on 5/16/24 at 12:43 PM, CNA V reported when her shift started at 3:00 PM on 5/14/24, it was very hectic with a lot of call lights on. CNA V reported it was the first time she cared for R359. CNA V reported the previous shift left R359's bed unmade and R359 was lying on a bare mattress. CNA V reported she wanted to make R359's bed and it took approximately 20 minutes to coerce R359 out of bed. When asked if there was any arguing, CNA V stated I guess you could call it arguing because I was like we have to get up and she would say no and start crying about her husband. When asked if raised voices were used, CNA V stated it was all kind of really loud because she was emotional and crying about her husband. CNA V denied swearing at R359. CNA V reported she was interviewed by NHA A and DON B and was told R359 reported she was mean towards her and that R359 was very upset. Review of the Grievance Summary provided by NHA A on 5/16/24 at 4:02 PM revealed On Tuesday, 5/14/24 am nurse notified Director of Nursing that community member was upset and she needed to go see her. DON met with member and completed complaint/grievance report. Resident stated that she was not happy with her CNA the afternoon previous and that she was rude and used inappropriate language. At no time did the resident allege abuse. She stated that she felt safe and thought the CNA was a good CNA but that she did not use proper etiquette and is ok with her providing care in the future. All residents within the set were questioned with no other identified concerns. Resident remains at her baseline and is exhibiting no catastrophic reaction that would signify abuse occurred. Customer service training and proper language etiquette have been provided. This was completed within 2 hours of notification and there were no allegations of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the State Agency for one (Resident #359) of three reviewed. Findings include: Review of the medical record revealed Resident #359 (R359) admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, depression, history of wedge compression fracture of thoracic vertebra, anxiety, and cerebral palsy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/8/24 revealed R359 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 5/14/24 at 9:32 AM, R359 was observed lying in bed. R359 reported yesterday, she was in her chair from 2:00 PM to 5:00 PM and had to go to the bathroom. R359 reported she took herself to the bathroom because her call light was not in reach. R359 reported afterwards, she transferred herself into her bed which was not made with a sheet or blanket. R359 reported Certified Nursing Assistant (CNA) V came into her room and wanted her to transfer back out of bed since the bed was not made. R359 reported CNA V said Why the f*ck* can't you get up and go to the bathroom? R359 stated she said the f word, she was literally cussing at me. R359 reported CNA V told her she was not going to change her bed if she could not get up and go to the bathroom. R359 stated I just don't like to be treated like that. That's why I'm here is because I need help with certain things. It's downgrading when someone literally swears at you and treats you like crap. R359 was tearful when recalling the incident. R359 reported her roommate (R37) was in the room at the time of the incident. R359 reported she reported the incident to Director of Nursing (DON) B this morning and DON B filled out a grievance form. On 5/16/24 at 9:56 AM, R359 reported she felt CNA V was inappropriate and that she was verbally abused. On 5/14/24 at 9:40 AM, DON B entered R359's room with a grievance form in her hand. DON B reported she spoke with R359 earlier that morning, has a concern form, discussed the incident with Nursing Home Administrator (NHA) A, and they have a call out to CNA V. Review of R359's Complaint/Grievance Report dated 5/14/24 and completed by DON B revealed Last night I was not happy with my CNA. She was rude and used inappropriate language. The findings of investigation revealed Resident is upset. I reassured her that I would follow up with concern. The Plan to resolve complaint/grievance was Interview CNA involved today. CNA educated on asking for assist. CNA educated on approach. The Complaint/Grievance Report revealed the incident was not reportable to the State Agency. The resolution was CNA will not be assigned to care for [R359]. [R359] agrees this will resolve concern. On 5/15/24 at 1:55 PM, NHA A and DON B reported R359 had one grievance from 5/14/24 that they were investigating. NHA A and DON B reported R359 was not happy with the CNA and reported CNA V was rude and used inappropriate language with R359. DON B reported they spoke with CNA V and reassured R359 that CNA V would not take care of her. When asked what was reported, DON B reported R359 reported CNA V used the f word. DON B reported R359's roommate, R37, reported R359 and CNA V were arguing about getting out of bed. NHA A and DON B reported CNA V was educated on her approach and that it's okay to step away and reapproach. NHA A reported the allegation was not reported to the State Agency because R359 did not say she perceived the incident as abusive. NHA A reported when they followed up again today, R359 did not feel like it was anything intentional. NHA A reported the facility was investigating this incident as a resident concern. In an interview on 5/16/24 at 9:54 AM, R37 (R359's roommate) was observed lying in bed. According to the MDS with an ARD of 4/9/24, R37 scored 11 out of 15 (moderate cognitive impairment) on the BIMS. R37 had a history of stroke and had difficulty expressing speech. As questions were asked, R37 pointed to her right side indicating she had a stroke and that she would have trouble with speech. Yes and no questions were asked. R37 reported she overheard the argument between CNA V and R359. R37 reported CNA V did swear and use the f word. R37 felt CNA V was inappropriate. In an interview on 5/16/24 at 10:42 AM, NHA A and DON B reported R359 reported CNA V used the f word and said why the f*ck didn't you get up to go. NHA A reported they considered it as more of a customer service and etiquette issue. When asked if CNA V did say that to R359, would that be considered abuse, NHA A and DON B did not answer the question. In a telephone interview on 5/16/24 at 12:43 PM, CNA V reported when her shift started at 3:00 PM on 5/14/24, it was very hectic with a lot of call lights on. CNA V reported it was the first time she cared for R359. CNA V reported the previous shift left R359's bed unmade and R359 was lying on a bare mattress. CNA V reported she wanted to make R359's bed and it took approximately 20 minutes to coerce R359 out of bed. When asked if there was any arguing, CNA V stated I guess you could call it arguing because I was like we have to get up and she would say no and start crying about her husband. When asked if raised voices were used, CNA V stated it was all kind of really loud because she was emotional and crying about her husband. CNA V denied swearing at R359. CNA V reported she was interviewed by NHA A and DON B and was told R359 reported she was mean towards her and that R359 was very upset. Review of the Grievance Summary provided by NHA A on 5/16/24 at 4:02 PM revealed On Tuesday, 5/14/24 am nurse notified Director of Nursing that community member was upset and she needed to go see her. DON met with member and completed complaint/grievance report. Resident stated that she was not happy with her CNA the afternoon previous and that she was rude and used inappropriate language. At no time did the resident allege abuse. She stated that she felt safe and thought the CNA was a good CNA but that she did not use proper etiquette and is ok with her providing care in the future. All residents within the set were questioned with no other identified concerns. Resident remains at her baseline and is exhibiting no catastrophic reaction that would signify abuse occurred. Customer service training and proper language etiquette have been provided. This was completed within 2 hours of notification and there were no allegations of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent further potential abuse for one (Resident #359) of three reviewed. Findings include: Review of the medical record revealed Resident #359 (R359) admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, depression, history of wedge compression fracture of thoracic vertebra, anxiety, and cerebral palsy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/8/24 revealed R359 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 5/14/24 at 9:32 AM, R359 was observed lying in bed. R359 reported yesterday, she was in her chair from 2:00 PM to 5:00 PM and had to go to the bathroom. R359 reported she took herself to the bathroom because her call light was not in reach. R359 reported afterwards, she transferred herself into her bed which was not made with a sheet or blanket. R359 reported Certified Nursing Assistant (CNA) V came into her room and wanted her to transfer back out of bed since the bed was not made. R359 reported CNA V said Why the f*ck* can't you get up and go to the bathroom? R359 stated she said the f word, she was literally cussing at me. R359 reported CNA V told her she was not going to change her bed if she could not get up and go to the bathroom. R359 stated I just don't like to be treated like that. That's why I'm here is because I need help with certain things. It's downgrading when someone literally swears at you and treats you like crap. R359 was tearful when recalling the incident. R359 reported her roommate (R37) was in the room at the time of the incident. R359 reported she reported the incident to Director of Nursing (DON) B this morning and DON B filled out a grievance form. On 5/16/24 at 9:56 AM, R359 reported she felt CNA V was inappropriate and that she was verbally abused. On 5/14/24 at 9:40 AM, DON B entered R359's room with a grievance form in her hand. DON B reported she spoke with R359 earlier that morning, has a concern form, discussed the incident with Nursing Home Administrator (NHA) A, and they have a call out to CNA V. Review of R359's Complaint/Grievance Report dated 5/14/24 and completed by DON B revealed Last night I was not happy with my CNA. She was rude and used inappropriate language. The findings of investigation revealed Resident is upset. I reassured her that I would follow up with concern. The Plan to resolve complaint/grievance was Interview CNA involved today. CNA educated on asking for assist. CNA educated on approach. The Complaint/Grievance Report revealed the incident was not reportable to the State Agency. The resolution was CNA will not be assigned to care for [R359]. [R359] agrees this will resolve concern. On 5/15/24 at 1:55 PM, NHA A and DON B reported R359 had one grievance from 5/14/24 that they were investigating. NHA A and DON B reported R359 was not happy with the CNA and reported CNA V was rude and used inappropriate language with R359. DON B reported they spoke with CNA V and reassured R359 that CNA V would not take care of her. When asked what was reported, DON B reported R359 reported CNA V used the f word. DON B reported R359's roommate, R37, reported R359 and CNA V were arguing about getting out of bed. NHA A and DON B reported CNA V was educated on her approach and that it's okay to step away and reapproach. NHA A reported the allegation was not reported to the State Agency because R359 did not say she perceived the incident as abusive. NHA A reported when they followed up again today, R359 did not feel like it was anything intentional. NHA A reported the facility was investigating this incident as a resident concern. In an interview on 5/16/24 at 9:54 AM, R37 (R359's roommate) was observed lying in bed. According to the MDS with an ARD of 4/9/24, R37 scored 11 out of 15 (moderate cognitive impairment) on the BIMS. R37 had a history of stroke and had difficulty expressing speech. As questions were asked, R37 pointed to her right side indicating she had a stroke and that she would have trouble with speech. Yes and no questions were asked. R37 reported she overheard the argument between CNA V and R359. R37 reported CNA V did swear and use the f word. R37 felt CNA V was inappropriate. In an interview on 5/16/24 at 10:42 AM, NHA A and DON B reported R359 reported CNA V used the f word and said why the f*ck didn't you get up to go. NHA A reported they considered it as more of a customer service and etiquette issue. When asked if CNA V did swear and say that to R359, would that be considered abuse, NHA A and DON B did not answer the question. In a telephone interview on 5/16/24 at 12:43 PM, CNA V reported when her shift started at 3:00 PM on 5/14/24, it was very hectic with a lot of call lights on. CNA V reported it was the first time she cared for R359. CNA V reported the previous shift left R359's bed unmade and R359 was lying on a bare mattress. CNA V reported she wanted to make R359's bed and it took approximately 20 minutes to coerce R359 out of bed. When asked if there was any arguing, CNA V stated I guess you could call it arguing because I was like we have to get up and she would say no and start crying about her husband. When asked if raised voices were used, CNA V stated it was all kind of really loud because she was emotional and crying about her husband. CNA V denied swearing at R359. CNA V reported she was interviewed by NHA A and DON B and was told R359 reported she was mean towards her and that R359 was very upset. Review of the Grievance Summary provided by NHA A on 5/16/24 at 4:02 PM revealed On Tuesday, 5/14/24 am nurse notified Director of Nursing that community member was upset and she needed to go see her. DON met with member and completed complaint/grievance report. Resident stated that she was not happy with her CNA the afternoon previous and that she was rude and used inappropriate language. At no time did the resident allege abuse. She stated that she felt safe and thought the CNA was a good CNA but that she did not use proper etiquette and is ok with her providing care in the future. All residents within the set were questioned with no other identified concerns. Resident remains at her baseline and is exhibiting no catastrophic reaction that would signify abuse occurred. Customer service training and proper language etiquette have been provided. This was completed within 2 hours of notification and there were no allegations of abuse. Review of CNA V's timecard revealed they worked 5/14/24 from 3:00 PM to 11:00 PM. Timecard comments revealed went right to meet with [NHA A and DON B]. Review of the facility's Abuse and Neglect Procedural Guidelines (undated) revealed the facility will immediately remove any alleged perpetrator from any further contact with any resident .When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be suspended from his/her position pending investigation and outcome.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 1 (Resident #14) of 14 reviewed resulting in the potential for decreased safety, increased injury risk, and unmet care needs. Review of the medical record revealed that Resident #14 (R14) was readmitted to facility 1/10/24 with diagnoses including vascular dementia, catatonic schizophrenia, specified disorder of bone density and structure, muscle weakness, and abnormalities of gait and mobility. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/24 revealed that R14 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 6 (severe cognitive impairment). Review of R14's ADL (Activities of Daily Living) Care Plan reflected that R14 required assist of one for bed mobility and bathing and assist of 2 for toilet use and transfers. In an observation and interview on 5/14/24 at 8:47 AM, R14 was observed lying in bed, on back, with body positioned toward right edge of mattress and head of bed at an approximate 60-degree angle. R14's entire bed was noted to be elevated between knee and hip level, left side of bed was positioned against the wall, and a black, cushioned mat was on the floor to the right of the bed. R14's over the bed table was positioned parallel to bed, on top of floor mat with R14 noted to lean to right side, reach over body with left arm to feed self from breakfast tray positioned on over the bed table. R14 stated that she could not walk, required a mechanical lift for transfer, and remembered falling a couple of times but couldn't recall details regarding the falls. In an observation on 5/14/24 at 10:11 AM, R14 was observed to remain positioned on back toward right edge of bed with head of bed remaining at an approximate 60-degree angle. Entire bed observed to remain elevated between knee and hip level with black, cushioned floor mat on floor to right of bed. In an observation on 5/15/24 at 8:19 AM, R14 was observed lying in bed, on back, feeding self-breakfast from tray positioned directly in front of her on over the bed table. The head of R14's bed was positioned at an approximate 60-degree angle with entire bed noted to be elevated to just above knee height level. Black cushioned floor mat noted at floor to right of bed. In an interview on 05/15/24 at 2:30 PM, Certified Nurse Aide (CNA) S confirmed familiarity with R14 and that she was her assigned aide that date. Per CNA S, R14 was alert, was generally able to make needs known, but had episodes of confusion. CNA S further stated that R14 required assist of 2 for transfer with use of mechanical lift but otherwise required assist of 1 for grooming, bathing, dressing, and bed mobility. CNA S stated that, to her knowledge, R14 had no recent falls but due to her confusion and dependence on staff for transfer, was at risk for and had the potential to fall or roll out of bed and therefore should have her bed lowered all the way to the floor and the mat placed at the bedside whenever she was in bed. CNA S stated that when she started her shift at 7:00 AM that date, R14's bed had been at knee height level, acknowledged that at that level it was higher than it should have been but maintained it at that level as knew that she would be eating breakfast soon. CNA S stated that R14's bed remained at knee height level until approximately 9:30 AM at which time she assisted her with care and out of bed. Review of R14's medical record completed with the following findings noted: Fall assessment dated [DATE] reflected that R14 had diminished safety awareness, predisposing medical conditions (dementia, hypertension, anemia), and medications (antihypertensive, antiseizure, diuretic, hypoglycemic, psychotropic medications) which contributed to fall risk. ADL Care Plan Focus with a revised date of 10/18/23 included Care Plan Interventions that stated, For my safety I need my room door open with an 8/13/2021 date of initiation and Resident moves in bed frequently, please check call light placement to be sure it is in reach with a 7/21/2021 date of initiation. Fall Care Plan Focus with a revised date of 4/12/24 stated, I am at risk for falls related to HX [history] of falling, encephalopathy, catatonic schizophrenia .hx fall with fracture . with associated interventions which included, Maintain bed in low position with a 7/17/21 date of initiation. [NAME] (tool used by the Certified Nurse Aide to guide them as to the care needs of a specific resident) section titled Safety reflected, Maintain bed in low position. In an interview on 5/15/24 at 4:39 PM, Director of Nursing (DON) B stated that safety interventions for a resident with a fall from bed could include floor mats, low bed, and a specialized mattress. DON B further stated that an intervention for a low bed would be reflected on both the resident care plan and [NAME] with the expectation that the indicated bed be maintained in the lowest position to the floor possible when the resident was in bed. DON B confirmed familiarity with R14, stated that she had dementia with some confusion and that, to her knowledge, had no recent falls. Nursing Home Administrator (NHA) A who was present during interview stated that R14's last documented fall was in 2022. Upon review of R14's fall care plan, DON B confirmed an active care plan intervention to Maintain bed in low position, stated that intervention was likely no longer warranted as did not believe that R14 would be considered a current fall risk and would be reviewing the care plan with the interdisciplinary team (IDT) for likely revision. Review of R14's progress notes post 5/15/24 interview with DON B was noted to include an IDT Note which stated, .IDT note r/t [related to] fall care plan. Fall care plan was reviewed and deemed appropriate. No changes needed at this time indicating ongoing need for the low bed for safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 1) ensure blood glucose values were documented in the medical record for one (R22) and failed to implement assessment/intervention for bowel constipation for one resident (R408) of 14 reviewed for quality of care. Findings include: Resident #22 Review of the Face Sheet revealed Resident #22 (R22) was admitted to the facility on [DATE] with diagnoses that included muscle weakness, unspecified severe protein calorie malnutrition, delirium due to known physiological source, Alzheimer's disease, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/19/24 revealed R22 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Care Plan revealed R22 required assistance of one staff member for toileting. Review of the MDS revealed R22 was coded always incontinent for bowels. On 05/14/24 at 3:56 PM, R22 was observed self propelling in the hallway. R22 was not easily conversant and preferred to independently propel through the hallway. Review of the Bowel Movement Task revealed R22 had not had a bowel movement from 5/8/24 to 5/12/24. In an interview on 5/16/24 at 12:12 PM, Unit Manager (UM) M reported that the nursing staff monitors for bowel movements and if the resident has not had a bowel movement in three days, the nurses are notified by an alert listing. UM M stated that the Interdisciplinary Team (IDT) also monitors all alert listings, complies a list, and informs the floor nurse when intervention is need. When the nurses are notified of the absence of a bowel movement, they should administer the as needed order for milk of magnesia which states Give 30 ml (milliliters) by mouth every 24 hours as needed for constipation/no bm (bowel movement) in 3 days. If the milk of magnesia is not effective, the nurse would refer to the next as needed order which reads Bisacodyl Suppository 10 MG; Insert 1 suppository rectally as needed for constipation or if no bowel movement in 24 hours after administration of milk of magnesia. If that is not effective, the nurse is to refer to the next as needed order which states Fleet Naturals Cleansing Enema Enema (Rectal Cleansers); Insert 1 application rectally every 24 hours as needed for constipation if no results from administration of Dulcolax/Bisacodyl suppository in 24 hours. UM Mreviewed the bowel movement documentation and verified that R22 had not had a bowel movement for a total of five days. UM M said the expectation would have been to implement the Bowel Protocol on day three. Review of the Medication Administration Record for R22 revealed that the as needed medication for constipation was not administered as required. In an interview on 5/16/24 at 2:41 PM, Director of Nursing (DON) B reported that the IDT team monitors the alert listing report for resident that had not had a bowel movement in three days. DON B stated that she will inform the corresponding nurse that the resident has not had a bowel movement in three days and ensure that staff had not missed documenting a bowel movement or that the resident had refused the as needed medication for constipation. DON B verified that the bowel protocol should have been implemented when R22 had not experienced a bowel movement for 5 days. Resident #408 Review of the Face Sheet revealed Resident #408 (R408) was admitted to the facility on [DATE] with diagnoses that included lower back pain, Alzheimer's disease, type two diabetes with hyperglycemia, and spinal stenosis. Review of a Skilled Note dated 5/15/24 at 12:48 PM revealed R408 was alert and oriented to person, place, date, time . [R408] can be understood all of the time and able to understand others all of the time . On 05/14/24 at 10:38 AM, R408 was observed in her room, dressed and seated in her recliner. R408 was easily conversant and understood questions. R408 stated that she had recently admitted to the facility for rehabilitation and lived at an assisted living facility prior to her admission. R408 reported a concern with her blood sugar checks. R408 stated they said my blood sugar was low yesterday and brought me crackers. Review of R408's Physician Order's revealed R408 had an order for Glipizide ER Oral Tablet Extended Release 24 Hour 10 MG (milligrams) . Give 1 tablet by mouth one time a day for Diabetes with a start date of 5/14/24 and an order for Lantus SoloStar Solution Pen-injector 100 UNIT/ML (Insulin Glargine) .Inject 15 unit subcutaneously one time a day . with a start date of 5/13/24. Review of the Physician's Orders revealed R408 had an order for Accuchecks (Blood Glucose checks) in the morning and in the evening with a start date of 5/13/24. Review of the Medical Record revealed a blood glucose reading on 5/13/2024 at 7:06 AM of 120.0 mg/dL (milligrams per deciliter), a reading on 5/15/2024 at 8:05 AM of 126.0 mg/dL, and a reading on 5/16/2024 at 7:48 AM of 168.0 mg/dL. Review of a Nutrition assessment dated [DATE] at 9:13 AM revealed R408 diet order was changed from a regular diet to a CCD (Consistent Carbohydrate) diet due to the elevated blood sugar. In an interview on 5/16/23 at 1:47 PM, Dietician W reported that she completed a nutritional assessment on R408 today and explained that the change in diet order was due to the increased blood sugar. Dietician W stated that she typically reviews blood sugar values when she conducts her assessment however, only had three values for the past four days. In an interview on 05/16/24 at 12:25 PM, Unit Manager M verified that R408 received twice daily for blood glucose checks. When queried if the blood sugar values should be documented in the medical record, UM M stated that they should be documented in the medical record. UM M reviewed the Physician Order's for R408 and stated that when the twice daily blood glucose check order was created, the option to include supplemental documentation did not trigger on the Physician Order. Due to this, the Medication Administration Record did not prompt a space to document blood glucose values and the blood glucose values did not get documented. In an interview on 05/16/24 at 2:37 PM, Director of Nursing (DON) B stated that the expectation for blood glucose monitoring would be to ensure the blood glucose values were documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure two out of three residents (Resident #6 and 32) had water available at the bedside, resulting in the potential for dehydration. Findings included: Resident #6 (R6): Per the facility face sheet R6 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis included dysphasia (difficulty in swallowing). In an observation and interview on 5/14/2024 at 11:00 AM, R6 was observed to have no water in his room. A small 7 oz clear cup was observed on the over the bed table that had juice in it, no other fluids were noted. R6 was asked why he did not have any water in his room, in which R6 stated that the staff would not let him have any water. R6 said he had to have thicken fluids and did not like the taste of the thickened water. In an observation and interview on 5/15/2024 at 2:34 PM. R6 was observed to be in his room sitting on the side of his bed. A small Styrofoam cup with a lid and straw was observed to be on the same table. The cup was dated 5/15 1st (shift), and was observed to have water with ice in it that was not thickened which R6 could not drink. In an observation on 5/16/2024 at 12:50 PM, R6 was observed in bed. A a small Styrofoam cup with ice and water was observed on the over the bed table. The water was not thickened. A small glass cup of orange juice was noted on the table also. The orange juice was thickened. Review of a physician's order revealed that on 9/4/2023 R6 was ordered to have nectar thick liquids. The order was marked as active (not discontinued). Review of a Minimum Data Set (MDS) assessment section KO510 dated 9/4/2023, revealed R6 was on thickened liquids. Review of an MDS dated [DATE] revealed R6 was assessed to be on thickened liquids. Review of a care plan dated 9/15/2020 and revised on 9/15/2023, revealed R6 was at risk for dehydration related to being on thickened liquids. Review of R6's [NAME] (document used by Certified Nurse Aid [CNA] to know how to provide care for a resident) revealed R6 was to receive nectar thick liquids. Review of a Nutritional Evaluation . dated 3/5/2024, revealed under section B. Diet Orders, R6 was on thickened liquids that were to be of nectar consistency. In an interview on 5/17/2024 at 8:14 AM, Certified Nurse Aid (CNA) X stated that all residents were given water at the start of each shift with the date and shift written on the cup. CNA X said R6 was to receive nectar thick liquids. CNA X said R6 did not like his water to be thickened, and would sometimes drink the thickened water and sometimes would not. CNA X said R6 would ask for non-thickened water but she would tell him he could not have that. In an interview on 5/17/2024 at 10:10 AM, Registered Dietician (RD) W said R6 was on nectar thick liquids, and stated that R6 would ask her for non-thickened ice water, but said she would tell him that he was not able to have that for safety. Resident #32 (R32): Per the facility face sheet R32 was admitted to the facility on [DATE], and readmitted on [DATE]. In an observation and interview on 5/14/2024 at 11:20 AM, R32 was in her room lying down, and was observed to have a 7 oz cup of water that was half empty, no other water was observed to be in room. R32 was asked if staff brought her fresh water daily or every shift. R32 said she would get her own water, from the bathroom sink, because staff never brought her water. In an observation and interview on 5/15/2024 at 2:46 PM, R32 was observed to be up walking in her room. The same type of water cup from 5/14/2024 was observed on the night stand, the cup was empty. R32 once again stated that staff did not bring her water, so she just filled up (the 7 oz cup) with water from the bathroom. In an interview on 5/17/2024 at 8:58 AM, Licensed Practical Nurse (LPN) J stated that the CNAs were to pass water each shift to residents. In an interview on 5/17/2024 at 12:20 PM, Administrator A stated that it was her expectation that each resident would received fresh water each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a medication was administered within the prescribed parameters and not in excessive dose for one (Resident #38) of six reviewed. Findings include: Review of the medical record revealed Resident #38 (R38) admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included fracture of lower end of right femur and hemiplegia and hemiparesis following a stroke. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/24 revealed R38 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 5/14/24 at 10:55 AM, R38 was observed in a Broda chair near the window in the dining room. Review of the Physician's Order dated 4/3/24 revealed an order for acetaminophen (Tylenol) give 1000 milligrams (mg) every 6 hours for pain not to exceed 3000 mg in 24 hours. Review of the Medication Administration Records (MAR) dated April and May 2024, revealed 1000 mg of acetaminophen was scheduled to be administered at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. R38 received 4000 mg of acetaminophen from 4/4/24 through 5/14/24 which exceeded the ordered parameter of not exceeding 3000 mg in 24 hours. In an interview on 5/16/24 at 10:49 AM, Director of Nursing (DON) B reviewed R38's acetaminophen order and agreed the ordered doses exceeded the prescribed parameter of 3000 mg.

Based on observation, interview and record review, the facility failed to ensure appropriate infection control practices during wound care for two (Resident #3 and #5) of two reviewed for wound care, resulting in the potential for cross contamination and the spread of infection. In a wound care observation on 5/15/24 at 1:34 PM, Licensed Practical Nurse (LPN) I removed her gloves, entered R3's bathroom, and washed her hands with soap and water for approximately four seconds. In an observation on 5/15/24 at 1:41 PM, Licensed Practical Nurse (LPN) N removed her gloves, entered R3's bathroom, and washed her hands with soap and water for approximately five seconds. In a wound care observation on 5/15/24 at 1:55 PM, LPN I removed her gloves, entered R5's bathroom, and used soap and water to wash her hands for approximately five seconds. In a wound care observation on 5/15/24 at 1:57 PM, LPN I entered R5's bathroom, and washed her hands with soap and water for approximately four seconds. In an wound care observation on 5/15/24 at 1:59 PM, LPN I doffed gloves, entered R5's bathroom, and washed her hands with soap and water for approximately six seconds. In a wound care observation on 5/15/24 at 2:04 PM, LPN I removed her gloves, entered R5's bathroom, and washed her hands with soap and water for approximately five seconds. According to the Centers for Disease Control and Management regarding handwashing, Rub your hands together until the soap forms a lather and then rub all over the top of your hands, in between your fingers and the area around and under the fingernails. Continue rubbing your hands for at least 20 seconds. Rinse your hands well under running water . In an interview 5/16/24 at 12:53 PM, MDS Coordinator O reported that the timing expectation for hand washing with soap and water would be to wash hands for at least 20 seconds. In an interview on 5/16/24 at 2:45 PM, Nursing Home Administrator A stated that per the facility policy, hands need to be washed with soap and water for at least 20 seconds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure four out of four observed resident room call lights were answered timely, resulting in the potential for unmet needs. Findings Included: In an observation on 5/14/2024 at 11:44 AM, the call light for room [ROOM NUMBER] was observed to be on. Two staff members were observed to pass by room [ROOM NUMBER] and not stop to answer the call light. At 11:47 AM the call light for room [ROOM NUMBER] was observed to be on, and one staff member was observed to walk by room [ROOM NUMBER] and not stop to answer the call light. At 11:48 AM a nurse was observed to walk past room [ROOM NUMBER], and go into room [ROOM NUMBER] without addressing the call light for room [ROOM NUMBER]. At 11:56 AM, the call light for room [ROOM NUMBER] was observed to be on, and at 11:58 AM, a staff member was observed to look up at the call light but turned and walked away without responding to the call light. At 12:07 PM room [ROOM NUMBER] call light was observed to be on. Five staff members were observed standing in the hall by the nursing station but did not respond to the call light. The nurses' station was observed to have a board on the wall that lit up and made an audible sound when a call light was turned on. The board also revealed which room the call light was on for. On 5/15/2024 at 2:50 PM, while standing in the hallway, the call light for room [ROOM NUMBER] was observed to be one. Two staff members were observed to walk past room [ROOM NUMBER] and did not stop to respond to the call light. In an interview on 5/17/2024 at 12:20 PM, Administrator A stated that it was her expectation that all staff answer call lights, and get the appropriate staff member if they are not able to fill the resident's need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 53 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 05/14/24 at 10:50 A.M., The flooring surface within resident room [ROOM NUMBER] was observed extremely tacky and sticky. Numerous dead insect carcasses (flies) were also observed within the restroom bathtub. On 05/14/24 at 01:19 P.M., Human feces was observed within the 2nd Floor Shower 1 Room shower stall, directly beneath the polyvinyl chloride (PVC) shower chair. The human feces measured approximately 1-inch-wide by 3-inches-long. On 05/15/24 at 09:05 A.M., A common area environmental tour was conducted with Director of Environmental Services C. The following items were noted: 2nd Floor The Northeast exterior window screen was observed loose-to-mount, allowing potential pests (flying insects) to enter the building. Two acoustical ceiling tiles were observed stained from previous moisture exposure, directly above the southeast portable terminal air-conditioning (PTAC) unit. Shower 1 Room: The toilet seat was observed loose-to-mount. Human feces was also observed within the shower stall. The human feces measured approximately 1-inch-wide by 2-inches-long. Day Room: 1 of 2 exterior window screens were observed (etched, scored, torn). The damaged window screen measured approximately 3-feet-wide by 5-feet-long. 3rd Floor The southeast and southwest exterior windowpanes were observed moist and fogged within the sealed double pane frame. Facilities Director for Preferred Care D stated: I will have to replace both fogged windows. On 05/15/24 at 01:50 P.M., An environmental tour of sampled resident rooms was conducted with Director of Environmental Services C. The following items were noted: 202: The restroom commode base caulking was observed (etched, scored, particulate). The restroom hand sink basin was also observed draining very slow. The Bed 1 drywall surface was further observed (etched, scored, particulate). The damaged drywall surface measured approximately 2-feet-wide by 2-feet-long. Director of Environmental Services C indicated he would contact maintenance as soon as possible. 211: The restroom commode base caulking was observed (etched, scored, particulate). The restroom return-air-exhaust ventilation grill was also observed soiled with dust and dirt deposits. 220: The entire resident room was observed extremely malodorous (urine and body odor). 221: The restroom commode base caulking was observed (etched, scored, particulate). 229: The restroom commode base caulking was observed (etched, scored, particulate). 232: The restroom hand sink faucet goose neck was observed (etched, scored, corroded). 322: The foyer overhead light bulb was observed non-functional. 335: The restroom hand sink faucet goose neck was observed (etched, scored, corroded). On 05/15/24 at 03:20 P.M., An interview was conducted with Director of Environmental Services C regarding the facility maintenance work order system. Director of Environmental Services C stated: We have the TELS system. On 05/16/24 at 10:45 A.M., Record review of the Policy/Procedure entitled: Cleaning and Disinfection of Environmental Surfaces dated 08/2019 revealed under Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA bloodborne pathogens standard. Record review of the Policy/Procedure entitled: Cleaning and Disinfection of Environmental Surfaces dated 08/2019 further revealed under Policy Interpretation and Implementation: (9) Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visible soiled. (10) Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. On 05/16/24 at 11:00 A.M., Record review of the Policy/Procedure entitled: Maintenance Service dated 12/2009 revealed under Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Record review of the Policy/Procedure entitled: Maintenance Service dated 12/2009 further revealed under Policy Interpretation and Implementation: (1) The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. On 05/16/24 at 11:15 A.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00142408. Based on interview and record review, the facility failed to ensure the physician documented required transfer/discharge information for one (Resident #3) of three reviewed. Findings include: Review of the medical record revealed Resident #3 (R3) was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, insomnia, and anxiety. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/9/23 revealed R3 was independent with cognitive skills for daily decision making. The MDS with an ARD of 2/7/24 revealed R3 had an unplanned discharge to a short-term general hospital with a return to the facility anticipated. R3 was not in the facility at the time of the survey. Review of the Care Plan initiated 11/17/22 revealed I wish to return back to the community when I am able. The goal of I will safely discharge to a lesser care environment within a reasonable time frame was initiated on 10/25/23 and had a target date of 5/9/24. The goal of my care needs will continue to be met at facility until I find appropriate placement through next review date was initiated on 11/7/22, revised on 10/25/23, and had a target date of 5/9/24. Care Plan interventions included: Coordinate resources with Region 2 to assist with housing placement (initiated 3/16/23), reassess my care needs and potential for discharge as needed (initiated 11/17/22), Referral to [name of a community agency] will be made for assistance with discharge resources and housing assistance (initiated 3/16/23), and support me, family, and/or representative as needed (initiated 11/17/22). Review of the Nursing/Clinical progress note dated 2/7/24 revealed Resident screaming HELP HELP HELP! Writer entered room, patient was sitting up with CPAP [continuous positive airway pressure- a machine that uses mild air pressure to keep breathing airways open while you sleep] removed and no oxygen on rocking back and forth with hands between legs. I cant breathe I cant breathe! Writer stated you have your oxygen off which would would if you placed it back on. Patient stated she was too tired to swap out the CPAP for the nasal cannula. When writer went to change it out, patient stated that she wanted to put the CPAP back on. Writer states it is right next to your hand right hand was now on bed, patient then stated CPAP IS OUT OF WATER. Cpap had water in it 1/3 of way filled, she stated it needed more and was empty, it's not empty there is water if you can't breathe let's put it on. Patient responded, No it need to be filled. CPAP was filled to max with distilled water and patient placed back on, after turning machine on and off 4 times. Patient was rolling around bed shaking of I can't breathe I can't breathe! Vitals could not be taken until patient stopped rolling around and shaking herself which lasted about 5 additional minutes, vitals were 99% on 5L [liters] via CPAP and [blood pressure] 122/90 p [pulse] 64. pain level 10/10 per patient. Patient was given meds, patient took meds and then reapplied CPAP. patient asked writer to look under her pants at her legs it hurts and is swollen, writer put on gloves assessed left groin and thigh, huge swelling under skin, asked writer what procedure she had done as there was no paperwork or instructions given prior or upon her return. Patient stated the paperwork and orders should be out there, writer had received in report that patient returned at 10/1030pm with no paperwork. Writer went to DON [Director of Nursing] and requested additional assessment since no info was given re: procedure. [DON] and Management Staff confirmed that [R3] should be sent out for further evaluation and treatment at hospital re: heavy swelling over 4 inches in left femoral, writer called ed EMS [emergency department emergency medical services] and requested transport. In an interview on 2/14/24 at 1:59 PM, with Nursing Home Administrator (NHA) A and DON B, DON B reported the facility told the hospital that they were not able to meet R3's needs because R3 would not collaborate care with the facility. On 2/15/24 at 10:38 AM, NHA A and DON B both reported R3 was transferred to the hospital and discharged from the facility because it was necessary for R3's welfare and that R3's needs could not be met in the facility. NHA A and DON B reported R3's physician did not document in the medical record that the transfer or discharge was necessary or the specific resident need(s) that could not be met, facility attempts to meet the resident need(s), and the service available at the receiving facility to meet the need(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00142408. Based on interview and record review, the facility failed to permit a resident to return to the facility after hospitalization for one (Resident #3) of three reviewed, resulting in R3 being denied return/readmission to the facility and having to find alternate placement at another facility. Findings include: Review of the medical record revealed Resident #3 (R3) was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, insomnia, and anxiety. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/9/23 revealed R3 was independent with cognitive skills for daily decision making. The MDS with an ARD of 2/7/24 revealed R3 had an unplanned discharge to a short-term general hospital with a return to the facility anticipated. R3 was not in the facility at the time of the survey. Review of the Care Plan initiated 11/17/22 revealed I wish to return back to the community when I am able. The goal of I will safely discharge to a lesser care environment within a reasonable time frame was initiated on 10/25/23 and had a target date of 5/9/24. The goal of my care needs will continue to be met at facility until I find appropriate placement through next review date was initiated on 11/7/22, revised on 10/25/23, and had a target date of 5/9/24. Care Plan interventions included: Coordinate resources with Region 2 to assist with housing placement (initiated 3/16/23), reassess my care needs and potential for discharge as needed (initiated 11/17/22), Referral to [name of a community agency] will be made for assistance with discharge resources and housing assistance (initiated 3/16/23), and support me, family, and/or representative as needed (initiated 11/17/22). Review of the Nursing/Clinical progress note dated 2/7/24 revealed Resident screaming HELP HELP HELP! Writer entered room, patient was sitting up with CPAP [continuous positive airway pressure- a machine that uses mild air pressure to keep breathing airways open while you sleep] removed and no oxygen on rocking back and forth with hands between legs. I cant breathe I cant breathe! Writer stated you have your oxygen off which would would if you placed it back on. Patient stated she was too tired to swap out the CPAP for the nasal cannula. When writer went to change it out, patient stated that she wanted to put the CPAP back on. Writer states it is right next to your hand right hand was now on bed, patient then stated CPAP IS OUT OF WATER. Cpap had water in it 1/3 of way filled, she stated it needed more and was empty, it's not empty there is water if you can't breathe let's put it on. Patient responded, No it need to be filled. CPAP was filled to max with distilled water and patient placed back on, after turning machine on and off 4 times. Patient was rolling around bed shaking of I can't breathe I can't breathe! Vitals could not be taken until patient stopped rolling around and shaking herself which lasted about 5 additional minutes, vitals were 99% on 5L [liters] via CPAP and [blood pressure] 122/90 p [pulse] 64. pain level 10/10 per patient. Patient was given meds, patient took meds and then reapplied CPAP. patient asked writer to look under her pants at her legs it hurts and is swollen, writer put on gloves assessed left groin and thigh, huge swelling under skin, asked writer what procedure she had done as there was no paperwork or instructions given prior or upon her return. Patient stated the paperwork and orders should be out there, writer had received in report that patient returned at 10/1030pm with no paperwork. Writer went to DON [Director of Nursing] and requested additional assessment since no info was given re: procedure. [DON] and Management Staff confirmed that [R3] should be sent out for further evaluation and treatment at hospital re: heavy swelling over 4 inches in left femoral, writer called ed EMS [emergency department emergency medical services] and requested transport. In an interview on 2/14/24 at 1:59 PM, with Nursing Home Administrator (NHA) A and DON B, DON B reported the facility told the hospital that they were not able to meet R3's needs because R3 would not collaborate care with the facility. In an interview on 2/15/24 at 9:16 AM, Admissions Director (AD) I reported she had been in contact with the hospital regarding R3. AD I reported approximately one week ago, the hospital sent a referral for R3 to be readmitted to the facility. AD I reported the team had discussions regarding R3's lack of collaboration with care and that it was putting her at risk. AD I reported a couple days ago she informed the hospital that the facility could not allow R3 to return to the facility because the facility could not meet R3's needs. In an interview on 2/15/24 at 10:38 AM, NHA A and DON B both reported R3 was transferred and discharged from the facility because it was necessary for R3's welfare and that R3's needs could not be met in the facility. NHA A and DON B reported R3's physician did not document in the medical record that the transfer or discharge was necessary or the specific resident need(s) that could not be met, facility attempts to meet the resident need(s), and the service available at the receiving facility to meet the need(s). NHA A reported the facility was not readmitting R3 and R3 was scheduled to be admitted to another local long-term care facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00138322. Based on observation, interview, and record review, the facility 1) failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and 2) failed to immediately report an allegation of abuse to the Nursing Home Administrator (NHA) and State Agency for one (Resident #2) of three reviewed, resulting in a sexual abuse allegation to go unreported to the NHA and State Agency and a reasonable suspicion of a crime to go unreported. Findings include: Review of the medical record revealed Resident #2 (R2) was admitted to the facility on [DATE] with diagnoses that included dementia, avoidant personality disorder, major depressive disorder, insomnia, and anxiety. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/23 revealed R2 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the complaint filed with the State Agency revealed The resident has made a complaint about a third shift nurse named [Licensed Practical Nurse (LPN) 'G]. She said he stuck his fingers in her vagina. She's told multiple cnas [Certified Nursing Assistants] and nurses. When it was addressed there should have been an investigation and the nurse [LPN G] has been on the floor almost every day since then. The management isn't even investigating the situation. He also has been kicked out of 2 other residents' rooms 1 which still is at the facility . The complaint further explained that facility staff, including Director of Nursing (DON) B was aware of the allegation. On 8/14/23 at 9:59 AM, R2 was observed sitting in a wheelchair in her room. When asked about the staff, R2 stated she didn't want to say anything. When asked about abuse, R2 stated, I don't want to get into it, okay. R2 reported it didn't do any good to say anything because nothing gets done. R2 refused to answer further questions. In a telephone interview on 8/14/23 at 1:02 PM, CNA D reported they were aware R2 had reported that LPN G had inappropriately touched R2 while changing her brief. CNA D reported LPN G was no longer allowed to care for R2. In a telephone interview on 8/14/23 at 1:16 PM, CNA E reported R2 had told them before that LPN G knows what he did to R2. CNA E reported they heard that LPN G was inappropriate with R2. CNA E reported they believed R2 and stated the allegation had been discussed a lot lately in the building. CNA E reported LPN G was no longer allowed in R2's room. In a telephone interview on 8/14/23 at 1:30 PM, LPN F stated, There was a time when I was in there [R2's room] when [R2] said [LPN G] was cleaning her up, taking her off the bed pan, and forcibly inserted his finger in her. LPN F reported this was a couple weeks ago around 10:00 PM and they called Director of Nursing (DON) B the following morning around 7:00 AM. In a telephone interview on 8/14/23 at 1:43 PM LPN G reported he was told not to care for R2 any longer. When asked why, LPN G reported there was a night approximately two months ago when R2 needed assistance getting off the bed pan which had spilled. LPN G reported he got tissue paper from the bathroom and wiped R2 front to back. LPN G reported R2 got mad at him and alleged that he penetrated her p*ssy. LPN G reported he informed LPN H of the allegation against him and worked the remainder of his shift and again spoke with R2 the next morning. LPN G reported the next morning, he notified a Unit Manager and DON B. LPN G reported DON B called him and discussed the allegation. LPN G reported he was not suspended. LPN G reported he was notified that he could administer medications to R2, but no longer provide direct care. LPN G reported he had since attempted to administer medications to R2 and R2 stated you are back, what are you doing here. In an interview on 8/14/23 at 2:15 PM, LPN H reported they worked the night LPN G provided care to R2. LPN H reported LPN G came out of R2's room, said he was wiping R2 and R2 accused him of sexually abusing her. LPN H reported they did not report the allegation because LPN G reported it to DON B. In an interview on 8/14/23 at 2:00 PM, DON B reported sometime in the last few weeks, R2 mentioned something to a CNA about LPN G doing care with her. When asked what was reported to her, DON B stated R2 said LPN G cleaned her more than he should have cleaned her. DON B reported herself and Nursing Home Administrator (NHA) A spoke with R2 the next morning, but R2 wouldn't talk to them. DON B reported R2 said she didn't have anything to say to us. In an interview on 8/14/23 at 3:13 PM, NHA A reported that morning, DON B approached her and said there was a concern that [LPN G] had cleaned her up too rough. NHA A reported herself and DON B attempted to speak with R2 that morning, but R2 did not want to speak with them. NHA A reported R2 said she was fine, felt safe here, and that was it. NHA A reported it was not reported to her that R2 alleged LPN G forcibly inserted his finger in her. NHA A reported if she were aware, she would have contacted the police, the State Agency, and interviewed all staff and residents who had contact with LPN G.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00138322. Based on observation, interview, and record review, the facility failed to investigate a sexual abuse allegation for one (Resident #2) of three reviewed, resulting in a sexual abuse allegation to not be investigated and the potential for abuse. Findings include: Review of the medical record revealed Resident #2 (R2) was admitted to the facility on [DATE] with diagnoses that included dementia, avoidant personality disorder, major depressive disorder, insomnia, and anxiety. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/23 revealed R2 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the complaint filed with the State Agency revealed The resident has made a complaint about a third shift nurse named [Licensed Practical Nurse (LPN) 'G]. She said he stuck his fingers in her vagina. She's told multiple cnas [Certified Nursing Assistants] and nurses. When it was addressed there should have been an investigation and the nurse [LPN G] has been on the floor almost every day since then. The management isn't even investigating the situation. He also has been kicked out of 2 other residents' rooms 1 which still is at the facility . The complaint further explained that facility staff, including Director of Nursing (DON) B was aware of the allegation. On 8/14/23 at 9:59 AM, R2 was observed sitting in a wheelchair in her room. When asked about the staff, R2 stated she didn't want to say anything. When asked about abuse, R2 stated, I don't want to get into it, okay. R2 reported it didn't do any good to say anything because nothing gets done. R2 refused to answer further questions. In a telephone interview on 8/14/23 at 1:02 PM, CNA D reported they were aware R2 had reported that LPN G had inappropriately touched R2 while changing her brief. CNA D reported LPN G was no longer allowed to care for R2. In a telephone interview on 8/14/23 at 1:16 PM, CNA E reported R2 had told them before that LPN G knows what he did to R2. CNA E reported they heard that LPN G was inappropriate with R2. CNA E reported they believed R2 and stated the allegation had been discussed a lot lately in the building. CNA E reported LPN G was no longer allowed in R2's room. In a telephone interview on 8/14/23 at 1:30 PM, LPN F stated, There was a time when I was in there [R2's room] when [R2] said [LPN G] was cleaning her up, taking her off the bed pan, and forcibly inserted his finger in her. LPN F reported this was a couple weeks ago around 10:00 PM and they called Director of Nursing (DON) B the following morning around 7:00 AM. In a telephone interview on 8/14/23 at 1:43 PM LPN G reported he was told not to care for R2 any longer. When asked why, LPN G reported there was a night approximately two months ago when R2 needed assistance getting off the bed pan which had spilled. LPN G reported he got tissue paper from the bathroom and wiped R2 front to back. LPN G reported R2 got mad at him and alleged that he penetrated her p*ssy. LPN G reported he informed LPN H of the allegation against him and worked the remainder of his shift and again spoke with R2 the next morning. LPN G reported the next morning, he notified a Unit Manager and DON B. LPN G reported DON B called him and discussed the allegation. LPN G reported he was not suspended. LPN G reported he was notified that he could administer medications to R2, but no longer provide direct care. LPN G reported he had since attempted to administer medications to R2 and R2 stated you are back, what are you doing here. In an interview on 8/14/23 at 2:15 PM, LPN H reported they worked the night LPN G provided care to R2. LPN H reported LPN G came out of R2's room, said he was wiping R2 and R2 accused him of sexually abusing her. LPN H reported they did not report the allegation because LPN G reported it to DON B. LPN H reported they had not been questioned about the allegation. In an interview on 8/14/23 at 2:00 PM, DON B reported sometime in the last few weeks, R2 mentioned something to a CNA about LPN G doing care with her. When asked what was reported to her, DON B stated R2 said LPN G cleaned her more than he should have cleaned her. DON B reported herself and Nursing Home Administrator (NHA) A spoke with R2 the next morning, but R2 wouldn't talk to them. DON B reported R2 said she didn't have anything to say to us. DON B reported other staff and residents were not interviewed. In an interview on 8/14/23 at 3:13 PM, NHA A reported that morning, DON B approached her and said there was a concern that [LPN G] had cleaned her up too rough. NHA A reported herself and DON B attempted to speak with R2 that morning, but R2 did not want to speak with them. NHA A reported R2 said she was fine, felt safe here, and that was it. NHA A reported other staff and residents were not interviewed. NHA A reported she did not interview LPN G, but she believed DON B did. NHA A reported it was not reported to her that R2 alleged LPN G forcibly inserted his finger in her. NHA A reported if she were aware, she would have contacted the police, the State Agency, and interviewed all staff and residents who had contact with LPN G.

This citation pertains to intake MI00134983 Based on observation, interview, and record review the facility failed to maintain dignity by allowing 1 of 4 residents reviewed to watch television while in their room resulting in the potential for residents to have feelings of frustration and anger. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility 11/27/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD), morbid obesity, type 2 diabetes, acute and chronic respiratory failure with hypoxia, asthma, metabolic encephalopathy (problem in the brain caused by chemical imbalance), bilateral hearing loss, muscle spasms, muscle weakness, restless leg syndrome, anxiety, hyperlipidemia (high fat levels in blood), atherosclerotic heart disease (plaque buildup in arteries , venous insufficiency, glaucoma, hypokalemia (low potassium levels in blood), hypomagnesemia (low magnesium levels in blood), osteoarthritis of knee, history of transient ischemic attack and cerebral infarction (stroke) without deficits, obstructive sleep apnea, gastroesophageal reflux, hypertensive heart disease with heart failure, myocardial infarction (heart attack), mitral insufficiency, and bipolar disorder. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/2023 revealed a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 06/22/2023 at 10:30 a.m. R1 was observed sitting in an electric wheelchair. R1 explained that staff at the facility would unplug her television while she was out of her the facility. She explained that she frequently leaves the facility for long periods at a time. When she returns, she is unable to watch her television because she is not able to get to the end of her bed and plug the tv into the electrical outlet. She explained that her bed is placed against the wall and she could not maneuver her wheelchair around to reach the electrical outlet. In a telephone interview on 06/22/2023 at 12:44 p.m. Licensed Practical Nurse (LPN) I explained that she has worked at the facility for approximately 6 months, and she usually works the 12-hour shift, 7pm to 7am shift. LPN I explained that she had witnessed times when the staff had pulled the plug on R1's television while R1 is not in the room. She further explained that she would just plug the television into the electrical outlet. She could not give specific dates when this occurred. When asked why the television volume was just not turned down, she explained that she could not locate the volume control on the television or could not find the television controller at the time and explained that she thought staff had the same issue. LPN I explained that she had report to Nursing Supervisor K but had not filled out a resident concern form for R1. In an interview on 06/26/2023 at 11:31 p.m. Nurse Manger K explained that she had not received any report or concern that R1's television was being unplugged so that R1 could not watch television. During record review R'1s plan of care revealed that she enjoyed participating in activities that included watching television.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00129395. Based on observation, interview, and record review, the facility failed to honor resident choices for bathing schedule in 1 of 1 resident reviewed for choices (Resident #47), resulting in bathing preferences not honored. Findings include: Resident #47 (R47) R47's Minimum Data Set (MDS) assessment dated [DATE], revealed she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 15 (13-15 Cognitively Intact), and was totally dependent for bathing care. In review of R47's medical record, under tasks, her preference for showers was on Monday and Thursday afternoons and as needed. The same document revealed in the last 14 days, R47 received a bed bath on 2/08/23, 2/11/23, and 2/12/23; none of which was on a Monday or Thursday or a shower per R47's preference. There was no documentation in R47's record that a shower was refused or changed due to resident preference. During an interview during interview with confidential staff member O, during the survey from 2/13/23 to 2/21/23, they stated there were not enough staff to meet resident needs, and they could not get showers completed per resident preferences. Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were interviewed on 2/15/23 and stated the staff do not always document showers in the residents' electronic medical record, they document on shower worksheets that are on paper and not kept in the medical record. The last 3 months of shower worksheets for R47 were requested and the following was all that was provided: 12/06/22, 12/19/22, 12/22/22, 12/26/22, and 1/12/23. In review of R47's shower worksheets on paper and bathing task in the electronic medical record, she received a shower on 1/23/23 and did not receive her next bath until 2/08/23. DON B was interviewed on 2/21/23 at 9:42 AM and stated she was not aware of staff not providing showers to residents due to staffing numbers. DON B stated she just started audits for showers and planned develop a performance improvement plan and bring the issue to the quality assurance committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act in one of 5 reviewed for abuse (Resident #8), resulting in the potential of misappropriation of resident property. Findings include: Resident #8 (R8) R8's Hospital Discharge Summary indicated he was hospitalized from [DATE] to 10/21/22. Admitting diagnoses included frequent falls at home, COVID-19 with pneumonia, failure to thrive, Alcohol use, heart, and lung disease. The same summary revealed R8 was alert and orientated to person and place, and was often forgetful. R8's Minimum Data Set (MDS) dated [DATE] revealed he admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 11 (8-12 Moderate Impairment). In review of R8's progress note dated 11/21/22 at 4:19 PM, the nurse attempted to review discharge information with resident, the resident stated that he could not go to a shelter because he could barely walk, he had no access to get his prescriptions, he was not able to repeat medications back to the nurse or when to take them after reviewing them, stated he had no access to his bank account that someone, that he named by first name, had stolen his truck and his debit cards so he was unsure what he had in his bank account. The same note indicated concerns were expressed to management staff. On 2/13/23 at 2:07 PM, R8 was observed lying in bed and stated his truck and debit card had been stolen since he had been admitted to the nursing home and he did not think anything could be done about it. Nursing Home Administrator (NHA) A was interviewed on 2/15/23 at 9:20 AM and stated R8 reported to business office that his debit card was being used and his truck was stolen. NHA A stated the business office manager had called the bank and stopped the use of R8's debit card. NHA A stated she had reported the allegation to the Ombudsman and the Ombudsman had come in to into talk to R8. NHA A stated she didn't call the police and wasn't aware she needed to report to the state agency because it happened before he was admitted here. NHA A stated R8's daughter was aware. NHA'A stated she did not complete an investigation and did not have an notes regarding the allegation. In review of general business office notes dated 12/16/22 at 12:17 PM, on 12/15/22, Business Office Manager (BOM) P met with R8 to complete a Medicaid application. R8's social security is applied to pay card and did not recall the holder. R8's friend and former housemate had his card. R8 allowed him to keep access funds for rent, food and miscellaneous items. R8 stated the friend was supposed to bring the card back to him as he was not returning to his home as of November 2022 and did not have permission to continue use. BOM P continued in the same note that she had spoken with social services and the nursing home administrator, social services was to assist in locating R8's friend. BOM P contacted social security and requested a hold until R8 had a proper payee. During an interview on 2/16/23 at approximately 11:00 AM, BOM P stated R8 was not able to tell her the name of his bank so she was not able to notify the bank to stop use of his debit card. BOM P stated she contacted social security to put a hold on his funds. BOM P stated she first heard from R8's daughter on 1/16/23 and she reported she had destroyed the card and was going to bring in bank statements, but had not as of the date of the interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00129119. Based on observation, interview, and record review, the facility failed to investigate an allegation of misappropriation of property in one of 5 reviewed for abuse (Resident #8), resulting in the potential of misappropriation of resident property and unmet needs. Findings include: Resident #8 (R8) R8's Hospital Discharge Summary indicated he was hospitalized from [DATE] to 10/21/22. Admitting diagnoses included frequent falls at home, COVID-19 with pneumonia, failure to thrive, Alcohol use, heart, and lung disease. The same summary revealed R8 was alert and orientated to person and place, and was often forgetful. R8's Minimum Data Set (MDS) dated [DATE] revealed he admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 11 (8-12 Moderate Impairment). In review of R8's progress note dated 11/21/22 at 4:19 PM, the nurse attempted to review discharge information with resident, the resident stated that he could not go to a shelter because he could barely walk, he had no access to get his prescriptions, he was not able to repeat medications back to the nurse or when to take them after reviewing them, stated he had no access to his bank account that someone, that he named by first name, had stolen his truck and his debit cards so he was unsure what he had in his bank account. The same note indicated concerns were expressed to management staff. On 2/13/23 at 2:07 PM, R8 was observed lying in bed and stated his truck and debit card had been stolen since he had been admitted to the nursing home and he did not think anything could be done about it. Nursing Home Administrator (NHA) A was interviewed on 2/15/23 at 9:20 AM and stated R8 reported to business office that his debit card was being used and his truck was stolen. NHA A stated the business office manager had called the bank and stopped the use of R8's debit card. NHA A stated she had reported the allegation to the Ombudsman and the Ombudsman had come in to into talk to R8. NHA A stated she didn't call the police and wasn't aware she needed to report to the state agency because it happened before he was admitted here. NHA A stated R8's daughter was aware. NHA'A stated she did not complete an investigation and did not have an notes regarding the allegation. In review of general business office notes dated 12/16/22 at 12:17 PM, on 12/15/22, Business Office Manager (BOM) P met with R8 to complete a Medicaid application. R8's social security is applied to pay card and did not recall the holder. R8's friend and former housemate had his card. R8 allowed him to keep access funds for rent, food and miscellaneous items. R8 stated the friend was supposed to bring the card back to him as he was not returning to his home as of November 2022 and did not have permission to continue use. BOM P continued in the same note that she had spoken with social services and the nursing home administrator, social services was to assist in locating R8's friend. BOM P contacted social security and requested a hold until R8 had a proper payee. During an interview on 2/16/23 at approximately 11:00 AM, BOM P stated R8 was not able to tell her the name of his bank so she was not able to notify the bank to stop use of his debit card. BOM P stated she contacted social security to put a hold on his funds. BOM P stated she first heard from R8's daughter on 1/16/23 and she reported she had destroyed the card and was going to bring in bank statements, but had not as of the date of the interview.

This Citation Pertains to Intake # MI00134460 Based on observation, interview, and record review the facility failed to complete an accurate level I and level II screening for one (Resident #61) of two residents reviewed for Preadmission Screening/Annual Resident Review (PASARR) resulting in the potential for the resident to not receive appropriate mental health treatment and services. Findings Included: Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 10/24/2022 with diagnoses that included myocardial infarction (heart attack), opioid use, morbid obesity, bilateral osteoarthritis (wearing down of cartilage at the end of bones), spinal stenosis (spinal narrowing) of lumbar region, radiculopathy (disease at the root of a nerve) cervical region, gastroesophageal reflux, post-traumatic stress disorder (PTSD), cocaine abuse, abnormalities of plasma proteins, anxiety disorder, gout (increase in uric acid crystallization and deposit in bone joints), hyperlipidemia (high levels of fat in the blood), hypertension, major depression, chronic pain, obstructive sleep apnea, atherosclerosis (buildup of cholesterol plaque in artery walls) of arteries of extremities bilateral legs, and insomnia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2022, revealed R61 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/07/23 at 02:07 p.m. R61 was sitting up on the side of his bed. R61 explained that he had been at the facility since October of 2022. R61 became tearful as he explained that his greatest worry was being homeless. He explained that he had been working with community services for his psychological needs because he had been diagnosed with post traumatic stress disorder (PTSD) related to serving in the military. During record review it was revealed that R61 had a 3877 Preadmission Screening (PAS) Annual Resident Review (ARR) completed 11/01/2022. The level one screen of the 3877 demonstrated section two screening criteria number one that R61 did not have a current diagnosis of mental illness. Number two of the same 3877 demonstrated that R61 had not received treatment for mental illness. Number three of the same 3877 demonstrated that R61 had not received antipsychotic or antidepressant medication in the last 14 days. Number four of the same 3877 demonstrated that R61 had not presented with evidence of mental illness. Review of the 38877 demonstrated instruction If any items 1-6 in section II are yes send to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH (Department Community Heath)-3878 if an exemption is requested. During further record review it was revealed that R61 had a 3877 Preadmission Screening (PAS) Annual Resident Review (ARR) change of condition completed 01/24/2023. The level one screen of the 3877 demonstrated section two screening criteria number one that R61 currently had a diagnosis of mental illness. Number two of the same 3877 demonstrated that R61 had received treatment for mental illness. Number three of the same 3877 demonstrated that R61 had received antipsychotic or antidepressant medication in the last 14 days. Number four of the same 3877 demonstrated that R61 had not presented with evidence of mental illness. Review of the 38877 demonstrated instruction If any items 1-6 in section II are yes send to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. A DCH-3878 could not be found in R61 medical record. During record review of R61's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/31/2022 (5-day MDS), section N-(Medications) revealed R61 had received anti-depressant medication seven times during the assessment 14 day look back period. In an interview on 02/14/2023 at 12:52 p.m. Social Worker (SW) G explained that R61 had a 3877 Preadmission Screening (PAS) Annual Resident Review (ARR) completed 11/01/2022. Social Worker G explained that this PASARR was not accurate and explained that R61 clearly had mental illness as evidence in his medical record. SW G explained that R61 had a PASARR change of condition completed 01/24/23 that identified that R61 had mental illness and had received antidepressants. SW G explained that a 3878 was necessary but could not locate one in the medical record. SW G could not explain why R61's 3877 (completed on 11/01/2022) was not accurate and could not explain why an accurate 3877 was not completed prior to 01/24/22. SW G could not explain why a 3878 had not been completed after the 3877 was completed on 01/24/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake # MI00134460 Based on interview and record review the facility failed to develop and implement a baseline care plan for one (Resident #61) of sixteen residents reviewed, resulting in the potential failure of those residents to receive effective and person-centered care that meets professional standard of quality care. Findings Include: Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 10/24/2022 with diagnoses that included myocardial infarction (heart attack), opioid use, morbid obesity, bilateral osteoarthritis (wearing down of cartilage at the end of bones), spinal stenosis (spinal narrowing) of lumbar region, radiculopathy (disease at the root of a nerve) cervical region, gastroesophageal reflux, post-traumatic stress disorder (PTSD), cocaine abuse, abnormalities of plasma proteins, anxiety disorder, gout (increase in uric acid crystallization and deposit in bone joints), hyperlipidemia (high levels of fat in the blood), hypertension, major depression, chronic pain, obstructive sleep apnea, atherosclerosis (buildup of cholesterol plaque in artery walls) of arteries of extremities bilateral legs, and insomnia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2022, revealed R61 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview 02/13/2023 at 01:54 p.m. R61 was observed sitting on the side of his bed coloring a picture. R61 explained that he did like activities. R61 explained that he had attended an art activity and but is favorite pass time was to color pictures. During record review R61's base line care plan did not contain any problem statement that addressed his activity interest. No care plan interventions were present that listed what specific activity events or intertest R61 desired to complete or attend. Review of the R61's Visual Bedside [NAME] Report (resident care guide used by direct care staff) did not list any activity programs or activity interest. During record review R61's Activity Evaluation completed 10/25/2022 demonstrated that he had a very important interest to listen to music that he preferred, a very important interest in keeping up to date with recent news, and an very important interest to complete his favorite activities. The Activity Evaluation demonstrated R61 had interest in cards (euchre and uno), arts and photography, football, motorcycle racing, pop music, soft rock music, author preference [NAME] King, television shows American Pickers, Pawn Stars and news, and his favorite type of movies was action and comedy. The Activity Evaluation also list that R61 required assistance to attend activities, received one to one visit, and was to receive leisure cart activities. In an interview on 02/14/2023 at 09:45 a.m. Certified Nursing Assistant (CNA) R explained that she determines which activities a resident attend by looking at the Activity Calendar that was posted in each resident's room. CNA R could not list what specific activities R61 preferred to attend but explained that she would just inquire with the resident. CNA R explained that the Visual Bedside [NAME] Report (resident care guide used by direct care staff) sometimes listed the activities of choice and sometimes it did not. CNA R confirmed that R61's Visual Bedside [NAME] Report did not list any activities. In an interview on 02/15/2023 at 10:36 p.m. Activity Director Q explained that R61 did not have an activity plan of care completed on admission. Activity Director Q confirmed R61's assessment of activity interest had been completed on his Activity Assessment which was completed 10/25/2022. She explained that R61's plan of care was one of the care plans of the residents that she had not completed yet. Activity Director Q explained that she is expected to complete an activity care plan with the base line care plan which is to be completed within 48 hours. Activity Director Q could not explain why R61's base line plan of care was not completed. In an interview on 02/15/2023 at 10:51 a.m. Nursing Home Administrator (NHA) A explained that it was her expectation that residents should have a base line care plan to include the resident's activity interest listed in the residents person centered plan of care. She further explained that this should be completed shortly after the time of admission but certainly within 48 hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #22 (R22) Review of an admission Record revealed Resident #22 (R22) admitted to the facility on [DATE] with pertinent diagnoses which included alcohol induced chronic pancreatitis, chronic obstructive pulmonary disease, abnormality of gait and mobility, unspecified severe protein-calorie malnutrition, dementia with unspecified severity with other behavioral disturbances, orthostatic hypotension, epilepsy, anemia, and prediabetes. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/5/23, reflected R22 scored 12 of out 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R22 required limited assistance one person to ambulate and perform personal hygiene activities, transfer, and dressing but extensive assistance of one person to toilet. Review of R22's Electronic Medical Record also revealed that R22 had a history of falls. In an observation on 02/13/23 at 01:52 PM, R22 was observed in his room, sleeping. R22's call light was on the floor and multiple spills of a red liquid were noted on the floor. Four empty red soda bottles were observed in his room. In an interview on 02/14/23 at 10:50 AM, R22 reported that he gets tired of sitting, I fell last night. The [Certified Nursing Assistants] take too long to come, sometimes I wait up to an hour. I eventually get up but I [am not] supposed to . There have been times I wet myself in bed and they had to clean me up. Review of R22's [NAME] (care plan for Certified Nurse's Assistants) interventions included ensuring walker was at bedside at night for safe transfers and ambulation, position bedside table next to wheelchair to allow open area, signage to use call light, and therapy was currently working with resident. Additionally, review of R22's progress notes indicted that on 2/13/2023, R22's therapy was discontinued due to highest practical level achieved. R22's risk for falls care plan dated 4/5/22, indicated his goal was to reduce risk of falls. An intervention dated 4/5/22 revealed have commonly used articles in place .bed in low position, offer assistance for transferring and ambulation, and reinforce the need to call for assistance, an intervention dated 7/27/22 reacher (handheld took used to increase the range of a person's reach when grabbing objects) to be provided for assistance grabbing items, an intervention dated 7/30/22 signage to use call light, an intervention dated 9/30/22 ensure walker is at bedside at night ., an intervention dated 10/6/22 offer (every two hours) toileting, an intervention dated 10/10/22 bedside commode in room, I often prefer for it [bedside commode] to be taken out of room ., an intervention dated 11/11/22 signage on walker to remind me to call for assistance, an intervention dated 12/16/22 revealed several attempts to move R22's room near the nursing station with multiple refusals, an intervention dated 1/12/22 educate on proper equipment use and safety with transferring, an intervention dated 1/22/23 therapy is currently working with resident, and an intervention dated 2/6/23 educate me on sitting up slowly and waiting a short period of time before transferring. In an interview on 02/14/23 at 02:22 PM, R22 was seated in a wheelchair and watching television. R22 inquired about this surveyor's name and job description which was discussed earlier in the day. Observed no sign on walker, no reacher in the room, and no bedside commode in the room. R22 again expressed that he waits for up to an hour for any help and that he cannot wait that long for help. R22 denies having staff come in and ask him if he had to use the bathroom every two hours and reported he would go to the nurse's station or out in hall to get help because it's better that way. Review of an Incident report dated 4/6/22 at 7:15 PM revealed R22 was discovered on the floor. The same report indicated that R22 had attempted to ambulate to the bathroom when he became dizzy and fell. R22 was transported to the Emergency Department. Immediate action was listed as adding signs to room to remind resident to use call light and educate on call light use. An intervention was added to the care plan on 4/6/22 that revealed send resident to hospital post fall. The intervention was resolved on 7/26/22. No intervention for education or signs were added to the care plan. Review of an Incident report dated 4/9/22 at 7:15 PM revealed R22 ambulated into the hallway with his walker when he was seen going slowly to the floor .and went into the laying position. The same report indicated that R22 was educated on sitting on the side of the bed before standing and educated on call light use. Record review revealed that these interventions were not added to the care plan on this date for this incident. An intervention was added to the care plan on 4/9/22 that revealed orthostatic blood pressures to be completed for three days . and the intervention was resolved on 7/27/2022. Record review revealed that the three days of orthostatic blood pressures (blood pressures taken in the lying position, sitting position, and standing position) were not completed. Review of an Incident Report dated 7/27/22 at 2:13 AM revealed R22 was discovered lying on the floor in front of a small dresser at 1:30 AM. R22 stated he was attempting to use a urinal, lost balance, and fell to the ground. The same report indicated R22 was reeducated on call light use and R22's call light was placed near him. Review of the Care Plan revealed an intervention of providing R22 with a reacher was initiated. No reacher was observed in R22's room. Review of an Incident Report dated 7/30/22 at 11:17 AM revealed R22 was discovered on the floor and had complaints of rib pain. R22 was sent to a local hospital for evaluation. The same Incident Report revealed an immediate intervention of adding signage to remind R22 to use the call light. R22's Care Plan was updated with signage as an intervention. Review of an Incident Report dated 9/18/22 at 2:15 PM revealed R22 sustained a fall while exiting a vehicle in the parking lot. The same report revealed an intervention of ensuring R22 had his walker when he took a leave of absence (LOA) from the facility. Review of R22's Care Plan revealed an intervention for taking a walker while on LOA was added on 9/20/22. Review of an Incident Report dated 9/21/22 at 5:45 AM revealed R22 had reported to staff that he had a fall in his room. Staff discovered an abrasion (cut) on R22's left knee. R22 was sent to a local hospital for evaluation. The same report revealed that the immediate action was to cleanse the wound. Review of the Care Plan revealed that an intervention implemented on 9/28/22 for orthostatic blood pressures, every shift, for three days. Review of the blood pressures for R22 revealed that the orthostatic blood pressures were not completed. Review of an Incident Report dated 9/30/22 at 1:00 AM revealed R22 was observed sitting on buttocks with back resting against bed with knees bent and hands on floor. The same incident report revealed that the immediate action taken was to provide care. Review of the Care Plan revealed an intervention of ensuring R22's walker was at his bedside at night for safe transfers and ambulation and a medication review was added. Another order was placed for orthostatic blood pressures every day shift, every month(s) starting on the 1st for one day(s). Review of R22's blood pressures revealed that only one orthostatic blood pressure was obtained for the date of 10/1/22. Review of an Incident Report dated 10/7/22 at 9:30 AM revealed R22 experienced lightheadedness and blurred vision while transferring to a bedside commode. A Certified Nursing Assistant witnessed R22 sit down on the floor. The same report revealed R22 was sent to a local hospital for evaluation. Review of the Care Plan revealed an intervention of bedside commode to be placed at bedside. [R22] often prefers to have it taken out of room until I ask for it initiated on 10/10/22. Review of an Incident Report dated 10/29/22 at 3:00 PM indicated that R22 had an unwitnessed fall while transferring himself to the bathroom. The same report revealed the immediate action taken was to provide care. Review of the Care Plan indicated another post fall medication review added as an intervention. Review of an Incident Report dated 11/7/22 at 9:41 AM revealed R22 had an unwitnessed, self-reported, fall while ambulating to the bathroom. The same Incident Report indicated R22 felt faint and fell to his knees. The report indicated the immediate action was applying an ice pack to R22's knee. Review of the Care Plan revealed an intervention was added on 11/11/22 to add signage to walker to remind to call for assistance. No signage on R22's walker was observed. Review of an Incident Report dated 11/19/22 at 11:30 AM revealed R22 sustained a fall while self-transferring himself from wheelchair to bed. The same report revealed the immediate action taken was to reinforce and re educating the need to call for assistance. Review of the Care Plan revealed an intervention of 30-minute checks until room is able to be moved was added on 11/21/22. This intervention was resolved on 12/16/22 but no room change occurred. Review of an Incident Report dated 12/2/22 at 4:30 PM revealed R22 sustained a self-reported fall where he reported that he lost balance when getting up from his wheelchair. The same report revealed that the immediate intervention was to re educate on calling for assistance. Review of the Care Plan revealed an intervention of position bedside table next to wheelchair to allow open area was initiated on 12/2/22. Review of an Incident Report dated 1/12/23 at 5:52 AM revealed R22 reported a fall in his room. The same report revealed the immediate action taken was to provide care. Review of R22's Care Plan revealed an intervention of education on proper equipment use and safety with transferring was initiated on 1/12/23. Review of an Incident Report dated 2/6/23 at 7:11 AM revealed R22 had a self-reported fall while attempting to transfer himself from the wheelchair to the bathroom. Review of the same report revealed the immediate intervention was encouraging R22 to call for assistance. Review of the Care Plan revealed an intervention of educate me on sitting up slowly and waiting a short time before transferring was initiated on 2/6/23. In an interview on 02/14/23 at 02:27 PM, Licensed Practical Nurse (LPN) L reported R22 tends to be forgetful, we educate and educate and reeducate but he does not retain. In an interview on 02/15/23 at 08:15 AM, Registered Nurse (RN) N reported R22's cognition and memory are sketchy . it's common that [R22] doesn't remember who I was the day before. [R22] is forgetful. In an observation and interview on 02/16/23 at 09:40 AM, R22 was observed opening the door to his room, peering out into the hallway, and then attempted to ambulate to his bed without any assistive devices. While ambulating to his bed, R22 was using the walls and the back of the wheelchair to make his way to the bed. R22 reported that he did not need anything, he just woke up and wanted his door open. This event went unwitnessed by staff. In an interview on 02/15/23 at 09:20 AM Director of Nursing (DON) B reported that the process for falls was to assesses the resident, implement an immediate intervention or action and then the team will go over the fall in clinical meetings every morning to do a thorough investigation of the fall. Care plans are updated during the clinical meetings in the mornings. DON B reported that she did not realize that his fall history was so extensive after reviewing the falls during the interview. DON B reported that R22 was forgetful at times and an attempt to appoint R22 a guardian was discussed with R22, but he refused. When asked about the reacher and the bedside commode not being in the room with R22, DON B reported that R22 would not use the reacher and bedside commode. When questioned about some of the fall intervention that were in place on the Care Plan, she agreed that once an intervention was no longer being implemented, it should no longer be considered an active intervention and should be removed from the care plan. Resident #263 (R263) Review of an admission Record revealed Resident #263 (R263) admitted to the facility on [DATE] with pertinent diagnoses which included two-part displaced fracture of surgical neck of right humerus subsequent encounter for fracture with routine healing, fall, asthma, unspecified severe protein-calorie malnutrition, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/12/23, reflected R263 scored 15 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the [NAME] (the [NAME] is a medical information system used by nursing staff to communicate important information about the resident) revealed R263 did not walk and required extensive assistance by two or more staff to perform most activities of daily living such as transferring and toileting. Review of a progress note on 2/8/23 revealed that R263 recently underwent surgery for percutaneous pinning of the right pelvis from a fall with fracture that occurred outside the facility that involved the right humeral neck and right femoral neck. In an observation on 02/13/23 at 09:59 AM, R263 was resting in bed, watching television, with her legs hanging off the left side of the bed. At the time the facilities call light system was not function, so the facility provided all residents with handheld bells to ring if assistance was needed. R263's bell was observed on the nightstand, out of reach of the resident. R263's bed was elevated at med thigh level. R263's risk for falls care plan dated 2/6/23, revealed R263 was at a risk for falls related to decreased mobility, history of falling with right humerus fracture and right femur fracture, old cerebral vascular accident with right hemiparesis, low back pain, neuropathy, and medication side effects. The same care plan revealed fall interventions dated 2/6/23 have commonly used articles within easy reach, maintain bed in lowest position, observe for s+sx (signs and symptoms) of medication side effects and report to physician as needed, and reinforce the need to call for assistance. In an observation and interview on 02/14/23 at 12:08 PM, R263 was resting in bed watching television. R263 was receiving intravenous (IV) solution at the time and the bed was in a low position. R263's call light out of reach from resident, tied to the IV pole. A staff member entered the room during the observation and offered a lunch tray to R263, which was refused. R263 reported that she fell two nights ago while attempting to transfer to her wheelchair to get into the bathroom, unassisted. R263's risk for falls care plan dated 2/6/23, revealed R263 was at a risk for falls related to decreased mobility, history of falling with right humerus fracture and right femur fracture, old cerebral vascular accident with right hemiparesis, low back pain, neuropathy, and medication side effects. The same care plan revealed fall interventions dated 2/6/23 have commonly used articles within easy reach, maintain bed in lowest position, observe for s+sx (signs and symptoms) of medication side effects and report to physician as needed, and reinforce the need to call for assistance. Review of an Incident report dated 2/12/23 at 11:00 AM revealed R263 was discovered lying on back in front of wheelchair. The immediate action taken was to assess range of motion, check vitals, and assist back to bed. The same incident report revealed R263 had no complaints of pain and was not sent to the hospital for further evaluation. Review of a progress note on 2/14/2023 at 09:01 revealed R263 returned from a local hospital via stretcher on 2/12/23 at approximately 5pm diagnosis- fall Non intractable headache and hip pain . follow up with surgeon. In an interview on 02/15/23 at 09:20 AM Director of Nursing (DON) B reported that the process for falls was to assesses the resident, implement an immediate intervention and then the team will go over the fall in clinical meetings every morning to do a thorough investigation of the fall. Care plans are updated during the clinical meetings in the mornings. DON B reported that the initial intervention after R63's fall was to ask for assistance when needed from transfers. DON B reported that R263 was ultimately sent to the hospital after the 2/12/23 fall due to hip pain. Review of R263's Care Plan on 2/15/23 revealed that no additional fall interventions were added to the falls Care Plan after the fall that occurred on 2/12/23. Resident #210 (R210) Review of the medical record revealed R210 was admitted to the facility 02/08/2023 with diagnoses that included protein calorie malnutrition, asthma, tachycardia, copper deficiency, dietary zinc deficiency, radiculopathy (disease at the root of nerves) cervical region, anesthesia (absence of feeling) of skin, disorientation, disease of the spinal cord, disorders of fluid and electrolyte balance, anxiety, hypokalemia (low potassium), alcohol use, cannabis use, vitamin B-12 deficiency, cyclical vomiting syndrome, hypoglycemia (low blood sugar), migraine, nicotine dependence, functional diarrhea, and opioid use. The facility Social Services Assessment and History, completed 02/14/23, demonstrated that R210 was orientated to person, place, time, and situation. During observation on 02/13/2023 at 08:59 a.m. R210 was lying in bed and her eyes were closed and observed unlabored respirations. Observed water, orange juice, and oatmeal all over the floor of her room. No facility staff were present in or near R210's room. During observation and interview on 02/13/2023 at 11:08 a.m. R210 was lying in bed. All previous liquid and food items were not present on the floor. R210 explained that she had concerns regarding her sanity and she was embarrassed by her behavior this morning. R210 explained that she was having personal issues with her mother and sister currently and she thought that was the cause of her throwing items in the room. R210 explained that she had a history bipolar disorder and that she does need to see psychiatric services. Review of 210's medical record demonstrated a care plan for depression. No plan of care was present for anxiety. Interventions listed on the plan of care demonstrated Monitor/record occurrence of for targeted behavior symptoms and document per facility protocol. No interventions were documented in R210's plan of care that listed specific behaviors or specific interventions to provide to R210 during those behaviors. In an interview on 02/21/2023 at 08:42 a.m. Minimum Data Set (MDS) Nurse V verified that R210 had a diagnosis of anxiety. She explained that R210 appeared anxious when she had met with the resident during her initial admission interview. When asked if R210 demonstrated any behaviors, MDS Nurse V explained that R210 was anxious for sure but could not list specific behaviors exhibited. MDS Nurse V explained that R210 should have a care plan related to her behaviors and anxiety. MDS Nurse V explained that the Social Worker would be the person responsible for completing or adding that care plan a care plan for anxiety and the appropriate interventions. In an interview on 02/21/2023 at 10:45 a.m. Social Worker (SW) G confirmed that R210 had a diagnosis of anxiety. She also confirmed that R210 did no have a care plan that addressed R210's anxiety or behavior. SW G explained that she was aware of the incident that occurred on 02/13/2023. SW G explained that R210 did not have any interventions listed in her plan of care that addressed those behaviors because those behaviors had not been exhibited since her time of admission. SW G could not explain why anxiety had not been added to R210's plan of care or why interventions had not been added to address the behaviors after seven days. Based on observation, interview and record review, the facility failed to revise the care plan for 3 residents (#'s 22, 210, and 263) and failed to involve the participation care planning process for one resident (#40) of 16 reviewed for care plans, resulting in unmet care needs. Findings include: Resident #40 According to the clinical record including the Minimum Data Set (MDS) with as Assessment Reference Date (ARD) of 1/12/23, Resident # 40 (R40) was an [AGE] year old female admitted to the facility with diagnoses that included depression, bilateral hearing loss and dementia. R40 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status. On 2/13/23 at 9:10am R40 was observed sitting in her room watching television, R40 engaged in conversation without difficulty. R40 voiced complaints about the food, specifically food preferences not being honored, R40 also stated she was in need of new glasses. When queried if she had spoken to anyone about her concerns, R40 stated she had told the nurses but it seemed to end there. When queried if it had been brought up in care conference ( a quarterly meeting held with the interdisciplinary team to discuss the plan of care), R40 had reported she had not been to or attended a care conference. Further review of R40's clinical record reflected a care conference was held on 1/19/23. The record reflected R40's Durable Power of Attorney (DPOA) was invited and did not attend, there was no evidence that R40 was invited to the meeting. After the 1/19/23 care conference, further record review determined care conference was not held with the quarterly assessments, the conference held prior to the 1/19/23 was held 10 months earlier on 3/23/22. On 02/14/23 at 10:44 AM, during an interview with Social Worker (SW) G who acknowledged care conference had not been held quarterly, and R40 had a 10 month gap in meetings. When R40's concerns related to dietary issues and R40's request for new eye glasses , SW G stated she was unaware of R40's concerns. When queried why R40 had not been invited to her own care conference in 1/19/23, SW G stated she invited R40's DPOA who declined to attend. When queried if R40 was able to articulate her needs, thoughts, likes, dislikes etc despite having a DPOA SW G agreed R40 could communicate effectively and had ability to participate in her own plan of care and communicate needs such as needing new eye glasses and having concerns that need to be addressed with dietary staff. According to the undated facility policy titled Resident Participation - Assessment/Care Plans 1. The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake number MI000134041. Based on observation, interview, and record review the facility failed to provide activities of daily living for one of 4 sampled residents (Resident #12), resulting in failure to give showers. Findings include: Resident #12 (R12) Review of an admission Record revealed Resident #12 (R12) admitted to the facility on [DATE] with pertinent diagnoses which included paraplegia, unspecified urethral stricture, cutaneous abscess of groin, and muscle weakness. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/23/23, reflected R12 scored 14 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R12 did not walk and requires extensive assistance of two or more people to transfer, toilet, and maintain person hygiene. In an observation and interview on 02/13/23 at 09:20 AM, R12 reported that he had been a paraplegic since the 1980's and lived at home prior to admission to the facility. R12 reported that he could navigate and care of himself just fine, including taking care of his indwelling catheter, navigating in a wheelchair, and doing basic hygiene at home. R12 expressed frustration in the lack of care he had been receiving at the facility, including showers. R12 reported that he does not get showers .and is unaware of a shower schedule. [R12] has had two showers since he got here and a bed bath maybe 2 times .bed baths are just quick a wipe down with wash clothes . I took a bath every day at home. R12 reported that he had told people (about not getting showers) so many times it doesn't make sense . [R12] reported it last night and [the nurse] said they were going to make a report .every time they clean me up, I still have bowel movement on me. I feel nasty. R12 was wearing a hospital gown at the time of the interview. Review of the Bathing Task Report revealed that R12 was scheduled to receive showers 2 times a week, on Monday and Friday afternoon. Review of the January 2023 Bathing Task Report for R12 revealed 3 showers were administered for the month of January. Multiple refusals documented. On Monday, January 16th the task report revealed no shower was given to the resident. On Friday, January 23rd the task report revealed no shower was given to the resident. On Friday, January 27th the task report revealed no shower was given to the resident. On Monday, January 30th the task report revealed no shower was given to the resident. Review of the February 2023 Bathing Task Report for R12 revealed one shower was administered for the month of February. Multiple refusals documented. On Friday, February 3rd the task report revealed no shower was given to the resident. On Monday, February 6th, the task report revealed no shower was given to the resident. On Friday, February 10th the task report revealed no shower was given to the resident. On Monday, February 13th the task report revealed no shower was given to the resident. In an interview on 02/14/23 at 11:09 AM, R12 reported that finally got a shower and was very thankful. When asked if R12 ever refuses showers, he reported that he had not refused a shower and he isn't even offered them to be able to refuse them. In an interview on 02/15/23 at 10:46 AM, DON B reported that it was the expectation that showers were to be given and shower days and bed baths are an everyday task except on shower days. Hair washing does not happen when residents are given bed baths, hair washing is preformed on shower days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI000134460 During observation, interview, and record review the facility failed to provide failed to provide meaningful, individualized activities for one resident (#61) of two residents reviewed for activities resulting in the potential for depression, boredom, and feelings of lack of self-worth. Findings Included: Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 10/24/2022 with diagnoses that included myocardial infarction (heart attack), opioid use, morbid obesity, bilateral osteoarthritis (wearing down of cartilage at the end of bones), spinal stenosis (spinal narrowing) of lumbar region, radiculopathy (disease at the root of a nerve) cervical region, gastroesophageal reflux, post-traumatic stress disorder (PTSD), cocaine abuse, abnormalities of plasma proteins, anxiety disorder, gout (increase in uric acid crystallization and deposit in bone joints), hyperlipidemia (high levels of fat in the blood), hypertension, major depression, chronic pain, obstructive sleep apnea, atherosclerosis (buildup of cholesterol plaque in artery walls) of arteries of extremities bilateral legs, and insomnia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2022, revealed R61 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview 02/13/2023 at 01:54 p.m. R61 was observed sitting on the side of his bed coloring a picture. R61 explained that he did like activities. R61 explained that he had attended an art activity and but is favorite pass time was to color pictures. During record review R61's base line care plan did not contain any problem statement that addressed his activity interest. No care plan interventions were present that listed what specific activity events or intertest R61 desired to complete or attend. Review of the R61's Visual Bedside [NAME] Report (resident care guide used by direct care staff) did not list any activity programs or activity interest. During record review R61's Activity Evaluation completed 10/25/2022 demonstrated that he had a very important interest to listen to music that he preferred, a very important interest in keeping up to date with recent news, and an very important interest to complete his favorite activities. The Activity Evaluation demonstrated R61 had interest in cards (euchre and uno), arts and photography, football, motorcycle racing, pop music, soft rock music, author preference [NAME] King, television shows American Pickers, Pawn Stars and news, and his favorite type of movies was action and comedy. The Activity Evaluation also list that R61 required assistance to attend activities, received one to one visit, and was to receive leisure cart activities. During record review of R61's Point of Care of activities documentation for November 2022 (30 days) individual activities demonstrated 11 times of chronical newspaper, two times for adult coloring, two times for TV, and one time for snacks. Documentation for November 2022 (30 days) group activities demonstrated four times for adult coloring, three times for movie, one time for bingo, three times for active games, and one time for snacks. Point of Care for December 2022 (31 days) individual activities demonstrated seven times for adult coloring, three times for chronical newspaper, one time for trivia, one time for DVD, two times for TV, one time for nail care, and one time for snack. Point of Care group activities for December 2022 (31 days) demonstrated five times for Movie, six times for bingo, one time for music/entertainment, three times for arts and crafts, one time for holiday party, and one time for snacks. Documentation for January (31 days) 2023 individual activities demonstrated one for cards, three for TV, and one for snacks. Documentation for January 2023 (31 days) group activities demonstrated 11 times for bingo, three times for education trivia, three times for arts and crafts, one time for music entertainment, and one time for snack. Documentation for February 2023 (until 02/14/2023) individual activities demonstrated four times for tv. Documentation for February 2023 (until 2/14/2023) group activities demonstrated one time for cards, three times for bingo, one time for education trivia, three times for arts and crafts, one time for exercise, one time for current events, and one time for snack. In an interview on 02/14/2023 at 09:45 a.m. Certified Nursing Assistant (CNA) R explained that she determines which activities a resident attend by looking at the Activity Calendar that was posted in each resident's room. CNA R could not list what specific activities R61 preferred to attend but explained that she would just inquire with the resident. CNA R explained that the Visual Bedside [NAME] Report (resident care guide used by direct care staff) sometimes listed the activities of choice and sometimes it did not. CNA R confirmed that R61's Visual Bedside [NAME] Report did not list any activities. In an interview on 02/15/2023 at 10:36 p.m. Activity Director Q explained that R61 did not have an activity plan of care completed on admission. Activity Director Q confirmed R61's assessment of activity interest had been completed on his Activity Assessment which was completed 10/25/2022. Activity Director Q explained that items that R61 had high interest in card games and music but had not been conducted on a regular basis during his stay at the facility. Activity Director Q could not explain why R61's activities program was not being individualized. She explained that R61's plan of care was one of the care plans of the residents that she had not completed yet. Activity Director Q explained that she is expected to complete an activity care plan with the base line care plan which is to be completed within 48 hours. Activity Director Q could not explain why R61's base line plan of care was not completed. In an interview on 02/15/2023 at 10:51 a.m. Nursing Home Administrator (NHA) A explained that it was her expectation that residents should have a base line care plan to include the resident's activity interest listed in the residents person centered plan of care. She further explained that this should be completed shortly after the time of admission but certainly within 48 hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review facility facilied to provide dressing changes as ordered for 1 (R12) of two reviewed for dressing changes resulitng in the potential of delay in healing. Findings include: Resident #12 (R12) Review of an admission Record revealed Resident #12 (R12) admitted to the facility on [DATE] with pertinent diagnoses which included paraplegia, unspecified urethral stricture, cutaneous abscess of groin, and muscle weakness. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/23/23, reflected R12 scored 14 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R12 did not walk and requires extensive assistance of two or more people to transfer, toilet, and maintain person hygiene. In an observation and interview on 02/13/23 at 09:20 AM, R12 reported that he had been a paraplegic since the 1980's and lived at home prior to admission to the facility. R12 reported that he could navigate and care of himself just fine, including taking care of his indwelling catheter, navigating in a wheelchair, and doing basic hygiene at home. R12 expressed frustration in the lack of care he had been receiving at the facility, including showers, indwelling foley catheter care, and wound dressing changes. In an interview on 02/13/23 at 09:05 AM, R12 reported that the wound doctor comes and checks me over on Fridays. The [Wound Doctor] said one the nurses are supposed to change my wound . no nurses change my wound . every now and then you might get [a nurse] to come in and do it. [The Wound Doctor] said the [abscess] was opening up again because it wasn't getting treated right . Review of the wound care orders for R12 revealed instructions to wash right groin and scrotum with wound wash and pat dry. Apply dermaseptin (a medication used to form a barrier on the skin to protect it from irritants/moisture) and cover with an abd (a thick absorbent dressing used to manage heavy draining wounds or large wounds) twice a day. Review of a Wound Care note on 02/03/2023 revealed the Wound Nurse Practitioner was at the facility for a visit for a wound care evaluation and follow up related to right groin abscess. According to the note, Wound status is stalled. Treatment continues to be the application of DermaSeptin cream as well as ABD pad . Dressings addressed . In an interview on 02/15/23 at 08:39 AM, Nurse Practitioner (NP) S reported that the healing was stalled for the past couple of weeks . The greatest concern is keeping the area clean. The current order for the wound was to clean the wound, apply dermaspetic, and apply an abd pad for drainage . the wound was closed, but it has opened slightly if i have concerns I document dressings addressed . which I did on my previous visit. Review of the Medication Administration Record on 2/15/23 revealed that the dressing order for R12 had been performed that morning by Registered Nurse (RN) N. In an interview on 2/15/23 at 07:51 AM, R12 reported that the dressing change had not been completed on the groin abscess that morning. In an observation and interview on 02/15/23 at 07:54 AM, R12 gave permission to vuew view groin abscess. Certified Nursing Assistant (CNA) R assisted with the observation of the abscess which showed no dressing on it at the time of observation. CNA R reported that nursing is responsible for dressing changes. In an interview on 02/15/23 at 08:11 AM, RN N reported that the process for the abscess wound care was to clean and put demaseptic on it every shift .no bandage or dressing is required . RN N reported that R12's dressing had not been done yet this morning even though RN N marked it off as done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist in access to hearing services in one of two residents reviewed for communication (Resident #33), resulting in unmet needs. Findings include: Resident #33 (R33) R33 was observed lying in bed and stated he had hearing aids, but his hearing aids were broken. R33 stated he had received his hearing aids from the Veteran's Administration (VA) and would like to return there for services. R33's Minimum Data Set (MDS) dated [DATE] revealed he admitted to the facility on [DATE]. R33 had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 14 (13-15 Cognitively Intact). Ear Care Exam dated 01/03/23 indicated R33 reported he had hearing aids for both ears from the VA but stated he had not used then for a year and a half because they did not work. The same document indicated R33 may benefit from a hearing test from an audiologist for hearing loss. Social Worker G was interviewed on 2/21/23 at 10:45 AM and stated she wasn't aware R33 wanted to see the VA for audiology services.

This citation pertains to Intake MI00134460. Based on observation, interview, and record review the facility failed to provide foot care services for one resident (#61) of one resident reviewed for foot care resulting in long toenails and the potential for discomfort. Findings Included: Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 10/24/2022 with diagnoses that included myocardial infarction (heart attack), opioid use, morbid obesity, bilateral osteoarthritis (wearing down of cartilage at the end of bones), spinal stenosis (spinal narrowing) of lumbar region, radiculopathy (disease at the root of a nerve) cervical region, gastroesophageal reflux, post-traumatic stress disorder (PTSD), cocaine abuse, abnormalities of plasma proteins, anxiety disorder, gout (increase in uric acid crystallization and deposit in bone joints), hyperlipidemia (high levels of fat in the blood), hypertension, major depression, chronic pain, obstructive sleep apnea, atherosclerosis (buildup of cholesterol plaque in artery walls) of arteries of extremities bilateral legs, and insomnia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2022, revealed R61 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/13/2023 at 02:03 p.m. R61 was observed setting on the side of his bed. R61 explained that he had a podiatry appointment prior to coming to the facility. R61 explained that he had requested a podiatry appointment because his recovery was taking longer than expected. R61 did not know who he told regarding this request but knew he had signed a document requesting the services During record review R61's medical record contained a facility document entitled Treatment Consent Form. This document was signed by R61 on 10/24/2023. On that document it demonstrated that R61 wanted to receive Podiatry Consultation Services. During observation and interview on 02/14/2023 at 01:08 p.m. R61 was observed setting on the side of his bed. R61's lower extremities were observed, and toenails were long (past end of toes). R61 explained that no one has assisted him yet with his toenails but that the facility knew he needed podiatry services. In an interview on 02/14/2023 at 10:59 a.m. Social Worker (SW) G explained that she was responsible for notifying the podiatrist of resident that required their services. SW G explained that podiatry services come on a regular basis to the facility and that the next visit is scheduled for Mach of 2023. She explained that she provides a list of residents needing services the week that podiatry services are to be in the building. SW G explained that she did not have a list for the next scheduled visit at this time. SW G explained that R61 was not placed on the list at an earlier time because he was receiving Medicare Services and had only recently changed to staying as a long-term care resident. She further explained that it would be necessary for him to see his own podiatrist for services prior during his stay as a Medicare resident. SW G could not explain why those external podiatry services had not been arranged or provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement interventions to prevent falls for two (Resident #22 and #263) of seven reviewed for accidents, resulting in the potential for falls and major injury. Resident #22 (R22) Review of an admission Record revealed Resident #22 (R22) admitted to the facility on [DATE] with pertinent diagnoses which included alcohol induced chronic pancreatitis, chronic obstructive pulmonary disease, abnormality of gait and mobility, unspecified severe protein-calorie malnutrition, dementia with unspecified severity with other behavioral disturbances, orthostatic hypotension, epilepsy, anemia, and prediabetes. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/5/23, reflected R22 scored 12 of out 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R22 required limited assistance one person to ambulate and perform personal hygiene activities, transfer, and dressing but extensive assistance of one person to toilet. Review of R22's Electronic Medical Record also revealed that R22 had a history of falls. In an observation on 02/13/23 at 01:52 PM, R22 was observed in his room, sleeping. R22's call light was on the floor and multiple spills of a red liquid were noted on the floor. Four empty red soda bottles were observed in his room. In an interview on 02/14/23 at 10:50 AM, R22 reported that he gets tired of sitting, I fell last night. The [Certified Nursing Assistants] take too long to come, sometimes I wait up to an hour. I eventually get up but I [am not] supposed to . There have been times I wet myself in bed and they had to clean me up. Review of R22's [NAME] (care plan for Certified Nurse's Assistants) interventions included ensuring walker was at bedside at night for safe transfers and ambulation, position bedside table next to wheelchair to allow open area, signage to use call light, and therapy was currently working with resident. Additionally, review of R22's progress notes indicted that on 2/13/2023, R22's therapy was discontinued due to highest practical level achieved. R22's risk for falls care plan dated 4/5/22, indicated his goal was to reduce risk of falls. An intervention dated 4/5/22 revealed have commonly used articles in place .bed in low position, offer assistance for transferring and ambulation, and reinforce the need to call for assistance, an intervention dated 7/27/22 reacher (handheld took used to increase the range of a person's reach when grabbing objects) to be provided for assistance grabbing items, an intervention dated 7/30/22 signage to use call light, an intervention dated 9/30/22 ensure walker is at bedside at night ., an intervention dated 10/6/22 offer (every two hours) toileting, an intervention dated 10/10/22 bedside commode in room, I often prefer for it [bedside commode] to be taken out of room ., an intervention dated 11/11/22 signage on walker to remind me to call for assistance, an intervention dated 12/16/22 revealed several attempts to move R22's room near the nursing station with multiple refusals, an intervention dated 1/12/22 educate on proper equipment use and safety with transferring, an intervention dated 1/22/23 therapy is currently working with resident, and an intervention dated 2/6/23 educate me on sitting up slowly and waiting a short period of time before transferring. In an interview on 02/14/23 at 02:22 PM, R22 was seated in a wheelchair and watching television. R22 inquired about this surveyor's name and job description which was discussed earlier in the day. Observed no sign on walker, no reacher in the room, and no bedside commode in the room. R22 again expressed that he waits for up to an hour for any help and that he cannot wait that long for help. R22 denies having staff come in and ask him if he had to use the bathroom every two hours and reported he would go to the nurse's station or out in hall to get help because it's better that way. Review of an Incident report dated 4/6/22 at 7:15 PM revealed R22 was discovered on the floor. The same report indicated that R22 had attempted to ambulate to the bathroom when he became dizzy and fell. R22 was transported to the Emergency Department. Immediate action was listed as adding signs to room to remind resident to use call light and educate on call light use. An intervention was added to the care plan on 4/6/22 that revealed send resident to hospital post fall. The intervention was resolved on 7/26/22. No intervention for education or signs were added to the care plan. Review of an Incident report dated 4/9/22 at 7:15 PM revealed R22 ambulated into the hallway with his walker when he was seen going slowly to the floor .and went into the laying position. The same report indicated that R22 was educated on sitting on the side of the bed before standing and educated on call light use. Record review revealed that these interventions were not added to the care plan on this date for this incident. An intervention was added to the care plan on 4/9/22 that revealed orthostatic blood pressures to be completed for three days . and the intervention was resolved on 7/27/2022. Record review revealed that the three days of orthostatic blood pressures (blood pressures taken in the lying position, sitting position, and standing position) were not completed. Review of an Incident Report dated 7/27/22 at 2:13 AM revealed R22 was discovered lying on the floor in front of a small dresser at 1:30 AM. R22 stated he was attempting to use a urinal, lost balance, and fell to the ground. The same report indicated R22 was reeducated on call light use and R22's call light was placed near him. Review of the Care Plan revealed an intervention of providing R22 with a reacher was initiated. No reacher was observed in R22's room. Review of an Incident Report dated 7/30/22 at 11:17 AM revealed R22 was discovered on the floor and had complaints of rib pain. R22 was sent to a local hospital for evaluation. The same Incident Report revealed an immediate intervention of adding signage to remind R22 to use the call light. R22's Care Plan was updated with signage as an intervention. Review of an Incident Report dated 9/18/22 at 2:15 PM revealed R22 sustained a fall while exiting a vehicle in the parking lot. The same report revealed an intervention of ensuring R22 had his walker when he took a leave of absence (LOA) from the facility. Review of R22's Care Plan revealed an intervention for taking a walker while on LOA was added on 9/20/22. Review of an Incident Report dated 9/21/22 at 5:45 AM revealed R22 had reported to staff that he had a fall in his room. Staff discovered an abrasion (cut) on R22's left knee. R22 was sent to a local hospital for evaluation. The same report revealed that the immediate action was to cleanse the wound. Review of the Care Plan revealed that an intervention implemented on 9/28/22 for orthostatic blood pressures, every shift, for three days. Review of the blood pressures for R22 revealed that the orthostatic blood pressures were not completed. Review of an Incident Report dated 9/30/22 at 1:00 AM revealed R22 was observed sitting on buttocks with back resting against bed with knees bent and hands on floor. The same incident report revealed that the immediate action taken was to provide care. Review of the Care Plan revealed an intervention of ensuring R22's walker was at his bedside at night for safe transfers and ambulation and a medication review was added. Another order was placed for orthostatic blood pressures every day shift, every month(s) starting on the 1st for one day(s). Review of R22's blood pressures revealed that only one orthostatic blood pressure was obtained for the date of 10/1/22. Review of an Incident Report dated 10/7/22 at 9:30 AM revealed R22 experienced lightheadedness and blurred vision while transferring to a bedside commode. A Certified Nursing Assistant witnessed R22 sit down on the floor. The same report revealed R22 was sent to a local hospital for evaluation. Review of the Care Plan revealed an intervention of bedside commode to be placed at bedside. [R22] often prefers to have it taken out of room until I ask for it initiated on 10/10/22. Review of an Incident Report dated 10/29/22 at 3:00 PM indicated that R22 had an unwitnessed fall while transferring himself to the bathroom. The same report revealed the immediate action taken was to provide care. Review of the Care Plan indicated another post fall medication review added as an intervention. Review of an Incident Report dated 11/7/22 at 9:41 AM revealed R22 had an unwitnessed, self-reported, fall while ambulating to the bathroom. The same Incident Report indicated R22 felt faint and fell to his knees. The report indicated the immediate action was applying an ice pack to R22's knee. Review of the Care Plan revealed an intervention was added on 11/11/22 to add signage to walker to remind to call for assistance. No signage on R22's walker was observed. Review of an Incident Report dated 11/19/22 at 11:30 AM revealed R22 sustained a fall while self-transferring himself from wheelchair to bed. The same report revealed the immediate action taken was to reinforce and re educating the need to call for assistance. Review of the Care Plan revealed an intervention of 30-minute checks until room is able to be moved was added on 11/21/22. This intervention was resolved on 12/16/22 but no room change occurred. Review of an Incident Report dated 12/2/22 at 4:30 PM revealed R22 sustained a self-reported fall where he reported that he lost balance when getting up from his wheelchair. The same report revealed that the immediate intervention was to re educate on calling for assistance. Review of the Care Plan revealed an intervention of position bedside table next to wheelchair to allow open area was initiated on 12/2/22. Review of an Incident Report dated 1/12/23 at 5:52 AM revealed R22 reported a fall in his room. The same report revealed the immediate action taken was to provide care. Review of R22's Care Plan revealed an intervention of education on proper equipment use and safety with transferring was initiated on 1/12/23. Review of an Incident Report dated 2/6/23 at 7:11 AM revealed R22 had a self-reported fall while attempting to transfer himself from the wheelchair to the bathroom. Review of the same report revealed the immediate intervention was encouraging R22 to call for assistance. Review of the Care Plan revealed an intervention of educate me on sitting up slowly and waiting a short time before transferring was initiated on 2/6/23. In an interview on 02/14/23 at 02:27 PM, Licensed Practical Nurse (LPN) L reported R22 tends to be forgetful, we educate and educate and reeducate but he does not retain. In an interview on 02/15/23 at 08:15 AM, Registered Nurse (RN) N reported R22's cognition and memory are sketchy . it's common that [R22] doesn't remember who I was the day before. [R22] is forgetful. In an observation and interview on 02/16/23 at 09:40 AM, R22 was observed opening the door to his room, peering out into the hallway, and then attempted to ambulate to his bed without any assistive devices. While ambulating to his bed, R22 was using the walls and the back of the wheelchair to make his way to the bed. R22 reported that he did not need anything, he just woke up and wanted his door open. This event went unwitnessed by staff. In an interview on 02/15/23 at 09:20 AM Director of Nursing (DON) B reported that the process for falls was to assesses the resident, implement an immediate intervention and then the team will go over the fall in clinical meetings every morning to do a thorough investigation of the fall. Care plans are updated during the clinical meetings in the mornings. DON B reported that she did not realize that his fall history was so extensive after reviewing the falls during the interview. DON B reported that R22 was forgetful at times and an attempt to appoint R22 a guardian was discussed with R22, but he refused. When questioned about some of the fall intervention that were in place on the Care Plan, she agreed that once an intervention was no longer being implemented, it should no longer be considered an active intervention and should be removed from the care plan. Resident #263 (R263) Review of an admission Record revealed Resident #263 (R263) admitted to the facility on [DATE] with pertinent diagnoses which included two-part displaced fracture of surgical neck of right humerus subsequent encounter for fracture with routine healing, fall, asthma, unspecified severe protein-calorie malnutrition, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/12/23, reflected R263 scored 15 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the [NAME] (the [NAME] is a medical information system used by nursing staff to communicate important information about the resident) revealed R263 did not walk and required extensive assistance by two or more staff to perform most activities of daily living such as transferring and toileting. Review of a progress note on 2/8/23 revealed that R263 recently underwent surgery for percutaneous pinning of the right pelvis from a fall with fracture that occurred outside the facility that involved the right humeral neck and right femoral neck. In an observation on 02/13/23 at 09:59 AM, R263 was resting in bed, watching television, with her legs hanging off the left side of the bed. At the time the facilities call light system was not function, so the facility provided all residents with handheld bells to ring if assistance was needed. R263's bell was observed on the nightstand, out of reach of the resident. R263's bed was elevated at med thigh level. R263's risk for falls care plan dated 2/6/23, revealed R263 was at a risk for falls related to decreased mobility, history of falling with right humerus fracture and right femur fracture, old cerebral vascular accident with right hemiparesis, low back pain, neuropathy, and medication side effects. The same care plan revealed fall interventions dated 2/6/23 have commonly used articles within easy reach, maintain bed in lowest position, observe for s+sx (signs and symptoms) of medication side effects and report to physician as needed, and reinforce the need to call for assistance. In an observation and interview on 02/14/23 at 12:08 PM, R263 was resting in bed watching television. R263 was receiving intravenous (IV) solution at the time and the bed was in a low position. R263's call light out of reach from resident, tied to the IV pole. A staff member entered the room during the observation and offered a lunch tray to R263, which was refused. R263 reported that she fell two nights ago while attempting to transfer to her wheelchair to get into the bathroom, unassisted. R263's risk for falls care plan dated 2/6/23, revealed R263 was at a risk for falls related to decreased mobility, history of falling with right humerus fracture and right femur fracture, old cerebral vascular accident with right hemiparesis, low back pain, neuropathy, and medication side effects. The same care plan revealed fall interventions dated 2/6/23 have commonly used articles within easy reach, maintain bed in lowest position, observe for s+sx (signs and symptoms) of medication side effects and report to physician as needed, and reinforce the need to call for assistance. Review of an Incident report dated 2/12/23 at 11:00 AM revealed R263 was discovered lying on back in front of wheelchair. The immediate action taken was to assess range of motion, check vitals, and assist back to bed. The same incident report revealed R263 had no complaints of pain and was not sent to the hospital for further evaluation. Review of a progress note on 2/14/2023 at 09:01 revealed R263 returned from a local hospital via stretcher on 2/12/23 at approximately 5pm diagnosis- fall Non intractable headache and hip pain . follow up with surgeon. In an interview on 02/15/23 at 09:20 AM Director of Nursing (DON) B reported that the process for falls was to assesses the resident, implement an immediate intervention and then the team will go over the fall in clinical meetings every morning to do a thorough investigation of the fall. Care plans are updated during the clinical meetings in the mornings. DON B reported that the initial intervention after R63's fall was to ask for assistance when needed from transfers. DON B reported that R263 was ultimately sent to the hospital after the 2/12/23 fall due to hip pain. Review of R263's Care Plan on 2/15/23 revealed that no additional fall interventions were added to the falls Care Plan after the fall that occurred on 2/12/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide services and assistance to restore bowel and bladder continence (Resident #48), resulting in the potential for falls and worsening incontinence. Findings include: Resident #48 (R48) On 2/13/23 at 9:28 AM R48 was observed lying in bed. R48's Minimum Data Set (MDS) assessment dated [DATE] introduced a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 14 (13-15 Cognitively Intact). R48 required extensive assistance for toilet use and personal hygiene. R48 was occasionally incontinent of bowel and bladder and a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission/reentry or since urinary/bowel incontinence was noted in the faciity. Physician Progress Note dated 1/02/23 revealed R48 had a history of dementia, gait instability, weakness, repeated falls, arthritis, depression, and anxiety. Licensed Practical Nurse (LPN) L was interviewed on 2/15/23 at 1:33 PM and stated R48 would use the toilet without assistance, did not use her call light, and would holler out for help when she would see someone walk by her room. On 2/21/23 at 9:42 AM Director of Nursing (DON) B was interviewed and unable to provide evidence of individualized continence treatment or services offered/provided for R48. According to the Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, October 2019, manual, each resident who was incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible. The same source indicated many incontinent residents (including those with dementia) respond to a toileting program, especially during the day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain weights per policy for 2 of 6 reviewed for nutrition (Resident #8 & #261, resulting in risk of altered nutrition status. Findings Include: Resident #261 (R261) Review of an admission Record revealed Resident #261 (R261) admitted to the facility 5-25-21 and readmitted on [DATE] with pertinent diagnoses which included asthma, Chronic Obstruction Pulmonary Disease, Type Two Diabetes, Epilepsy, unspecified severe protein-calorie malnutrition, and repeated falls. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/6/22, reflected R261 scored 15 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R261 did not walk and required limited to extensive assistance of one or more people to transfer, toilet, and maintain personal hygiene. In an observation on 02/13/23 at 10:30 AM, R261 was observed in bed laying on her back with the call light clipped on the blanket. At the time of the observation the facilities call light system was not functioning, so, the facility provided handheld bells for all residents to use to call for assistance. R261's bell was son the nightstand, out of reach of the resident. In an observation on 02/13/23 at 12:25 PM, R261 was in same position, lying flat on her back. R261's call light was clipped to the blanket, but the bell remained out of reach from the resident. Review of the Care Plan revealed R261 had a nutritional problem Care Plan related to poor intake, prior weight loss, and increased needs due to a pressure injury. Interventions included explaining and reinforcing the importance of maintaining the diet ordered, monitor signs and symptoms of weight loss, and weight per policy. These interventions were implemented on 12/27/22. Review of a Nutrition Note on 2/6/2023 revealed R261 had history of refusing supplements and does not want to eat . R261 is high risk for further skin breakdown d/t (due to) high risk for malnutrition . Review of Nutritional Note on 2/8/2023 at 12:47 PM revealed R261 had a follow up for poor intake and severe protein calorie malnutrition .R261 declined breakfast this (morning). Visited in after lunch was served and she was sleeping and did not arouse to verbally speaking her name .Further weight loss and skin breakdown is unavoidable if PO (by mouth) intake continues to decline. According to the facility's Weight Policy dated 11/22, Weight changes have significant nutritional implications. To help maintain acceptable parameters of nutritional status . admission height and weight are to be obtained by nursing staff and recorded in the resident chart . Weekly weights are obtained on those residents within the first 4 weeks of admission . Review of the Electronic Medical Record (EMR) revealed R261 had an admission weight on 2/1/23 of 141 pounds. No other weights were in R261's EMR. In a phone interview on 02/15/23 at 11:13 AM, Registered Dietician E reported that the weight policy was to obtain a weight on admission and a weight once a week for 4 weeks. Resident #8 (R8) R8's Hospital Discharge Summary indicated he was hospitalized from [DATE] to 10/21/22. Admitting diagnoses included frequent falls at home, COVID-19 with pneumonia, failure to thrive, alcohol use, heart, and lung disease. The same summary revealed R8 was alert and orientated to person and place and was often forgetful. R8's Minimum Data Set (MDS) dated [DATE] revealed he admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 11 (8-12 Moderate Impairment). R8's care plan dated 10/21/22 indicated his goal was to maintain adequate nutritional and hydration status as evidenced by a stable weight. In review of R8's weight summary, his admission weight on 10/21/22 was 96.2 pounds (lbs.), on 1/06/23 he weighed 95.5 pounds (lbs.) and his weight on 2/10/23 was 84.4 lbs. Physician's Order dated 2/10/23 indicated to obtain R8's weight weekly, and to begin on 2/14/23. In review of R8's medical record on 2/21/23, no weight was documented on 2/14/23. Registered Dietician (RD) F was interviewed on 2/21/23 and 8:55 AM and when asked why a weight was not documented for R8 on 2/14/23, and she stated would call the facility and make sure R8 was weighed on 2/21/23.

Based on observation, interview, and record review the facility failed to provide ongoing communication and collaboration with the contracted dialysis facility regarding dialysis care and continued assessment for one resident (#14) of one resident reviewed resulting in the potential of unmet care needs and possible complications for residents receiving dialysis services. Findings Included: Resident #14 (R14) Review of the medical record revealed R14 was admitted to the facility 01/03/23 with diagnoses that included osteomyelitis (bone infection) right ankle and foot, end stage renal failure, type 2 diabetes, diabetic neuropathy (nerve damage), anterior dislocation of left humorous, oxygen dependence, hypokalemia (low potassium levels in blood), elevated white blood cells, restless leg syndrome, congestive heart failure, atrioventricular second degree (heart block), atrial fibrillation, dependence on renal dialysis, major depression, chronic anemia (low red blood cells), hypertension, hyperlipemia (high levels of fat in the blood), sleep apnea, myocardial infarction (heart attack), atherosclerotic heart disease (buildup of cholesterol on artery walls), hypothyroidism (low thyroid hormone), irritable bowel syndrome (intestinal disorder), esophageal reflux, and peripheral vascular disease (narrowing of blood vessels). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/10/2023, revealed R14 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/13/2023 at 11:52 a.m. R14 was observed sitting up in her wheelchair, at her bedside. R14 demonstrated that she had a left subclavian dialysis catheter that was covered by a dressing. R14 explained that she had just returned to the facility from dialysis and that she had been receiving dialysis for 11 years. During record review of R14's care plan it was demonstrated a problem statement which stated, I need hemodialysis M/W/F. Review of the care plan interventions did not demonstrate her dialysis schedule, or what type of dialysis catheter or dialysis port R14 was using. The interventions stated, No blood pressure to (specify right or left) arm with graft placement. In an interview on 02/14/2023 at 03:58 p.m. Nursing Home Administrator (NHA) A was requested to provide access to Point of Care (PPC-computerized medical record) dialysis communication forms for R14, as the surveyor was unable to access all dialysis documents. NHA A explained that access could not be provided to this surveyor as all communication documents were not completed in PCC. NHA A explained that the facility would print all communication documents and provide them to the surveyor. During record review of facility Dialysis Communication Form 2 it was demonstrated that R14 had incomplete documentation for the dates of 1/4/23, 1/13/23, 1/16/23, 1/25/23, 2/1/23, 2/3/23, 2/10/23 and 2/13/23. Review also demonstrated that Dialysis Communication Forms 2 were not provided for 1/6/23, 1/9/23, 1/11/23, 1/18/23, 1/20/23, 1/23/23, 1/27/23, 1/30/23, 2/18/23. The Dialysis Communication Form 2 template in PCC contained: A. Center Nurse-Pre-Dialysis, which included 1. Access site, 1A. dressing place, 2. bleeding after last treatment, 3. bruit/thrill present, 4. signs of infection, 5. blood pressure, 6. temperature, 7. pulse, 8. respiration, 9. date and time of last meal, 10. diet order, 11a-11i list of medications, 12. note any changes or additional information, 12a. not any information to provide to dialysis center, 13. name of nurse completing the form, 14. date and time signed. B. Dialysis Center 1. any lab work done, 2. pre dialysis weight, 3. Pre-vital signs, 4. Post dialysis weight, 5. Post vial signs, 6. is the dressing present, 7. Directions for dressing changes, 8. Access problems, 9. Change in condition, 10. Explain any access problems, change in condition, or other pertinent information, 11. Medications given during/after treatment, and 12. dialysis nurse signature. C. Center Nurse-Post Dialysis 1. Blood pressure, 2. Temperature, 3. Pulse, 4. Respirations, 5. Thrill palpated, 6. Bruit auscultated, 7. Bleeding at graft site, 8. Document if any of the following are present (bleeding, hypotension, leg cramps, fatigue, nausea, seizures, s/s(signs and symptoms) of infection, chest pain, headache, and none present), 9. Is there a dressing present, 10. Describe dressing. All Dialysis Communication Form 2 that were provided by Nursing Home Administrator (NHA) A contained missing information in one or many section of the Dialysis Communication Form 2. In an interview on 02/15/2023 at 10:55 a.m. Director of Nursing (DON) B confirmed that multiple Dialysis Communication Form 2 s had not been completed or had been done incompletely for R14. DON B acknowledge that she had not known this was an issue until this surveyor had requested the dialysis communication documents. DON B explained that it was her expectation that Dialysis Communication Form 2 documents were to be done in their entirety by the facility staff and the dialysis staff. DON B explained that the facility had already started reviewing the adoption of a different process for dialysis communication. DON B explained that she did not feel the current process for assessing resident receiving dialysis and communication with the center providing dialysis was effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to honor food preferences for one resident (#40) of one resident reviewed for food preferences. Resulting in anger and the potential for weight loss. Findings include: Resident #40 According to the clinical record including the Minimum Data Set (MDS) with as Assessment Reference Date (ARD) of 1/12/23, Resident # 40 (R40) was an [AGE] year old female admitted to the facility with diagnoses that included depression, bilateral hearing loss and dementia. R40 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status. On 2/13/23 at 9:10am R40 was observed sitting in her room watching television, R40 easily engaged in conversation without difficulty. R40 voiced complaints about the food, specifically food preferences not being honored. When queried if she had lost weight , R 40 stated she hadn't but she attributed her ability to maintain her weight to her daughter bringing her food. On 02/13/23 at 12:23 PM, R40's lunch tray was observed, the plate contained ground meat loaf with gravy over the meat, mashed potatoes with gravy, apple juice, corn bread, fruit and yogurt parfait. Review of 40's tray ticket sitting next to the plate of food read dislikes gravy. On 02/14/23 at 08:30 AM, R40 was observed in her room eating breakfast, the plate was observed to have scrambled eggs, biscuit and gravy, and cold cereal (all items partially eaten with the exclusion of biscuit and gravy which was no touched). R40 was queried if she enjoyed her breakfast was, R 40 responded, its ok I don't like gravy though. When queried if she liked biscuits with butter, jelly honey etc .R 40 stated that sounded good. When queried if she had been offered something different R40 stated no. On 02/16/23 at 11:55 AM R40 was observed eating lunch in her room, a full untouched plate of Swedish meatballs and gravy was observed with a side of vegetables. Resident # 40 was observed eating the vegetables, when asked how lunch was, R40 rolled her eyes and stated No good. On 02/21/23 at 08:39 AM, during an interview with Certified Dietary Manager (CDM) D , she reported dietary staff was to read the tray ticket and follow resident preferences. When queried if a resident didn't like gravy and biscuits and gravy were on the menu what would they get? CDM D stated R40 should have received a biscuit with jelly or butter. Upon further discussion pertaining to observations of the mashed potato's and gravy, meatloaf with gravy, Swedish meatballs with gravy , CDM D stated due to R40 having ground meat the dietary staff were required to add gravy for moisture. When queried if other/substitute foods could be used to add moisture opposed gravy (which was a well known dislike for R40), such as milk, butter, broth etc CDM D stated yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12 (R12) Review of an admission Record revealed Resident #12 (R12) admitted to the facility on [DATE] with pertinent diagnoses which included paraplegia, unspecified urethral stricture, cutaneous abscess of groin, and muscle weakness. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/23/23, reflected R12 scored 14 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R12 did not walk and requires extensive assistance of two or more people to transfer, toilet, and maintain personal hygiene. In an observation and interview on 02/13/23 at 09:20 AM, R12 reported that he had been a paraplegic since the 1980's and lived at home prior to admission to the facility. R12 reported that he could navigate and care of himself just fine, including taking care of his indwelling foley catheter, navigating in a wheelchair, and doing basic hygiene at home. R12 expressed frustration in the lack of care he had been receiving at the facility, including showers, indwelling foley catheter care, and wound dressing changes. In an observation on 02/14/23 at 11:12 AM, R12's foley catheter bag was resting on the floor of R12's room, along with about 4 to 6 inches of the foley catheter tubing. In an interview on 2/21/23 at 12:33, Infection Control Licensed Practical Nurse (LPN) T reported that the expectation of indwelling foley catheter care was to keep the catheter bag below the bladder, use a secure device, utilize a privacy bag, and not be on the floor (the catheter bag). According to Centers for Disease Control (CDC) website, It is best practice to keep the collecting bag (of the indwelling foley catheter) below the level of the bladder at all times. Do not rest the bag on the floor. This citation pertains to intake MI00133146. Based on observation, interview, and record review, the facility failed to follow the standards of infection control for catheters and use a barrier for medication administration, in a census of 59 residents, resulting in the potential for cross-contamination and bacterial harborage, which placed a vulnerable population at high risk for infections. Findings include: During a medication pass observation on 2/21/23 at 8:21 AM, Licensed Practical Nurse (LPN) U took a box of nasal spray into a residents room, placed the box on the seat of a chair in the resident room before administering the medication. After LPN U administered the nasal spray medication, it was returned to the box and the box was placed again on top of the seat of the chair in the residents room. LPN U placed the box on top of another medication cart that was outside the residents room and then returned the box to her medication cart, into the cart drawer. Infection Control Nurse T was interviewed on 2/21/23 at 1:32 PM and stated the expectation would be for the nurse to use a barrier when taking a box of medication into a residents room and added the facility had foam trays available in the medication cart for use.

Based on interview, and record review the facility failed to provide influenza vaccination to one resident (#30) of five residents, during Flu season, reviewed for influenza vaccination status resulting in the exposure of serious illness to the resident. Findings Included: Resident #30 (R30) Review of the medical record revealed R30 was admitted to the facility 01/02/2023 with diagnoses that included multiple fractures ribs, malignant neoplasm of bladder (bladder cancer), obstructive and reflux uropathy (blockage of urinary tract), hydronephrosis (enlargement of kidney), type 2 diabetes, severe protein calorie malnutrition, displacement of indwelling ureteral stent, adult failure to thrive, gastroesophageal reflux, major depression, chronic kidney disease, chronic anemia (low red blood cells), hyponatremia (low sodium), hyperkalemia (high potassium), diverticulosis (bulging pouches in the intestinal tract), and hemiplegia (paralysis on one side of body). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/13/2023, revealed R30 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. During record review of R30's influenza vaccination status it was revealed that R30 had signed a facility declination entitled, Infection Control Information Consent Form dated 01/06/23. On the above document R30 had yes that the facility may give the influenza vaccine, intramuscularly, during Flu season. Review of R30's medication administration record, since date of admission, did not demonstrate that he had received the influenza vaccination. In an interview on 02/13/2023 at 12:23 p.m. Infection Control Preventionist (ICP) T confirmed that R30 had not received the influenza vaccination since his date of admission. ICP T also confirmed that R30's immunization declination demonstrated that he had given the approval to receive the influenza vaccination. ICP T explained that R30 was on her list of to provided influenza vaccination but that she had not completed it to date. She explained that she had not been able to obtain the vaccination from pharmacy because she was notified by the pharmacy that the Director of Nursing needed to approve the vaccination being sent to the facility. Director of Nursing (DON) B, who was present during this interview, explained that she knew nothing of this delay or anything regarding her approval of the influenza vaccinations. ICP T explained that a facility supply of influenza vaccines was kept at the facility for all new admit residents that requested the influenza vaccination but currently there is none in the facility because DON (T) needed to approve the request. DON B denied knowledge of this required approval process of pharmacy. During record review of the facility policy entitled, Influenza Vaccine with a review date of 10/2020 demonstrated that number one stated, Between October 1st and March 31st of each year, the influenza vaccine shall be offered to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake # MI00134460 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for five out of 16 residents (Residents #14, 22, 61, 261 and 263), resulting in the potential for unmet care needs. Findings Included: Resident #22 (R22) Review of an admission Record revealed Resident #22 (R22) admitted to the facility on [DATE] with pertinent diagnoses which included alcohol induced chronic pancreatitis, chronic obstructive pulmonary disease, abnormality of gait and mobility, unspecified severe protein-calorie malnutrition, dementia with unspecified severity with other behavioral disturbances, orthostatic hypotension, epilepsy, anemia, and prediabetes. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/5/23, reflected R22 scored 12 of out 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R22 required limited assistance one person to ambulate and perform personal hygiene activities, transfer, and dressing but extensive assistance of one person to toilet. Review of R22's Electronic Medical Record also revealed that R22 had a history of falls. In an observation on 02/13/23 at 01:52 PM, R22 was observed in his room, sleeping. R22's call light was on the floor and multiple spills of a red liquid were noted on the floor. Four empty red soda bottles were observed in his room. In an interview on 02/14/23 at 10:50 AM, R22 reported that he gets tired of sitting, I fell last night. The [Certified Nursing Assistants] take too long to come, sometimes I wait up to an hour. I eventually get up but I [am not] supposed to . There have been times I wet myself in bed and they had to clean me up. Review of R22's [NAME] (care plan for Certified Nurse's Assistants) interventions included ensuring walker was at bedside at night for safe transfers and ambulation, position bedside table next to wheelchair to allow open area, signage to use call light, and therapy was currently working with resident. Additionally, review of R22's progress notes indicted that on 2/13/2023, R22's therapy was discontinued due to highest practical level achieved. R22's risk for falls care plan dated 4/5/22, indicated his goal was to reduce risk of falls. An intervention dated 4/5/22 revealed have commonly used articles in place .bed in low position, offer assistance for transferring and ambulation, and reinforce the need to call for assistance, an intervention dated 7/27/22 reacher (handheld took used to increase the range of a person's reach when grabbing objects) to be provided for assistance grabbing items, an intervention dated 7/30/22 signage to use call light, an intervention dated 9/30/22 ensure walker is at bedside at night ., an intervention dated 10/6/22 offer (every two hours) toileting, an intervention dated 10/10/22 bedside commode in room, I often prefer for it [bedside commode] to be taken out of room ., an intervention dated 11/11/22 signage on walker to remind me to call for assistance, an intervention dated 12/16/22 revealed several attempts to move R22's room near the nursing station with multiple refusals, an intervention dated 1/12/22 educate on proper equipment use and safety with transferring, an intervention dated 1/22/23 therapy is currently working with resident, and an intervention dated 2/6/23 educate me on sitting up slowly and waiting a short period of time before transferring. In an interview on 02/14/23 at 02:22 PM, R22 was seated in a wheelchair and watching television. R22 inquired about this surveyor's name and job description which was discussed earlier in the day. Observed no sign on walker, no reacher in the room, and no bedside commode in the room. R22 again expressed that he waits for up to an hour for any help and that he cannot wait that long for help. R22 denies having staff come in and ask him if he had to use the bathroom every two hours and reported he would go to the nurse's station or out in hall to get help because it's better that way. Review of an Incident report dated 4/6/22 at 7:15 PM revealed R22 was discovered on the floor. The same report indicated that R22 had attempted to ambulate to the bathroom when he became dizzy and fell. R22 was transported to the Emergency Department. Immediate action was listed as adding signs to room to remind resident to use call light and educate on call light use. An intervention was added to the care plan on 4/6/22 that revealed send resident to hospital post fall. The intervention was resolved on 7/26/22. No intervention for education or signs were added to the care plan. Review of an Incident report dated 4/9/22 at 7:15 PM revealed R22 ambulated into the hallway with his walker when he was seen going slowly to the floor .and went into the laying position. The same report indicated that R22 was educated on sitting on the side of the bed before standing and educated on call light use. Record review revealed that these interventions were not added to the care plan on this date for this incident. An intervention was added to the care plan on 4/9/22 that revealed orthostatic blood pressures to be completed for three days . and the intervention was resolved on 7/27/2022. Record review revealed that the three days of orthostatic blood pressures (blood pressures taken in the lying position, sitting position, and standing position) were not completed. Review of an Incident Report dated 7/27/22 at 2:13 AM revealed R22 was discovered lying on the floor in front of a small dresser at 1:30 AM. R22 stated he was attempting to use a urinal, lost balance, and fell to the ground. The same report indicated R22 was reeducated on call light use and R22's call light was placed near him. Review of the Care Plan revealed an intervention of providing R22 with a reacher was initiated. No reacher was observed in R22's room. Review of an Incident Report dated 7/30/22 at 11:17 AM revealed R22 was discovered on the floor and had complaints of rib pain. R22 was sent to a local hospital for evaluation. The same Incident Report revealed an immediate intervention of adding signage to remind R22 to use the call light. R22's Care Plan was updated with signage as an intervention. Review of an Incident Report dated 9/18/22 at 2:15 PM revealed R22 sustained a fall while exiting a vehicle in the parking lot. The same report revealed an intervention of ensuring R22 had his walker when he took a leave of absence (LOA) from the facility. Review of R22's Care Plan revealed an intervention for taking a walker while on LOA was added on 9/20/22. Review of an Incident Report dated 9/21/22 at 5:45 AM revealed R22 had reported to staff that he had a fall in his room. Staff discovered an abrasion (cut) on R22's left knee. R22 was sent to a local hospital for evaluation. The same report revealed that the immediate action was to cleanse the wound. Review of the Care Plan revealed that an intervention implemented on 9/28/22 for orthostatic blood pressures, every shift, for three days. Review of the blood pressures for R22 revealed that the orthostatic blood pressures were not completed. Review of an Incident Report dated 9/30/22 at 1:00 AM revealed R22 was observed sitting on buttocks with back resting against bed with knees bent and hands on floor. The same incident report revealed that the immediate action taken was to provide care. Review of the Care Plan revealed an intervention of ensuring R22's walker was at his bedside at night for safe transfers and ambulation and a medication review was added. Another order was placed for orthostatic blood pressures every day shift, every month(s) starting on the 1st for one day(s). Review of R22's blood pressures revealed that only one orthostatic blood pressure was obtained for the date of 10/1/22. Review of an Incident Report dated 10/7/22 at 9:30 AM revealed R22 experienced lightheadedness and blurred vision while transferring to a bedside commode. A Certified Nursing Assistant witnessed R22 sit down on the floor. The same report revealed R22 was sent to a local hospital for evaluation. Review of the Care Plan revealed an intervention of bedside commode to be placed at bedside. [R22] often prefers to have it taken out of room until I ask for it initiated on 10/10/22. Review of an Incident Report dated 10/29/22 at 3:00 PM indicated that R22 had an unwitnessed fall while transferring himself to the bathroom. The same report revealed the immediate action taken was to provide care. Review of the Care Plan indicated another post fall medication review added as an intervention. Review of an Incident Report dated 11/7/22 at 9:41 AM revealed R22 had an unwitnessed, self-reported, fall while ambulating to the bathroom. The same Incident Report indicated R22 felt faint and fell to his knees. The report indicated the immediate action was applying an ice pack to R22's knee. Review of the Care Plan revealed an intervention was added on 11/11/22 to add signage to walker to remind to call for assistance. No signage on R22's walker was observed. Review of an Incident Report dated 11/19/22 at 11:30 AM revealed R22 sustained a fall while self-transferring himself from wheelchair to bed. The same report revealed the immediate action taken was to reinforce and re educating the need to call for assistance. Review of the Care Plan revealed an intervention of 30-minute checks until room is able to be moved was added on 11/21/22. This intervention was resolved on 12/16/22 but no room change occurred. Review of an Incident Report dated 12/2/22 at 4:30 PM revealed R22 sustained a self-reported fall where he reported that he lost balance when getting up from his wheelchair. The same report revealed that the immediate intervention was to re educate on calling for assistance. Review of the Care Plan revealed an intervention of position bedside table next to wheelchair to allow open area was initiated on 12/2/22. Review of an Incident Report dated 1/12/23 at 5:52 AM revealed R22 reported a fall in his room. The same report revealed the immediate action taken was to provide care. Review of R22's Care Plan revealed an intervention of education on proper equipment use and safety with transferring was initiated on 1/12/23. Review of an Incident Report dated 2/6/23 at 7:11 AM revealed R22 had a self-reported fall while attempting to transfer himself from the wheelchair to the bathroom. Review of the same report revealed the immediate intervention was encouraging R22 to call for assistance. Review of the Care Plan revealed an intervention of educate me on sitting up slowly and waiting a short time before transferring was initiated on 2/6/23. In an interview on 02/14/23 at 02:27 PM, Licensed Practical Nurse (LPN) L reported R22 tends to be forgetful, we educate and educate and reeducate but he does not retain. In an interview on 02/15/23 at 08:15 AM, Registered Nurse (RN) N reported R22's cognition and memory are sketchy . it's common that [R22] doesn't remember who I was the day before. [R22] is forgetful. In an observation and interview on 02/16/23 at 09:40 AM, R22 was observed opening the door to his room, peering out into the hallway, and then attempted to ambulate to his bed without any assistive devices. While ambulating to his bed, R22 was using the walls and the back of the wheelchair to make his way to the bed. R22 reported that he did not need anything, he just woke up and wanted his door open. This event went unwitnessed by staff. In an interview on 02/15/23 at 09:20 AM Director of Nursing (DON) B reported that the process for falls was to assesses the resident, implement an immediate intervention or action and then the team will go over the fall in clinical meetings every morning to do a thorough investigation of the fall. Care plans are updated during the clinical meetings in the mornings. DON B reported that she did not realize that his fall history was so extensive after reviewing the falls during the interview. DON B reported that R22 was forgetful at times and an attempt to appoint R22 a guardian was discussed with R22, but he refused. When asked about the reacher and the bedside commode not being in the room with R22, DON B reported that R22 would not use the reacher and bedside commode. When questioned about some of the fall intervention that were in place on the Care Plan, she agreed that once an intervention was no longer being implemented, it should no longer be considered an active intervention and should be removed from the care plan. Resident #263 (R263) Review of an admission Record revealed Resident #263 (R263) admitted to the facility on [DATE] with pertinent diagnoses which included two-part displaced fracture of surgical neck of right humerus subsequent encounter for fracture with routine healing, fall, asthma, unspecified severe protein-calorie malnutrition, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/12/23, reflected R263 scored 15 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the [NAME] (the [NAME] is a medical information system used by nursing staff to communicate important information about the resident) revealed R263 did not walk and required extensive assistance by two or more staff to perform most activities of daily living such as transferring and toileting. Review of a progress note on 2/8/23 revealed that R263 recently underwent surgery for percutaneous pinning of the right pelvis from a fall with fracture that occurred outside the facility that involved the right humeral neck and right femoral neck. In an observation on 02/13/23 at 09:59 AM, R263 was resting in bed, watching television, with her legs hanging off the left side of the bed. At the time the facilities call light system was not function, so the facility provided all residents with handheld bells to ring if assistance was needed. R263's bell was observed on the nightstand, out of reach of the resident. R263's bed was elevated at med thigh level. R263's risk for falls care plan dated 2/6/23, revealed R263 was at a risk for falls related to decreased mobility, history of falling with right humerus fracture and right femur fracture, old cerebral vascular accident with right hemiparesis, low back pain, neuropathy, and medication side effects. The same care plan revealed fall interventions dated 2/6/23 have commonly used articles within easy reach, maintain bed in lowest position, observe for s+sx (signs and symptoms) of medication side effects and report to physician as needed, and reinforce the need to call for assistance. In an observation and interview on 02/14/23 at 12:08 PM, R263 was resting in bed watching television. R263 was receiving intravenous (IV) solution at the time and the bed was in a low position. R263's call light out of reach from resident, tied to the IV pole. A staff member entered the room during the observation and offered a lunch tray to R263, which was refused. R263 reported that she fell two nights ago while attempting to transfer to her wheelchair to get into the bathroom, unassisted. R263's risk for falls care plan dated 2/6/23, revealed R263 was at a risk for falls related to decreased mobility, history of falling with right humerus fracture and right femur fracture, old cerebral vascular accident with right hemiparesis, low back pain, neuropathy, and medication side effects. The same care plan revealed fall interventions dated 2/6/23 have commonly used articles within easy reach, maintain bed in lowest position, observe for s+sx (signs and symptoms) of medication side effects and report to physician as needed, and reinforce the need to call for assistance. Review of an Incident report dated 2/12/23 at 11:00 AM revealed R263 was discovered lying on back in front of wheelchair. The immediate action taken was to assess range of motion, check vitals, and assist back to bed. The same incident report revealed R263 had no complaints of pain and was not sent to the hospital for further evaluation. Review of a progress note on 2/14/2023 at 09:01 revealed R263 returned from a local hospital via stretcher on 2/12/23 at approximately 5pm diagnosis- fall Non intractable headache and hip pain . follow up with surgeon. In an interview on 02/15/23 at 09:20 AM Director of Nursing (DON) B reported that the process for falls was to assesses the resident, implement an immediate intervention and then the team will go over the fall in clinical meetings every morning to do a thorough investigation of the fall. Care plans are updated during the clinical meetings in the mornings. DON B reported that the initial intervention after R63's fall was to ask for assistance when needed from transfers. DON B reported that R263 was ultimately sent to the hospital after the 2/12/23 fall due to hip pain. Review of R263's Care Plan on 2/15/23 revealed that no additional fall interventions were added to the falls Care Plan after the fall that occurred on 2/12/23. Resident #261 (R261) Review of an admission Record revealed Resident #261 (R261) admitted to the facility 5-25-21 and readmitted on [DATE] with pertinent diagnoses which included asthma, Chronic Obstruction Pulmonary Disease, Type Two Diabetes, Epilepsy, unspecified severe protein-calorie malnutrition, and repeated falls. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/6/22, reflected R261 scored 15 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R261 did not walk and required limited to extensive assistance of one or more people to transfer, toilet, and maintain personal hygiene. In an observation on 02/13/23 at 10:30 AM, R261 was observed in bed laying on her back with the call light clipped on the blanket. At the time of the observation the facilities call light system was not functioning, so, the facility provided handheld bells for all residents to use to call for assistance. R261's bell was son the nightstand, out of reach of the resident. R261's bed was elevated knee high, and the bed appeared to be outfitted with a pressure mattress. A blue heels up wedge was observed on the floor in the corner of R261's room. No floor mat was noted in the room In an observation on 02/13/23 at 12:25 PM, R261 was in same position, lying flat on her back. R261's call light was clipped to the blanket, but the bell remained out of reach from the resident. The blue heels up positioning wedge remained on the floor. No floor mat was observed in the room. Review of the Care Plan revealed that R261 had a risk for falls care plan that was initiated on 12/22/22. A listed intervention was to place a fall mat at the beside which was initiated on 2/13/23. Review of the same Care Plan revealed that R261 had a risk for altered skin integrity Care Plan initiated on 12/22/22. One of the interventions was to have a heels up cushion under R261's legs to keep heels floated. Review of a Progress Note dated 2/13/23 at 2:08 AM revealed At 1 AM CENA (certified nursing assistant) called this nurse to resident room, upon observation noted resident noted to be having actively seizure activity which lasted 4 minutes followed by unresponsive spell for 5 minutes . Review of a Progress Note dated 2/13/23 revealed R261 had a seizure in the night. Intervention to place a fall mat beside bed . No fall mat observation was made in R261's room during the survey. Resident #14 (R14) Review of the medical record revealed R14 was admitted to the facility 01/03/23 with diagnoses that included osteomyelitis (bone infection) right ankle and foot, end stage renal failure, type 2 diabetes, diabetic neuropathy (nerve damage), anterior dislocation of left humorous, oxygen dependence, hypokalemia (low potassium levels in blood), elevated white blood cells, restless leg syndrome, congestive heart failure, atrioventricular second degree (heart block), atrial fibrillation, dependence on renal dialysis, major depression, chronic anemia (low red blood cells), hypertension, hyperlipemia (high levels of fat in the blood), sleep apnea, myocardial infarction (heart attack), atherosclerotic heart disease (buildup of cholesterol on artery walls), hypothyroidism (low thyroid hormone), irritable bowel syndrome (intestinal disorder), esophageal reflux, and peripheral vascular disease (narrowing of blood vessels). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/10/2023, revealed R61 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/13/2023 at 11:52 a.m. R14 was observed sitting up in her wheelchair, at her bedside. R14 demonstrated that she had a left subclavian dialysis catheter that was covered by a dressing. R14 explained that she had just returned to the facility from dialysis and that she had been receiving dialysis for 11 years. During record review of R14's care plan it was demonstrated a problem statement which stated, I need hemodialysis M/W/F. Review of the care plan interventions did not demonstrate her dialysis schedule, or what type of dialysis catheter or dialysis port R14 was using. The interventions stated, No blood pressure to (specify right or left) arm with graft placement. In an interview on 02/15/2023 at 10:55 a.m. Director of Nursing (DON) B reviewed R14's plan of care. DON B confirmed that R14's care plan did not specify the type or location of R14's dialysis port or catheter. She explained that she would have to observe the resident before she could state what type of dialysis port or catheter was present. She also explained that she would have to observe R14 for the location of the dialysis port or catheter. DON B explained that it was her expectation that R14's plan of care should have listed the location and what type of dialysis port or catheter was present. DON B also explained that it was her expectation that specific directions for obtaining blood pressures with residents that had dialysis ports or catheters should be included in the plan of care. DON B could not explain why R14's plan of care did not include the above information. Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 10/24/2022 with diagnoses that included myocardial infarction (heart attack), opioid use, morbid obesity, bilateral osteoarthritis (wearing down of cartilage at the end of bones), spinal stenosis (spinal narrowing) of lumbar region, radiculopathy (disease at the root of a nerve) cervical region, gastroesophageal reflux, post-traumatic stress disorder (PTSD), cocaine abuse, abnormalities of plasma proteins, anxiety disorder, gout (increase in uric acid crystallization and deposit in bone joints), hyperlipidemia (high levels of fat in the blood), hypertension, major depression, chronic pain, obstructive sleep apnea, atherosclerosis (buildup of cholesterol plaque in artery walls) of arteries of extremities bilateral legs, and insomnia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2022, revealed R61 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/07/23 at 02:07 p.m. R61 was sitting up on the side of his bed. R61 explained that he had been at the facility since October of 2022. R61 became tearful as he explained that his greatest worry was being homeless. He explained that he had been working with community services for his psychological needs because he had been diagnosed with post-traumatic stress disorder (PTSD) related to serving in the military. During record review of R61's care plan revealed that he wanted to return to the community. The care plan did not list any services that the facility was working with to assist R61 in that goal. In an interview on 02/14/2023 at 12:56 p.m. Social Worker (SW) G explained that originally R61 had a discharge plan of returning to the community. She explained that the facility had been working with a community resource that R61 had been working with prior to his admission. Those services included transportation, housing, and psychiatric services. SW G explained that a meeting with the community organization had occurred sometime in January 2023. When asked why this information was not listed on R61's plan of care she could not explain why the information was not present in the resident's plan of care and explained that the information was not included in 61's record. SW G explained that this information should have been provided in R61's plan of care. SW G explained that there should have been demonstration of the psychiatric and discharge planning coordination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a qualified Activity Director was employed by the facility to provide a meaningful and individualized activity program for one resident (#61) of two residents reviewed for activities with the potential to affect all 59 residents at the facility resulting in the potential for lack of meaningful and resident individualized activities. Findings Included: Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 10/24/2022 with diagnoses that included myocardial infarction (heart attack), opioid use, morbid obesity, bilateral osteoarthritis (wearing down of cartilage at the end of bones), spinal stenosis (spinal narrowing) of lumbar region, radiculopathy (disease at the root of a nerve) cervical region, gastroesophageal reflux, post-traumatic stress disorder (PTSD), cocaine abuse, abnormalities of plasma proteins, anxiety disorder, gout (increase in uric acid crystallization and deposit in bone joints), hyperlipidemia (high levels of fat in the blood), hypertension, major depression, chronic pain, obstructive sleep apnea, atherosclerosis (buildup of cholesterol plaque in artery walls) of arteries of extremities bilateral legs, and insomnia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2022, revealed R61 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview 02/13/2023 at 01:54 p.m. R61 was observed sitting on the side of his bed coloring a picture. R61 explained that he did like activities. R61 explained that he had attended an art activity and but is favorite pass time was to color pictures. During record review R61's base line care plan did not contain any problem statement that addressed his activity interest. No care plan interventions were present that listed what specific activity events or intertest R61 desired to complete or attend. Review of the R61's Visual Bedside [NAME] Report (resident care guide used by direct care staff) did not list any activity programs or activity interest. During record review R61's Activity Evaluation completed 10/25/2022 demonstrated that he had a very important interest to listen to music that he preferred, a very important interest in keeping up to date with recent news, and an very important interest to complete his favorite activities. The Activity Evaluation demonstrated R61 had interest in cards (euchre and uno), arts and photography, football, motorcycle racing, pop music, soft rock music, author preference [NAME] King, television shows American Pickers, Pawn Stars and news, and his favorite type of movies was action and comedy. The Activity Evaluation also list that R61 required assistance to attend activities, received one to one visit, and was to receive leisure cart activities. In an interview on 02/15/2023 at 10:36 p.m. Activity Director Q explained that she had been in her current position for a few months. She explained that she had worked at the facility for two and a half years in the housekeeping department. R61 did not have an activity plan of care completed on admission. Activity Director Q confirmed R61's assessment of activity interest had been completed on his Activity Assessment which was completed 10/25/2022. Activity Director Q explained that items that R61 had high interest in card games and music but had not been conducted on a regular basis during his stay at the facility. Activity Director Q could not explain why R61's activities program was not being individualized. She explained that R61's plan of care was one of the care plans of the residents that she had not completed yet. Activity Director Q explained that she is expected to complete an activity care plan with the base line care plan which is to be completed within 48 hours. Activity Director Q could not explain why R61's base line plan of care was not completed. In an interview on 02/21/2023 at 10:10 a.m. the Nursing Home Administrator (NHA) A explained that Activity Director Q was currently in the process of completing an approved state training program for activities but had not yet completed the class. In an interview on 02/21/23 at 11:44 a.m. the Nursing Home Administrator (NHA) A provided the facility Activity Director job description which was signed by the Activity Director Q on 01/23/2023. The section listed Job Specifications stated, experience: 2 years' experience in a healthcare setting. NHA A was informed that the job description does not meet the federal regulation for qualification of an activity professional as the requirement states Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program. NHA A explained that Activity Director Q had worked in the activity department over the last two years to fill in and assist with the activity program, while she was working in the housekeeping department. NHA A was asked to provide proof of the hours that she had worked in that department. Nursing Home Administrator (NHA) A could not provide documentation demonstrating that Activity Director Q had worked in the activity department for 2 years in the last 5 years. NHA A did provide a sworn statement by Director of Activity Q (signed 02/21/2023) stating that she had worked in the activity department since 02/02/2021 in the role of assisting with outings, providing some 1:1 activity, and assisting with group programs. The statement did not demonstrate that Director of Activity Q was working in the activity department for a period that included one of two years full-time in a therapeutic activities program. NHA A did not provide documentation to satisfy the federal regulation by the time of survey exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview with confidential former staff member K during the survey from 2/13/23 to 2/21/23, Former staff member K stated the residents are getting taken care of properly due to a severe staffing shortage. Former Staff Member K reports that K witnessed on multiple occasions residents not receiving showers, not being properly supervised, mattresses soaked with feces and urine due to residents not getting appropriate brief changes, and residents not being turned appropriately causing an issue with pressure injuries. During an interview with confidential staff member R during the survey from 2/13/23 to 2/21/23, staff member R stated that someday's she does not have enough help due to shirt staffing to appropriately care for the residents during a shift. During an interview with confidential staff member W during the survey from 2/13/23 to 2/21/23, staff member W reported staffing sucks here and they cannot do job within its entirety. Staff member W: reported that the Certified Nursing Assistants are not able to do their job within its entirely either. Staff Member W reports that the Unit Mangers do not step in and pitch in when staffing is short. During an interview with confidential staff member X during the survey from 2/13/23 to 2/21/23, staff member X reported they often felt they worked with unsafe staffing levels. Staff member X reported the staffing is not an ideal situation and they struggle to complete their work during the shift. Staff member X stated that even if the facility has new hires, no one will stay because of the short staffing issue, it will drive them away> Director of Nursing (DON) B was interviewed on 2/21/23 at 9:42 AM and stated the facility had hospitality staff that were available to answer call lights, pass trays, and answer call lights. DON B stated she was not aware of staff not giving showers due to staffing numbers. DON B stated she just started audits for showers and planned develop a performance improvement plan and bring the issue to the quality assurance committee. This citation pertains to intakes MI00134041, MI00128303, MI00129119, and MI00127074. Based on observation, interview and record review, the facility failed to ensure adequate nursing staff to provide necessary care and services, 2 of 7 reported during a confidential resident council meeting, in a census of 59 residents and a sample size of 16 residents (Resident #23, #33, #47, #264, #18, #14, #41, #51, #23, #211, #61, and #12) resulting in unmet needs. Findings include: Resident #33 (R33) On 2/13/23 at 9:12AM R33 was observed lying in bed with his call light on. R33 expressed concern the facility was short of staff. R33 stated there was only one certified nurse assistant (CNA) and Registered Nurse for hall. R33 stated he had been wafting an hour and half for his brief, soiled with bowel, to be changed, and he had to wait until after breakfast. CNA M entered R33's room with linens and stated she was the only CNA for 18 residents. R33's Minimum Data Set (MDS) dated [DATE] revealed he admitted to the facility on [DATE]. R33 had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 14 (13-15 Cognitively Intact). R33's same MDS assessment indicated he was frequently incontinent of bowel and bladder. Resident #47 (R47) During an interview on 2/13/23 at 9:46 AM, R47 stated sometimes there were not enough staff. Resident #41 (R41) On 2/13/23 at 10:21 AM R41 stated it took an average of one-half hour for staff to respond to her call light. Resident #51 (R51) On 2/13/23 at 9:58 AM, R51 was observed lying on sheet that was soiled with dried blood. R51 stated the staff had brought in linens to change his gown and sheets when they had time. R51 complained that his hospital type gown smelled, and hoped someone would help change this afternoon. R51 stated he had sat in bowel for 4 hours waiting for care. On 2/16/23 at 11:14 AM a confidential Resident Council meeting was held with 6 residents in attendance. 2 residents reported there were not enough staff, and had to wait 2 hours to receive pain medication. During an interview during interview with confidential staff member O, during the survey from 2/13/23 to 2/21/23, they stated there were not enough staff to meet resident needs, and they could not get showers completed per resident preferences. During an interview during interview with confidential staff member I during the survey from 2/13/23 to 2/21/23, they stated sometimes they were staffed with 2 CNAs, and 19 residents on each assignment; it was overwhelming, showers were not done and if the resident had an appointment, it was really difficult. Director of Nursing (DON) B was interviewed on 2/21/23 at 9:42 AM and stated the facility had hospitality staff that were available to answer call lights, pass trays, and answer call lights. DON B stated she was not aware of staff not giving showers due to staffing numbers. DON B stated she just started audits for showers and planned develop a performance improvement plan and bring the issue to the quality assurance committee. Resident 23 According to the Minimum Data Set (MDS) dated [DATE], Resident 23 (R23) scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 02/13/23 at 09:50 AM, during an interview with (R23) she voiced complaints of long call light response times. R23 stated this was frequently an hour or longer and the identified a pattern of particularly long wait times on second shift. R23 stated she had complained to Director of Nursing (DON) B and Social Worker G. R23 stated this had been an ongoing problem for several and had filed grievances with no resolution , the usual response staff get busy. R23 reported due to the delay in call light response time she has had to sit in soiled briefs for an extended periods of time. On 2/14/23 at 11:28 am during a phone interview with former employee J it was reported that staffing levels were terrible and impossible to achieve or complete assigned duties such as repositioning, getting residents dressed, showered, fed, toileted, changed, oral care, returned to bed for a rest, gotten up again etc Former employee J reported usually being assigned 20 residents but did have up to 30 on a few occasions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 2/16/23 at 11:14 AM a confidential Resident Council meeting was held with 6 residents in attendance. All 6 residents reported they would like better food. 3 of 6 reported they had received burnt food and most of the time food was cold. Resident #12 Review of an admission Record revealed Resident #12 (R12) admitted to the facility on [DATE] with pertinent diagnoses which included paraplegia, unspecified urethral stricture, cutaneous abscess of groin, and muscle weakness. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/23/23, reflected R12 scored 14 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R12 did not walk and requires extensive assistance of two or more people to transfer, toilet, and maintain person hygiene. In an interview on 2-13-23 at 9:59 AM, R12 reported that the food is cold, yesterday it was so cold the chicken looked awful . the majority of the time it (the food) is cold .majority of the time (the food) is not good . (R12) had an employee try my french fry and they agreed with me . Resident # 18 Review of an admission Record revealed Resident #18 (R18) admitted to the facility on [DATE] with pertinent diagnoses which included neuropathy and depression. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/22, reflected R18 scored 11 of out 15 (moderate cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). In an observation and interview 02/16/23 at 09:47 AM, R18 reported the food is disgusting. (The food) was either undercooked over overcooked. R18 reports that she makes her own food in her room, she purchased food items from other places such as grocery stores and gas stations, and makes her own egg salad sandwiches and peanut butter and jelly sandwiches. Observed bread, pringles, muffins, a jar of olives, a jar of mayonnaise, potato chips, two-liter bottles of soda, and paper plates in R18's room. On 02/13/23 at 12:17 PM, during the dining observation on the 2nd floor of the facility, the food cart which contained food trays for the 2nd floor residents was observed to consistently have the door to the cart left open leaving the remaining trays to cool. Licensed Practical Nurse (LPN) H was observed to constantly shut the door and verbally remind staff to shut doors to cart , but the instructions were observed to be ignored. Certified Nursing Assistant (CNA) I was observed to remove three trays from the cart and set them on top of the cart then deliver one tray down the hall, leaving the remaining trays/food to get cold. On 02/13/23 at 12:36 PM, during the dining observation on the 3rd floor af the facility, the food cart which contained food trays for the 3rd floor reisdents was observed to consistently have the doors open to the cart left open, leaving the remaining trays to cool. Additionally, when the food cart was delievered to the 3rd floor, 3 food trays were observed on the top of the food cart leaving the three food trays suseptable to coolong to unsafe and undesirable food temperatures. Based on observations, interviews, record reviews, the facility failed to effectively provide palatable food products effecting 58 residents and 6 of 6 from the confidential group meeting, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline. Findings include: On 02/13/23 at 11:25 A.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded: Meat Loaf - 199.9 Mashed Potatoes/Brown Gravy - 139.9 Roasted Carrots - 194.1 Fruit & Yogurt Parfait - 61.2* Cornbread - 145.2 Beverage (2% Milk) - 47.3* (*) The 2017 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5ºC (41ºF) or less. On 02/13/23 at 11:41 A.M., An interview was conducted with Dietary Manager D regarding the meal food tray delivery schedule. Dietary Manager D stated: We deliver two food carts to 2nd floor and one food cart to 3rd floor. On 02/13/23 at 11:48 A.M., An interview was conducted with Dietary Manager D regarding current enteral feeding residents. Dietary Manager D stated: One resident (#4) is total Non-Per-Oral (NPO). On 02/13/23 at 12:09 P.M., Lunch meal food trays (24) were observed leaving the food production kitchen. On 02/13/23 at 12:10 P.M., Lunch meal food trays (24) were observed arriving to 2nd floor. On 02/13/23 at 12:19 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #40's lunch meal food tray: Meat Loaf - 112.0* Mashed Potatoes - 122.7* Cornbread - 105.4* Fruit & Yogurt Parfait - 57.1* Beverage (Apple Juice) - 64.4* Beverage (Coffee) - 146.4 Beverage (Vanilla Nutritional Shake) - 56.8* (*) The 2017 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5ºC (41ºF) or less. On 02/13/23 at 12:22 P.M., Lunch meal food trays (14) were observed leaving the food production kitchen. On 02/13/23 at 12:23 P.M., Lunch meal food trays (14) were observed arriving to 2nd floor. On 02/13/23 at 12:35 P.M., Lunch meal food trays (20) were observed leaving the food production kitchen. On 02/13/23 at 12:36 P.M., Lunch meal food trays (20) were observed arriving to 3rd floor. On 02/13/23 at 12:45 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #12's lunch meal food tray: Meat Loaf - 125.2* Mashed Potatoes - 132.8* Carrots - 119.4* Cornbread - 109.0* Fruit & Yogurt Parfait - 55.9* Beverage (Red Fruit Punch) - 56.1* (*) The 2017 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5ºC (41ºF) or less. On 02/15/23 at 11:50 A.M., Lunch meal food trays (20) were observed leaving the food production kitchen. On 02/15/23 at 11:52 A.M., Lunch meal food trays (20) were observed arriving to 3rd floor. On 02/15/23 at 11:56 A.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #18's lunch meal food tray: Toast - 144.2 Fried Eggs - 135.3 Mandarin Oranges - 53.6* Beverage (Red Fruit Punch) - 44.7* (*) The 2017 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5ºC (41ºF) or less. On 02/15/23 at 12:05 P.M., Lunch meal food trays (19) were observed leaving the food production kitchen. On 02/15/23 at 12:07 P.M., Lunch meal food trays (19) were observed arriving to 2nd floor. On 02/15/23 at 12:21 P.M., Lunch meal food trays (21) were observed leaving the food production kitchen. On 02/15/23 at 12:23 P.M., Lunch meal food trays (21) were observed arriving to 2nd floor. On 02/15/23 at 12:24 P.M., The insulated vulcanized transport cart was observed with 1 of 2 doors open between food tray deliveries on 2nd floor. On 02/15/23 at 12:28 P.M., The insulated vulcanized transport cart was observed with 2 of 2 doors open between food tray deliveries on 2nd floor. On 02/15/23 at 01:00 P.M., Record review of the Policy/Procedure entitled: Accuracy and Quality of Tray Line Service dated (no date) revealed under Policy: Tray line positions and set up procedures will be planned for efficient and orderly delivery. All meals will be checked for accuracy by the food and nutrition services staff, and by the service staff prior to serving the meal to the individual. Record review of the Policy/Procedure entitled: Accuracy and Quality of Tray Line Service dated (no date) further revealed under Procedure: (5) Staff will refer to the meal identification (ID) card/ticket for food dislikes, allergies, and other details, and substitute appropriately for those items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 59 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 02/14/23 at 10:30 A.M., A common area environmental tour was conducted with Nursing Home Administrator (NHA) A and Director of Maintenance C. The following items were noted: First Floor Occupational Therapy: The refrigerator interior appliance light bulb was observed non-functional. Physical Therapy: Staff restroom return air ventilation grill was observed heavily soiled with dust and dirt deposits. Staff Break Room: The microwave oven interior was observed (corroded, particulate, bubbled). The (NHA) indicated she would have the damaged microwave oven replaced as soon as possible. Main Dining Room: The Old Fashioned Theatre Popcorn Machine interior (side window and ceiling) surfaces were observed soiled with accumulated and encrusted food residue. Second Floor Day Room: One severely frayed and soiled hand broom was observed resting upright, within the corner. One black plastic dustpan interior was also observed heavily soiled with (dust, dirt, and grime), located adjacent to the red emergency medical crash cart. Staff Restroom: The hand sink was observed loose-to-mount, creating an approximate 0.5-1.0-inch-wide gap between the hand sink basin and drywall surface. The hand sink caulking bead was also observed (cracked, separated, missing). The return air exhaust ventilation grill was additionally observed heavily soiled with accumulated and encrusted dust/dirt deposits. Laundry Chute Room: The return air ventilation grill was observed heavily soiled with accumulated dust and dirt deposits. Clean Linen Closet: The return air ventilation grill was observed heavily soiled with dust and dirt deposits. Third Floor Laundry Chute Room: The return air ventilation grill was observed heavily soiled with dust and dirt deposits. Personal Protective Equipment (PPE) Storage Room: The return air ventilation grill was observed heavily soiled with dust and dirt deposits. The metal door frame jamb was also observed soiled with accumulated dust and dirt deposits. Soiled Utility Room: The hand sink faucet assembly was observed (corroded, leaking, particulate). Replace faucet assembly. The Laboratory Specimen Refrigerator freezing compartment was also observed one-quarter occluded with ice [NAME]. On 02/14/23 at 12:30 P.M., An environmental tour of sampled resident rooms was conducted with Nursing Home Administrator (NHA) A. The following items were noted: 206: The drywall surface was observed (etched, scored, particulate), adjacent to Bed 1. The damaged drywall surface measured approximately 24-inches-wide by 36-inches-long. The restroom entrance door was also observed swelled and extremely difficult to close. 212: The Bed 1 overbed light assembly upper 48-inch-wide fluorescent light bulb was observed non-functional. Two pink plastic wash basins were also observed soiled and resting directly on the restroom flooring surface. One blue hospital gown and two used wash clothes and one used hand towel were additionally observed resting directly on the restroom flooring surface, located beneath the hand sink basin. The waste basket plastic liner was further observed ill placed, creating a soiled interior container surface. 224: The geriatric blue scoop mattress exterior surfaces were observed (etched, worn, torn), exposing the inner foam padding. The flooring surface (wall/floor junctures and corners) were also observed soiled with accumulated and encrusted dust and dirt deposits. The flooring surface was further observed soiled with (paper products, plastic lids, wash cloth, hand towel, etc.) The closet door interior surface was additionally observed soiled with bodily waste (fecal material). The closet door exterior surface was further observed soiled with moist facial tissue remnants. 226: The Bed 1 and Bed 2 overbed light assembly upper light lens covers were observed soiled with accumulated dust and dirt deposits. The flooring surface was also observed very soiled and sticky. (NHA) A indicated she would have staff thoroughly clean and sanitize the flooring surface as soon as possible. 228: The Bed 2 fitted bed sheet was observed heavily soiled with bodily fluids and waste. The Bed 2 flooring surface was also observed soiled with bodily fluids and waste. The neutral-colored plastic waste basket interior and exterior surfaces were further observed heavily soiled with accumulated (dirt, food residue, and grime). Resident #51 stated: I have not had a shower in a month. Resident #51 additionally stated: I have been wearing the same hospital gown for 14 days. 230: The Bed 1 designated area was observed in disarray. Bed 1 was also observed covered with clothing and bedding articles. The nightstand was additionally observed covered with miscellaneous items: (bowl, ranch salad dressing containers, paper products, Styrofoam cups, etc.). The Bed 1 overbed light assembly plastic light lens cover was also observed soiled with accumulated dust and dirt. The Bed 1 night light pull string extension was additionally observed missing. The drywall surface was further observed (etched, scored, particulate), adjacent to the Bed 2 headboard. The damaged drywall surface measured approximately 12-inches-wide by 36-inches-long. Resident #11's clear plastic oxygen tubing and nasal canula was further observed stored directly on the restroom flooring surface. The hand sink basin was also observed draining extremely slow. The restroom neutral-colored plastic waste basket was further observed cracked and broken. 301: The entrance door latch assembly was observed to not latch properly and securely. 304: The Bed 2 overbed light assembly pull string extension was observed missing. 309: The HVAC Unit filter was observed soiled with accumulated dust and dirt deposits. 322: The Bed 2 overbed light assembly night light was observed non-functional. The Bed 2 light switch plate and adjacent area was also observed soiled with accumulated and encrusted food residue. 331: The HVAC Unit filter was observed soiled with accumulated dust and dirt deposits. On 02/14/23 at 02:45 P.M., An interview was conducted with Nursing Home Administrator (NHA) A regarding the facility maintenance work order system. (NHA) A stated: We have the TELS software system. On 02/14/23 at 04:15 P.M., Record review of the Direct Supply TELS Work Orders for the last 30 days revealed no specific entries related to the aforementioned maintenance concerns. On 02/14/23 at 04:30 P.M., Record review of the Policy/Procedure entitled: Cleaning and Disinfecting Resident Rooms dated (08/2013) revealed under Purpose: The purpose of this procedure is to provide guidelines for cleaning and disinfecting resident's rooms. Record review of the Policy/Procedure entitled: Cleaning and Disinfecting Resident Rooms dated (08/2013) further revealed under General Guidelines: (1) Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visible soiled. (2) Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. On 02/14/23 at 04:45 P.M., Record review of the Policy/Procedure entitled: Cleaning and Disinfection of Environmental Surfaces dated (08/2019) revealed under Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. Record review of the Policy/Procedure entitled: Cleaning and Disinfection of Environmental Surfaces dated (08/2019) further revealed under Policy Interpretation and Implementation: (6) A one-step process and an EPA-registered hospital disinfectant designed for housekeeping purposes will be used in resident care areas where: (a) uncertainty exists about the nature of the soil on the surfaces (e.g., blood or body fluid contamination versus routine dust or dirt); or (b) uncertainty exists about the presence of multidrug-resistant organisms on such surfaces.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 58 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 02/13/23 at 08:47 A.M., An initial tour of the food service was conducted with Dietary Manager D. The following items were noted: One 6-inch-wide non-stick fry pan interior food contact surface was observed severely (etched, scored, particulate). One 10-inch-wide non-stick fry pan interior food contact surface was observed severely (etched, scored, particulate). One 16-inch-wide non-stick fry pan interior food contact surface was observed severely (etched, scored, particulate). The 2017 FDA Model Food Code section 4-202.11 states: (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; and (4) Finished to have SMOOTH welds and joints. The can opener assembly and mounting bracket was observed soiled with accumulated and encrusted food residue. Dietary Manager D indicated she would have staff thoroughly clean and sanitize the can opener assembly and mounting bracket as soon as possible. The two Vulcan convection oven interior and exterior surfaces were observed soiled with accumulated and encrusted food residue. The two Vulcan conventional oven exterior surfaces were observed soiled with accumulated and encrusted food residue. Dietary Manager D indicated she would have staff thoroughly clean and sanitize the convection and conventional oven interior and exterior surfaces as soon as possible. Mop Closet: The mop sink basin was observed heavily soiled with accumulated and encrusted (dust, dirt, and grime) deposits. Dietary Manager D indicated she would have staff thoroughly clean and sanitize the soiled mop sink basin as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 02/13/23 at 11:48 A.M., An interview was conducted with Dietary Manager D regarding current enteral feeding residents. Dietary Manager D stated: One resident (#4) is total Non-Per-Oral (NPO). On 02/15/23 at 09:15 A.M., Record review of the Policy/Procedure entitled: Cleaning and Sanitation of Dining and Food Service Areas dated (no date) revealed under Policy: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. On 02/15/23 at 09:30 A.M., Record review of the Policy/Procedure entitled: Cleaning Instructions: Ranges/Griddles dated (no date) revealed under Policy: The cook/chef on each shift is responsible for keeping the range and/or griddle as clean as possible during the preparation of the meal. The range/griddle will be cleaned after each use. Spills and food particles will be wiped up as they occur. On 02/15/23 at 09:45 A.M., Record review of the Policy/Procedure entitled: Cleaning Instructions: Ovens dated (no date) revealed under Policy: Ovens will be cleaned as needed and according to the cleaning schedule (at least once every two weeks). Spills and food particles will be removed after each use.