This deficiency pertains to Intake MI00143784. Based on interview and record review, the facility failed to timely report an allegation of abuse to the State Agency for one Resident (R15) of three residents reviewed for abuse. This deficient practice resulted in the potential for continuation of potential abuse for vulnerable facility residents. Findings include: All times are in Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of R15's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R15 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R15 had clear speech, understood others, and was able to make her needs known. During an interview on 10/21/24 at 3:15 p.m., Resident #15 (R15) was asked if there were any concerns with physical or verbal abuse, or disrespectful care in the provision of care and services by staff. R15 stated, I told [Certified Nurse Aide (CNA) B] first that they were poking their gloved finger in my [vaginal area] . and it hurt . There are a lot of older women in here that are not on the ball, and I am hoping that they are not doing that to them, and they don't know . During an interview on 10/22/24 at approximately 7:55, a.m., CNA B was asked if R15 had reported to her that [CNA A] had poked her vaginal area with their gloved finger. CNA B confirmed R15 had reported the concern, and stated, I told the nurse four days ago - on Friday. During an interview on 10/22/24 at 9:10 a.m., R15 was asked about any further concerns related to mistreatment by staff. R15 stated, [CNA A] is mean. [CNA A] yells at you. [CNA A] gets right in your face. You get so tired of [them] yelling in your face you agree with [them] so [they] get out of your room. [CNA A] is not a nice person . [They are] sticking [their] finger in my vaginal area. [They] said there was poop in there . I don't know what [they were] trying to prove, but I know it hurt. When [they] went back again and poked me in the vaginal area. I had had it. I don't tell the DON (Director of Nursing) anything anymore, because she doesn't do a damn thing. When [the Nursing Home Administrator (NHA) ]was here yesterday, she asked if I wanted to file with the police . During an interview on 10/22/24 at 1:28 p.m., the NHA was asked if they had reported R15's allegation of potential sexual abuse to the State Agency. The NHA acknowledged she had heard staff talking about a finger in someone's vagina but was unaware of any additional detail. The NHA said the allegation of potential sexual abuse was not reported to the State Agency. Review of the facility Abuse Prevention Program Policy & Procedure, reviewed 01/2024, revealed the following, in part: All alleged or suspected violations are to be reported immediately to the Administrator or Director of Nursing, which are responsible to notify required officials, including to the State Survey Agency, Adult Protective Services, Local Public Safety, Licensure Boards, Regional Director of Operations or Regional clinical Directors and any other agencies in accordance with state law .All alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse .

This deficiency pertains to Intake MI00143784. Based on interview and record review, the facility failed to timely and fully investigate an allegation of abuse for one Resident (R15) of three residents reviewed for abuse. This deficient practice resulted in the potential for continuation of potential abuse for vulnerable facility residents. Findings include: All times are in Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of R15's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R15 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R15 had clear speech, understood others, and was able to make her needs known. During an interview on 10/21/24 at 3:15 p.m., Resident #15 (R15) was asked if there were any concerns with physical or verbal abuse, or disrespectful care in the provision of care and services by staff. R15 stated, I told [Certified Nurse Aide (CNA) B] first that they were poking their gloved finger in my [vaginal area] . and it hurt . There are a lot of older women in here that are not on the ball, and I am hoping that they are not doing that to them, and they don't know . During an interview on 10/22/24 at approximately 7:55, a.m., CNA B was asked if R15 had reported to her that [CNA A] had poked her vaginal area with their gloved finger. CNA B confirmed R15 had reported the concern, and stated, I told the nurse four days ago - on Friday. During an interview on 10/22/24 at 1:28 p.m., the NHA was asked for any investigation documentation related to CNA A's treatment of facility residents. The NHA said they were in the middle of an investigation of a staff-to-staff incident with CNA A but had no investigations regarding inappropriate provision of care by CNA towards R15 or any other facility resident. The NHA acknowledged she had heard staff talking about a finger in someone's vagina but was unaware of any additional details. When asked if she had any previous or current resident or staff grievances related to CNA's treatment of facility residents, the NHA said she had not had any other concerns voiced by either facility residents or facility staff about CNA A. Review of the facility Abuse Prevention Program Policy & Procedure, reviewed 01/2024, revealed the following, in part: Staff to Resident Abuse: All staff are expected to be in control of their own behavior, are to behave professionally, and should appropriately understand how to work with the nursing home population . The Administrator and or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Investigations must be initiated immediately and concluded as soon as possible not to exceed (5) days .Identify and interview (witness statements) all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s) such as roommate . interview with co-workers or other supervisors in regard to the alleged perpetrator's work performance . In order to complete the Resident Abuse Investigation, all information must be gathered and reviewed, with a final summary analysis with an action plan to prevent reoccurrence . Residents are protected from physical and psychosocial harm during and after the investigation .

Based on interview and record review, the facility failed to appropriately conduct a gradual dose reduction (GDR) for an antidepressant medication for one Resident (R19) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for adverse medication side effects. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted Resident #19 (R19) Review of R19's Electronic Medical Record (EMR) revealed admission to the facility on 7/8/22 with diagnoses including anxiety disorder, depression, and adult failure to thrive. Review of her 10/18/24 Brief Interview for Mental Status (BIMS) score on her Minimum Data Set (MDS) assessment revealed an 8/15, indicating moderately impaired cognition. Review of the Consultation Report from [Pharmacy Name} for 9/13/24 read, in part, (R19) has received Lexapro (antidepressant medication) 10 mg (milligrams) daily since Sept (September) 2022. Her last PHQ-9 score from July was 0 indicating no signs/symptoms of depression. According to the (name of Company) progress note from July it states that a GDR for Lexapro is overdue. Moods and behaviors are stable, and she does well with non-pharmacological interventions. It is time for a periodic review for a possible dose reduction. Recommendation: Please consider a lower dose such as Lexapro 5 mg daily. Further review of the Consultation Report dated 9/13/24 had Physician N respond I decline the recommendation .Resident doing well with dose reduction likely to lead to clinical decline Review of R19's Psychoactive Medication Quarterly Evaluation dated 10/15/24 read, in part, Dose: Lexapro 10 mg daily .comments/recommendations: Lexapro therapy started 6/2/22; CI (contraindicated) 9/23/24; next GDR evaluation due 9/23/25 . An interview was conducted with Physician N on 10/23/24 at 1:35 p.m. Physician N stated that R19 did not receive a dose reduction of her Lexapro because she had been functioning well on the medication. Physician N stated that she has known R19 in the facility for about two years and knew her in the community as well. When asked if Physician N ordered for R19 to be seen by (name of Company), she stated no. When asked if Physician N is aware of the facility's policy regarding GDR's, she stated no. An interview was conducted with the Director of Nursing (DON) on 10/23/24 at approximately 1:45 p.m. The DON confirmed that R19 should have had an attempted GDR of Lexapro and would discuss the facility's policy with Physician N Review of R19's Physician Orders on 10/23/24 revealed she was still receiving Lexapro 10 mg every day since September 2022. Review of the facility's Gradual Dose Reduction of Psychotropic Drugs policy reviewed on 1/2024 read, in part, .Psychotropic Drug is defined as any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, antianxiety, and hypnotics .Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility will attempt a GDR in two separate quarters .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident/residents durable power of attorney (DPOA) understood the purpose of binding arbitration agreements (an out of court alternate form of dispute resolution) for one Resident #19 (R19) of three residents reviewed for arbitration. Findings include: Resident #19 (R19) A review of R19's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/8/22, with active diagnoses that included anxiety disorder, depression, and hypertension. R19 scored 6 of 15 on the Brief interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Review of facility arbitration document titled Freeman Resolving Potential Disputes, revealed R19 signed the agreement on 12/29/22. Review of facility document titled Decision Making Capacity Determination, read in part . This form serves as documentation of the determination of [R19's] capacity to participate in medical treatment and decision following examination .this has been determined by two physicians .R19 has been evaluated and determined to lack capacity to make reasoned medical decisions. One signature was obtained by a physician on 7/26/24 and a second signature was obtained by a physician on 8/8/24. Review of facility arbitration document titled [Facility] Resolving Potential Disputes, read in part . Right to cancel agreement . the personal representative of the residents estate in the event of the residents death or incapacity as the right to cancel this agreement . During an interview on 10/23/24 at 12:24 p.m., Social Services Designee M acknowledged that the arbitration agreement was not revisited when R19 was determined not to have the capacity to make decisions for herself and R19's Durable Power of Attorney (DPOA) was activated.

Based on observation, interview, and record review, the facility failed to ensure disinfection of environmental surfaces, appropriate hand hygiene and donning and doffing of gloves to prevent the spread of infection for one Resident (R15) of three residents reviewed for wound care. This deficient practice resulted in the potential for increased transmission of infectious organisms between the environment and/or contaminated hands during wound care. Findings include: All times noted are Eastern Daylight Savings Time (EDST), unless otherwise noted. During observation of R15's thoracic (back) wound on 10/22/24 at approximately 7:50 a.m., revealed the dressing was dated 10/21/24. The dressing was bunched up on the bottom, and not properly sealed onto R15's skin. The black sweatshirt R15 was wearing was visibly soiled with the oozing drainage from the wound, which had saturated the dressing and spilled out onto the sweatshirt. During an interview at this same time, Licensed Practical Nurse (LPN) D was asked about the drainage that had escaped R15's wound dressing unto their clothing. LPN D said she was going to change the dressing today (10/22/24) because the dressing was not intact, and it was leaking drainage unto R15's clothing. Certified Nurse Aide (CNA) B held up R15's sweatshirt and showed the wound drainage stain on the clothing. CNA B confirmed R15's black sweatshirt was stained with the oozing drainage from R15's open, draining thoracic wound. Observation of wound care for R15 on 10/23/24 at 9:10 p.m., was performed by Registered Nurse (RN)/Nurse Manager F, with assistance from CNA B and CNA C. RN F brought wound dressing change supplies into R15's room on a small tray with extra gloves carried in her gloved hand. RN F set the clean gloves down on R15's dirty overbed table that was not disinfected prior to use. R15's back, thoracic wound was covered with a dressing dated 10/21/24, the same dressing as observed on the morning of 10/22/24 with LPN D. R15's thoracic dressing was fully saturated and dripping serosanguinous drainage as it was removed from R15's back. The skin under the saturated dressing appeared red and inflamed. RN F discarded the saturated dressing from R15's back. RN F picked up the wound cleanser container and clean gauze and was going to begin cleansing R15's open, thoracic wound when this Surveyor requested, she change her dirty gloves. RN F removed her dirty gloves and picked up a pair of gloves from R15's dirty overbed table. RN F was asked if she had disinfected the overbed table and acknowledged they had not. RN F threw the gloves that had been sitting on the overbed table away and started to don clean gloves from a box in R15's room. RN F was stopped and asked to perform hand hygiene by this Surveyor prior to donning clean gloves and continuation of wound care. Review of R15's Physician Orders on 10/23/24 at 9:20 p.m., revealed the following order, in part: Cleanse thoracic wound with NS, (normal saline) pat dry, apply DermaCol to wound bed, apply calcium alginate over DermaCol, cover with adhesive foam, change daily. Once a Day, 6:00 p.m. to 6:00 a.m. [Central Daylight Savings Time (CDST)] . Created 6/22/24. During an interview at this same time, when asked about the lack of a PRN (as needed) order for the thoracic dressing, the DON stated, That may be a problem. R15, present in the room stated, That is a problem for me too. [CNA B] tells them (the nurses) the dressing needs to be changed. [CNA B] has seen it ooze all the way down (my back) . During an interview on 10/23/24 at 11:23 a.m., the DON and Regional Clinical Manager K were asked about the infection control breaches observed during wound care for R15. The DON stated, They (staff) should remove their gloves and re-sanitize (their hands) and put on a fresh pair (of gloves). I would stop them if they didn't do those things. That is against infection control practices. If you are going to set your gloves down, you would want a barrier (on the overbed table). The DON confirmed there was no PRN order for change of R15's wound dressing, if it was not intact or the dressing was leaking until that day, 10/23/24. The DON said it would be a Standard of Practice to change the dressing if it was fully saturated and leaking. Review of the Centers for Disease Control (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, dated February 27, 2024, revealed the following, in part: Cleaning your hands reduces: The potential spread of deadly germs to patients. Some healthcare personnel may need to clean their hands as often as 100 times during a work shift to keep themselves, patients and staff safe . Know when to clean your hands: - Immediately before touching a patient . - After touching a patient or patient's surroundings. - After contact with blood, body fluids, or contaminated surfaces. - Immediately after glove removal. Know when to wear (and change) gloves: - If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. - Always clean your hands after removing gloves. - Remember to remove gloves carefully to prevent hand contamination as dirty gloves can soil hands .

Based on observation, interview, and record review, the facility failed to provide a comfortable mattress and functional, intact shelving for clothing storage for one Resident (R15) of 13 sample residents reviewed for comfortable and functional furniture. This deficient practice resulted in the use of an under-inflated, uncomfortable mattress and a built in four-shelf drawer unit with the third drawer missing. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of R15's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R15 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R15 had clear speech, understood others, and was able to make her needs known. During an interview on 10/21/24 at 2:52 p.m., when asked about care received in the facility, R15 stated, I am laying on a bed right now, and the lady came in from [Facility Corporation] and said, 'What is wrong with your bed'. I am lying on the springs . They took my good mattress, and I have been laying on this Mattress and [Regional Clinical Director K] came in and said there is no air in there (the mattress) . I am laying on a flat (under-inflated) bed again and it hurts. What do you think about that? [The Director of Nursing (DON)] was in here today, and she said we have to get hoses for the bed . I thought the Maintenance guy (Maintenance Director J) would come in to look at the bed, and no - nothing. Now I am laying right back on the flat bed. They switched the mattress about three weeks ago at 1:00 a.m. in the morning. The (facility staff) told me to be quiet, it was the only time they had to switch the mattress . Observation of R15's dresser shelving unit found the third drawer missing, leaving an open space where the clothing below in the fourth drawer could be visualized. During an interview and observation on 10/22/24 at 7:45 a.m., R15 again complained that the mattress was not comfortable. Certified Nurse Aide (CNA) B, and Licensed Practical Nurse (LPN) D transferred R15 to a wheelchair. The mattress R15 had been laying on appeared indented and underinflated with air where R15's buttocks was positioned on the bed. The indentation did not change as time passed with R15 in the wheelchair. LPN D pressed down on the mattress at the indentation point, and confirmed there was no inflation of the mattress and stated, There is something hard here. CNA B, also pressed down at the point of indentation where R15's buttocks had been positioned and said there was no inflation that she felt in the mattress. Both LPN D and CNA B agreed that the bed frame and mattress tubing was felt, exactly as R15 had described. During an interview and observation on 10/22/24 at approximately 8:00 a.m., the DON, was asked to press on the mattress indentation. The DON pressed down on the mattress and said she didn't know anything about the bed, but it was supposed to work without air inflation. The DON said she believed the rental company brought the bed in, inflated it, and perhaps it was placed on her bed at a later time. During a telephone interview on 10/22/24 at 8:15 a.m., mattress manufacturer Director of Customer Services H was asked about the mattress delivery to the facility. Customer Services H stated, It was delivered October 5th 2024, a Saturday . There are 144 Roho cushion cells - on a foam base. Those cushions (cells) should be inflated. It was left in the hallway to be placed by the facility . It needs to be adjusted occasionally. Some of those can leak . There are three ports : one for the head section, middle section, and foot section. You can't inflate it if a hose isn't connected. Open the mattress - there is a fire barrier . you will see the external port and you will see the three hoses and it goes up the side of the mattress up by the rail and you can see where each section leads. You will be able to see the uninflated cells . During an observation and interview with the DON and Maintenance Director J on 10/22/24 at 8:31 a.m., both agreed that the middle section of air cells on the mattress appeared to be under-inflated in comparison to the foot section and the head section. Maintenance Director J said he was not responsible for the mattresses in the facility, and he did not have any idea how this (rented) mattress worked. The head section, upon palpation by this Surveyor also had under-inflated air cells as did the middle section where R15's bottom would have been positioned. The DON stated she would contact [the mattress manufacturer] and see if they could get someone there to inflate the mattress air cells. During an interview on 10/22/24 at 9:10 a.m., when asked if they had complained about the uncomfortable mattress, R15 stated, They would look me right in the eye and said that mattress was ok - so I just laid on it. I don't complain about too much of anything anymore. They don't do anything anyway . Maybe they just don't like me and my personality . During an interview and observation on 10/22/24 at 4:00 p.m., when asked about the mattress that was just removed from R15's bed, Customer Service I (who had been dispatched that day (to inspect the mattress by the rental company), stated, I think the mattress may have been inflated at a lower pressure for a different resident. The middle air cells were creased up on each other, collapsing some of the air cells so the [R15's] butt was going right down to the cushion (foam mattress). The creased air cells forced all the air to one side of the cushion, so it could not inflate all the cells. Customer Service I said that the mattress was an older mattress, so they had just replaced it with a newer model that day. During an interview and observation of R15's room during wound care on 10/23/24 at approximately 9:05 a.m., found the third shelf still missing from the built-in shelving unit in the room. When asked why the drawer was missing, R15 said they had told her someone needed a drawer, so they came and took the third drawer out of her shelving unit. R15 said it had been missing for a long time. The clothing in the bottom drawer was still visible. RN/Nurse Manager F, and CNAs B' and C were all present in the room at the time of the interview. Review of the [Model Name] LTC (long term care) 105 mattress manufacturer instructions, copyright 2008-2013, provided by Maintenance Director J revealed the following, in part: .Caregiver: Before using this product read these instructions and save for future reference . Cautions: CHECK EACH MATTRESS SECTION AND ACCESSORY AT LEAST ONCE PER DAY in order to make sure it is properly inflated, adjusted, and if applicable, snapped together . UNDER-INFLATION: DO NOT use an under-inflated product. Using a product that is under-inflated reduces or eliminates the product's benefits, increasing the risk to skin and other soft tissue. If the product appears under-inflated or does not appear to be holding air, check to make sure that all hoses are connected and refer to Troubleshooting section of this manual. If the product is still not holding air, contact your health care provider, distributor, or supplier or [Manufacturer] immediately. WEIGHT LIMIT: The mattress should be correctly sized to the end-user and the bed . DO NOT allow end-user to lie on an under-inflated or over-inflated mattress. Check at least once a day for proper adjustment .

Based on interview and record review, the facility failed to ensure the provision of dignified and respectful care and treatment for four Residents (R15, R24, R131, and R17) of 13 sampled residents reviewed for resident rights. This deficient practice resulted in resident dissatisfaction, frustration, and fear of mistreatment. Findings include: All times are in Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident R15 Review of R15's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R15 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R15 had clear speech, understood others, and was able to make their needs known. During an interview on 10/22/24 at 7:45 a.m., R15 said she had been told by CNA A that she was not a priority for [them] to provide care for. CNA B also present in the room providing care for R15 was asked if they had ever heard CNA A tell R15 that she was not a priority for [them] to care for. CNA B confirmed R15 had told her CNA A told her (R15) that she was not a priority to [them]. CNA B said CNA A had also directly told [CNA B] that R15 was not a priority to them in the provision of care. During an interview on 10/22/24 at 9:10 a.m., when asked about disrespectful and/or undignified treatment by staff, R15 stated, [Certified Nurse Aide (CNA) A] is mean. [They] yell at you. [They] get right in your face. You get so tired of [them] yelling in your face you agree with [them] so [they] get out of your room. [CNA A] is not a nice person . I have heard [CNA A] yelling at [R24], so I know [they are] mean to [R24], I have heard it. Resident R24 Review of R24's MDS assessment, dated 9/23/24, revealed R24 scored 13 of 15 on the BIMS, reflective of intact cognition. R24 had clear speech, understood others, and was able to make their needs known. During an interview on 10/22/24 at 9:00 a.m., R24 was asked if there were any staff that treated them disrespectfully. R24 stated, That big, fat [individual] (confirmed with R24 as CNA A). [They] treat me roughly. [They] have good moods, but when [they[ are in a bad mood . what happens then . I don't even want to tell you. [They] yell . If it (the facility) could be without [CNA A] it would be good. Everybody hates [them] . Resident R131 Review of R131's Face Sheet revealed they were a new admission to the facility. R131 was listed as their own responsible party, and was admitted for a short-term rehabilitation stay following a fall with fracture prior to admission. R131 had no diagnoses that indicated impaired cognitive function. The MDS assessment, dated 10/10/24, contained no documentation of cognitive function. During an interview on 10/22/24 at 9:45 a.m., R131 was asked if they had any concerns with the care provided by facility staff. R131 stated, Sometimes I have to wait an hour or an hour and a half to go to the bathroom. I have this hernia, and it starts pulsing when my bladder is full. I call them (CNA staff), a little before I really have to pee and sometimes, I have to wait an hour . I was actually crying. My hernia was pulsing, and it was hurting . During this interview R131 was able to clearly answer all questions without hesitation, or any indication of impaired cognition. During an interview on 10/23/24 at 1:41 p.m., CNA C was asked if they were aware of any staff member that had provided disrespectful or undignified care. CNA C stated, They (staff) call [them] 'The Creeper'. (It is) the way [CNA A] approaches the residents - [their] demeanor towards them (the residents) . There have been multiple times that residents have complained, and I reported to the [nurses] . With (resident who was) a constant ringer, CNA A would swing the door open and yell 'What are you doing ringing that bell all the time.' . [CNA A] boils my blood. I reported [CNA A] more than once. I yelled at the Director of Nursing (DON). I am not trying to get anybody fired, but where do you draw the line. [CNA A's] best intentions are not for the resident . I would rather have my residents safe that to have a resident look at me and say I don't want [CNA A] in my room. Resident (R25) has said they don't want [CNA A] in [their] room. [R2] has complained about [CNA A]. [R5] has complained about [CNA A]. I got mean enough that something needed to be done so they moved [CNA A] to afternoons, (from the night shift) so there were more people to watch [CNA A]. The nurse cannot babysit [CNA A]. We are adults here . It does not surprise me what they are investigating now .I took an oath to protect and make sure that these people are safe .[CNA A] got booted off (not working on) south because everyone was complaining about [CNA A] over there . I have reported [CNA B] (to facility administration) . Resident R17 An interview was conducted with R17 on 10/22/24 at 10:17 a.m. R17 stated that she has concerns with the care provided by CNA A. RN17 stated, (CNA A) is rude and inappropriate. I don't want [CNA A] to take care of me. Awhile ago I turned on my call light and (CNA A) told me to 'Find my own help' and turned off my call light and walked away. R17 stated that she did tell the DON about her issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to add or revise nutritional interventions in a timely manner for one (Resident #20) of twelve residents reviewed for care plans. This deficient practice resulted in the potential for unnecessary weight loss. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Resident #20 (R20) Review of R20's electronic medical record (EMR) revealed admission to the facility on 2/6/23 with diagnoses including adult failure to thrive, severe unspecified dementia, and Parkinson's disease. Review of R20's Minimum Data Set (MDS) Significant Change assessment dated [DATE] indicated R20 weighed 121 lbs. (pounds). A quarterly MDS assessment dated [DATE] indicated R20 weighed 112 lbs. which represented a 7.44% weight loss in approximately 30 days. Review of Dietary Progress note by the Registered Dietitian (RD) dated 9/19/23 read in part, Wt (weight) review: current wt 111#, signif (significant) wt loss 30, 90, 180 days, 13.4%, 17.2%, 23% respectively. wts have declined over the the (sic) last 6 months, po intake varies25-100% .no recommendations at this time, will continue to monitor. May be candidate for Hospice Services. Review of R20's nutrition care plan identified, Problem: Resident is at Nutritional/Hydration risk d/t (due to) cognitive impairment r/t (related to) Dementia with a goal that read in part, Resident will have adequate intake AEB (as evidenced by) no noted significant weight loss. R20's care plan revealed one updated goal since the Significant Change Assessment on 9/7/23 reading, Approach Start Date: 9/29/29. DPOA (durable power of attorney) wishes for resident have clothing protector on during meals. No other updates were evident on the care plan despite a documented 13.4% weight loss over the previous 30 days. Review of facility policy titled, Dietary Manual, Nutritional Assessment revised 4/21, read in part, Once a problem has been identified and the Dietitian has been consulted, the primary nurse should work with the Dietitian and resident in setting realistic goals and identify approaches to be used . No updated goals were evident in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent new pressure ulcers from developing for one Resident (R14) of one resident reviewed for pressure ulcer care. This deficient practice resulted in two new, facility-acquired pressure injuries to R14's coccyx. Findings include: All times reported are in Eastern Standard Time (EST) unless otherwise noted. During an observation and interview on 11/28/23 at 2:41 p.m., R14 was asked about the presence of any pressure ulcers. R14 stated, I don't know if I have any open areas on my bottom today . My rear is sore . During an observation of her bottom with Certified Nurse Aides (CNAs) L and M, the presence of one Stage II pressure injury to R14's coccyx was observed. CNA L and M said R14 had repeatedly complained about the presence of a hole in the air mattress. CNA M felt underneath the air mattress and stated, I found the hole here, as she guided this Surveyors hand to an under-inflated area in the middle of the bed where R14's buttocks was positioned. Review of R14's Minimum Data Set (MDS) assessment, dated 9/20/2023, revealed R14 was admitted to the facility on [DATE] with current, active diagnoses that included: neurogenic bladder, diabetes mellitus, paraplegia, anxiety disorder, depression and depression. R14 scored a 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. The MDS assessment, Section M - Skin Conditions identified a risk for the development of pressure ulcers, with no Stage I or higher unhealed pressure ulcers present at the time of the assessment. During an interview on 11/29/23 at 1:44 p.m., when asked if she had observed R14's bottom (buttocks and coccyx) the Director of Nursing (DON) stated, No, I have not looked at her bottom at all. I have it scheduled for today. The DON confirmed R14 had previously complained about not being checked and changed (for incontinence and brief changes) and lack of repositioning. During an observation and interview on 11/30/23 at 8:49 a.m., the DON observed R14's bottom and confirmed the presence of two new Stage II coccyx pressure ulcers. Observation of R14's coccyx found two separate coccyx slits: two separate skin openings. R14 said it was because she had been left in wet and/or soiled incontinence briefs for too long. When asked who had removed the old air mattress, that R14 alleged had a hole in the middle of the mattress, the DON said Maintenance Staff C had removed the mattress from the bed on 11/28/23 after the start of the recertification survey. During an interview and observation on 11/30/23 at 8:58 a.m., Staff C observed the lavender colored air mattress removed from R14's bed on 11/28/23 in a back storage room with this Surveyor. Staff C unzipped the air mattress cover to reveal the air baffles inside the mattress. Staff C closely examined the 11th inflatable baffle (from the bottom of the mattress) and confirmed there was a hole in the baffle which would not allow the mattress to properly inflate with air. Staff C confirmed the lack of air in the 11th baffle would feel like a hole in the mattress to a resident laying on the mattress. Staff C documented the air mattress manufacturer and model number and said he would provide the Manufacturer's Instructions for Use for the air mattress removed from R14's bed. During an interview on 11/30/23 at 12:11 p.m., CNA L was asked if R14 had complained about the air mattress on the bed. CNA L said R14 had repeatedly said it felt like she was laying on the bed frame. R14 had complained about that for about a month. CNA M, also present during the interview, said she was present when [R14] complained about the discomfort of laying on the under-inflated air mattress. CNA M stated, I told the nurses, and we told [Staff C] . The afternoon aide [CNA N] . got [Staff C] and they looked at the bed. He said nothing was wrong with the bed. She would bring it up every so often. I think she just got tired of talking about it . I kept telling them she (R14) was sitting on the bed frame. Review of R14's Care Plans revealed the following ADL/Skin Integrity Approach: Approach Start Date 02/17/2023, Use pressure reducing air mattress . Review of the [Name Brand] 8 Alternating Pressure Mattress Replacement system with Low Air Loss User Manual, by [Corporation Name], dated 9/2020, revealed the following, in part: Pressure injuries are defined as localized injuries of the skin and/or underlying tissue over a bony prominence as a result of pressure or pressure in combination with shear. Support surfaces or specialized mattress systems are used as part of an overall, multi-disciplinary, multi-dimensional care plan intended to prevent and treat pressure injuries . If the pressure is consistently low, open the zipper and confirm that all the hoses are properly connected. Then check for any noticeable leakage in any of the tubes. If necessary, contact your local dealer to replace any damaged tubes or hoses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care to prevent contamination of the urinary drainage system for one Resident (R15) of one resident reviewed for catheter care. This deficient practice resulted in the potential for cross-contamination of infectious organisms between the floor and R15's urinary drainage system. Findings include: All times reported are in Eastern Standard Time (EST) unless otherwise noted. Observation on 11/30/23 at 2:17 p.m., found R15 self-propelling in a wheelchair with the urinary drainage bag lying flat on the floor as he moved between several hallways in the facility. The urinary drainage bag was not placed in a dignity cover, and it loudly swished on the floor as the wheelchair made each roll forward. R15 moved from the dining room door entrance on the service hall to his room on the [NAME] Hall of the facility. No staff intervened to reposition the urinary drainage bag off the floor during his locomotion between the hallways. Review of R15's Minimum Data Set (MDS) assessment, dated 11/6/2023, revealed R15 was re-admitted to the facility on [DATE] with active diagnoses that included obstruction uropathy, Alzheimer's disease, and dementia. R15 scored 99 (unable to complete) on the Brief Interview for Mental Status (BIMS) and was documented with Severely impaired cognition. R15 had an indwelling catheter. During an interview on 11/30/23 at 2:15 p.m., Certified Nurse Aide (CNA) M, standing outside of R15's room door with CNA L, stated, I just seen (sic) that. [CNA O] was supposed to switch (R15's urinary drainage bag to a leg bag). CNA M said CNA O was no longer working in the building that day. CNA M and CNA L both confirmed that R15's urinary drainage bag should not have been dragging on the hallway floors as he self-propelled in the building. CNA M said the urinary drainage leg bag was supposed to be put on when R15 was up in the wheelchair. Review of R15's Physician Order Report: 10/30/2023 - 11/30/2023 revealed the following, in part: CENA Flow Sheet: Order Type: General, Start Date: 1/30/2023 - Open Ended; Resident to have urine leg bag applied every AM and changed to a foley bag at HS (hour of sleep) every day. Twice a Dat: Days 07:00 AM - 11:00 AM [Central Standard Time (CST)], Evenings 08:00 PM - 10:00 PM (CST). Prescription: Start Date: 11/28/2023 - 12/04/2023, Sulfamethoxazole-trimethoprim tablet; 400-80 mg, amt: 1 tag; oral. Special Instructions: Per urology for UTI (Urinary Tract Infection). [DX (diagnosis): Urinary tract infection . During an interview on 11/30/23 at 2:15 p.m., the Director of Nursing and the Regional Clinical Director were asked about any concerns with R15's catheter urinary drainage bag dragging on the floor for an extended amount of time during locomotion in his wheelchair. The DON confirmed R15 was supposed to have a leg bag (for urine drainage) when up in the wheelchair. The DON said infection control was the concern and stated, (We) can't have it (urinary drainage bag) dragging on the floor. Review of the Incontinence Management Policy, reviewed 1/2022, revealed the following, in part: Staff will be educated to the infection control aspects of incontinence care as well as promoting the resident's dignity, privacy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement nutrition interventions for two (Resident #12 and Resident #20) of twelve residents reviewed for nutrition and hydration. This deficient practice resulted in significant weight loss and the potential for choking and aspiration. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Resident #20 (R20) Review of R20's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, severe unspecified dementia, and Parkinson's disease. Review of the weight history revealed R20 weighed 117.0 lbs. (pounds) on 9/3/23 and weighed 110.6 lbs. on 10/2/23, for a total weight loss of 6.4 lbs. This resulted in a 5.47% weight loss within a 30-day period. On 7/5/23, R20 weighed 132.4 lbs., which represented an additional 15.4 lb. weight loss equating to a 16.47% weight loss in 90 days. Furthermore, R20 weighed 141.2 lbs. on 4/2/23, an additional 8.8 lb. weight loss in 180 days. This represented a 21.67% in a total of 180 days. Review of the policy titled, Care Standards, Weight Monitoring reviewed 1/2023 read, The RD (registered dietitian)/CDM (certified dietary manager)/RDT must document on weight gains and losses of those residents that experience 5% for 30 days, 7.5% for 90 days, and 10% for 180 days in the medical record to meet the professional standards for Dietitians. Review of R20's medical records did not reveal documentation by dietary staff regarding weight loss in the month of October 2023 despite meeting the criteria stated in the facility policy. Review of R20's physician orders dated 10/6/23 revealed, administer 60mL (milliliters) of (Brand Name) supplement with medications BID (twice a day) daily. Review of R20's Medication Administration Record (MAR) dated 11/1/23 - 11/30/23 revealed 60mL (Brand Name) supplement was not administered from 11/7/23 to 11/14/23 with the reason listed as, Drug/Item Unavailable. On 11/30/23 at 12:16 PM, an interview was conducted with the Director of Nursing (DON). When asked why R20 was not administered (Brand Name) supplement as ordered from 11/7/23-11/14/23, the DON stated either the facility was out of (Brand Name) supplement or the vendor was late with delivery. The DON stated that in these circumstances, the kitchen should have offered a replacement. On 11/30/23 at 12:19 PM, an interview was conducted with the Certified Dietary Manager (CDM). CDM A stated on the days (Brand Name) supplement was unavailable, she doubled R20's house supplement order as a substitute. CDM A was unable to provide documentation that indicated a substitute had been offered. Review of R20's Care Plan revealed, Problem: Resident is at Nutritional/Hydration risk d/t (due to) cognitive impairment r/t (related to) Dementia with listed goal as, Approach: encourage snacks between meals; assist as needed with start date of 6/6/23. Review of R20's Intakes (including AM snack, PM snack, bedtime snack, and supplements) revealed one snack and/or supplement was offered in the month of November (11/2/23), five in October (three snacks on 10/25/23, 10/16/23, 10/12/23), three in September (9/13/23, 9/6/23, 9/3/23), six in August (8/23/23, 4 snacks on 8/16/23, 8/3/23), four in July (7/26/23, 7/13/23, 7/9/23, 7/8/23), and two in June (6/23/23 and 6/7/23). No snack or supplement refusals were documented in the given period. On 11/30/23 at 1:44 PM, an interview with the DON was conducted regarding implementation of R20's care plan nutritional goal. The DON stated that patient should be offered a daily snack at minimum. When questioned why R20 was only offered one snack in the month of November the DON stated, I'm not sure, maybe the nursing staff aren't documenting correctly. The facility was unable to provide further documentation that snacks were offered to R20 according to the care plan. Resident #12 (R12) Review of R12's EMR revealed the most recent admission to the facility was 7/31/23 with diagnoses including dysphagia (difficulty swallowing), unspecified severe protein-calorie malnutrition, gastrostomy status (a surgical procedure to insert a tube through the abdomen and into the stomach for feeding), diabetes mellitus and myocardial infarction (heart attack). The Care Plan for R12 revealed a Nutritional Status Problem: (R12) is at Nutritional / Hydration risk and receiving 100% of nutrition and hydration via tube feeding as well as po (by mouth) intake. This problem was initiated on 9/19/23 and included approaches of: - Diet per doctors order. Mech (mechanical) soft, thick liquids, no straws - Offer me a PB&J (Peanut Butter and Jelly) sandwich . pudding - Give Tube Feeding per doctors order Glucerna 1.5 (type of feeding flowing at) @ 120 cc (1/2 cup per hour) from 10 pm to 6 am On 11/29/23 at 8:39 AM, R12's bedside table in his room was observed to contain a foam cup of water with a straw inserted. On 11/29/23 at 1:19 PM, R12 was observed in the dining room with a straw in a tumbler of chocolate milk. The tray card for R12 read in part, NO STRAWS. On 11/29/23 at 2:28 PM, R12's bedside table in his room was observed to contain water in a foam cup with a lid and a straw. During an interview on 11/29/23 at 1:30 PM, the Director of Therapy (Staff H) reviewed the EMR for R12 and confirmed the Speech Therapist notes indicated R12 was at risk for swallowing difficulties and should not have straws. In an email dated 12/1/23, the Speech Therapist (Staff P) confirmed the plan for R12. The email read in part: I made the no straws recommendation on 11/7/2023 when I re-evaluated him and upgraded him to thin liquids. I have continued to use the current plan of care since that time. To answer your question: ' So you recommended a continuation of the no straw recommendation for the reasons listed below. Correct? ' Yes, I recommend continuation of no straws. Review of the EMR revealed R12 weighed: - 97.6 lbs. on 11/11/23, - 104.6 lbs. on 11/16/23, - 95.8 lbs. on 11/25/23 No other follow up weights were observed. An interview was conducted on 11/30/23 at 2:00 PM, the DON and CDM stated reweights should occur if there was a 3 lb change in weight for a resident weighing less than 100 lb. and a reweight should also occur if there was a 5 lb. change in weight for a resident over 100 lbs. The EMR was reviewed with the DON and CDM for R12 and no reweights had been taken to verify the accuracy of the weights. The facility policy titled Monthly and Weekly Weights dated as reviewed on 1/2022, read in part: Reweights: conducted on resident that: a. Have experienced a 5% weight gain or loss from the previous month if current weight is over 100 lbs. b. Have experienced a 3 lb. weight loss or gain from the previous month if current weight is under 100 lbs. If a re-weigh is required it should be conducted in the presence of a licensed nurse and the weight recorded with the nurse's initials in the medical record, re-weights should be done within 48 hours . .

. Based on observation, interview and record review the facility failed to provide the appropriate treatment and services to restore oral eating skills of one Resident (R12) of one who was maintained on enteral feedings. This deficient practice resulted in resident dissatisfaction with his quality of life and resorting to stealing of food from the dietary department so he could eat food by mouth rather than via a tube. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Review of R12's EMR (Electronic Medical Record) revealed the most recent admission to the facility as 7/31/23 with diagnoses including dysphagia (difficulty swallowing), unspecified severe protein-calorie malnutrition, gastrostomy status (a surgical procedure to insert a tube through the abdomen and into the stomach for feeding), diabetes mellitus and myocardial infarction (heart attack). The Care Plan for R12 revealed a Nutritional Status Problem: (R12) is at Nutritional / Hydration risk and receiving 100% of nutrition and hydration via tube feeding as well as po (by mouth) intake. This problem was initiated on 9/19/23 and included approaches of: - Diet per doctors order. Mech (mechanical) soft, thick liquids, no straws - Offer me a PB&J (Peanut Butter and Jelly) sandwich . pudding - Give Tube Feeding per doctors order Glucerna 1.5 (type of feeding flowing at) @ 120 cc (1/2 cup per hour) from 10 pm to 6 am The tube feeding provides 1440 calories per day during the night hours. On 11/29/23 at 08:38 AM, R12 was observed in the dining room and had only crusts of a sandwich left on his plate. He said he was not very hungry at breakfast. (His tube feeding runs all night and finishes in the morning.) R12 reported he did get peanut butter and jelly per his request, and he had consumed the entire sandwich except some of the crust. On 11/29/23 at 1:19 PM, R12 was observed in the dining room with a straw in a tumbler of chocolate milk. The chocolate milk had been consumed and only a splash of it remained at the bottom of the tumbler. R12 was eating his meal slowly. The EMR revealed a 11/15/23 Therapy Communication Note for R12 which read as follows: Recommendation: ST (Speech Therapy) Recommendation for Weaning patient off of peg tube: - Consult with dietician to begin reducing peg (percutaneous endoscopic gastrostomy) tube supplements to allow patient to begin eating more food. - Encourage snacks through out the day. - Encourage patient to increase water intake. This Communication Note indicated Therapy provides copies to the following: DON (Director of Nursing) and Dietary if related. The following day on 11/16/23 at 9:19 PM, the Registered Dietitian (RD) progress note read as follows Met with resident regarding current nutrition regimen. Resident receiving nocturnal TF (tube feeding) regimen of Glucerna 1.5 TF via PEG tube, 120ml [milliliters (1/2 cup)] from 10p-6a, with additional 100ml free water flush Q (every) 4. Total TF regimen provides 1440 kcal (kilocalorie)/day (calories per day), 78 gms (grams) protein/1420 ml free water/day, along with mechanical soft/thin liquid diet. PO (by mouth) intake had improved, d/t (due to) to upgrade in liquid status from nectar to thin. Avg. (average) intake 50-75% at this time with meals. Breakfast continues to be less than 50%, however, resident remarks that he has never been a big breakfast eater, intake at lunch and supper avg. 75%. RD and CDM (Certified Dietary Manager) met with resident to go over food preferences, in attempt to enhance kcal/protein options of choice, with meal card updated, dietary staff aware. Resident has had positive weight gain since admission (approximately 12.6lbs (pounds)x last 4 months (13.7%) however BMI(Body Mass Index) remains below average at 17. Resident remains risk for malnutrition at this time. Desires return to home. IDT (Interdisciplinary Team) to meet regarding outcome and RD continues to follow. The RD progress note did not address the ST communication even though it was written the day before. No reduction of the tube feeding per recommendation of the ST was considered. Calorie needs to continue to promote improved BMI and maintain this resident were not assessed. On 11/30/2023 at 9:02AM, the CDM progress note read as follows: This writer witnessed resident observing our food delivery over the last couple of weeks. I had asked res. (resident) if he was looking for anything in particular and he stated, no, I'm just looking. Yesterday afternoon I saw resident back down by the stock order. I walked away for a time and came back to have another staff member tell me that the res. had taken two 4 packs of chocolate pudding out of the case that was sitting there. I saw the resident going up the hall and I went to ask him if he had taken the pudding. He told me yes, two packs. I explained to him that if he wanted such things to ask me or other staff for them and that I needed to be accountable for all of the items in the order. He said ok. I will continue to monitor. During an interview on 11/30/23 at 1:50 PM, the recommendation from the ST was reviewed with the DON and the CDM. The DON stated recommendations go to the IDT and are discussed. The DON stated a previous recommendation on 11/7/23 had been discussed but she did not receive the 11/15/23 recommendation, so there had not been follow through. The CDM remarked she had observed R12 was stealing pudding. During an interview on 12/01/23 at 9:25 AM, R12 stated he was tired of the tube feeding and wishes it would go away. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary standards of care and services for diabetes management in four (Resident #3, #18, #27 and #229) of seven residents reviewed for diabetic management. This deficient practice resulted in the potential for diabetic related complications including organ damage, stroke, and death. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Review of facility policy titled, Care Standards: Diabetic Management Program reviewed 1/2022 read, All residents with orders for insulin or oral diabetic medications should have orders for blood glucose monitoring and treatment for hypoglycemia (low blood sugar). Resident #27 (R27) Review of R27's electronic medical record (EMR) revealed readmission to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, and sepsis. Record review of R27's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. Review of R27's Medication Administration Record (MAR) revealed the following: Humalog KwikPen Insulin (insulin lispro) insulin pen; 100 unit/mL (milliliter); Amount to Administer: 5 units; subcutaneous (under the skin), before meals. Lantus Solostar U-100 (100 units of insulin per milliliter of fluid) Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); Amount to Administer: 18 units; subcutaneous, once a day. Glucagon (medication used to treat low blood sugar) Emergency Kit (human) (glucagon) recon (reconstituted) soln (solution); 1 mg (milligram); Amount to Administer: 1mg; injection, as needed. Special instructions: If UNCOOPERATIVE/UNCONSIOUS (sic) patient: If BS (blood sugar) <70mg/DL (deciliter) Give 1mg IM (intramuscular). May cause N/V (nausea/vomiting); Keep HOB (head of bed) elevated or position resident on either side. Notify physician for further orders. Fasting Accu (a device used to measure blood glucose levels) Checks x 3 days, once per morning. R27's fasting blood glucose levels from [DATE] to [DATE] were recorded as 349mg/dL, 131mg/dL, and 100mg/dL, respectively. Review of R27's Progress Notes (nursing), revealed the following: [DATE] 6:49 AM [CT (Central Time)] (5:28 AM CT) Writer was called to resident's room by Certified Nursing Assistant (CNA), reports that resident is unresponsive. Sternal rubbing and shaking would not arouse resident. Resident's eyes were rolled back in her head and pupils were responsive (constricted in response to light). VS (vital signs): T (temperature) 98.5, P (pulse) 69, RR (respiratory rate) 5 apneic (a temporary stop in breathing), B/P (blood pressure) 97/60, O2 sat (oxygen saturation) 91% on RA (room air), blood sugar read Lo (Manufacturer's Instructions indicated Lo meant the blood sugar sample tested was less than 20 mg/dL.) (5:40 AM CT) 1mg of glucagon was administered SQ (subcutaneous), 911 was called. (5:45 AM CT) CNA notified writer that resident had no pulse. (5:46 AM CT) ambulance arrived at facility and CPR was initiated. (6:07 AM CT) ambulance left the facility with the resident, resident had a pulse. On [DATE] at 3:26 PM, a phone interview was conducted with CNA E regarding finding R27 unresponsive. CNA E stated, I was the CNA who found her. I went in there and I looked at her and her eyes were rolling back in her head, and I called her name quite a few times and did the sternal rubs with no response. I ran and got the nurse . it seemed like she was doing better and all of a sudden, she just stopped breathing. I ran and got the nurse again .and he called 911, he called [the DON] .We knew she was sickly. I had gotten her up to go to the bathroom, she was telling us that she just didn't feel right. That was about 1:00AM or 1:30AM [CT]. We let [Registered Nurse (RN) G] know that she didn't feel right . On [DATE] at 6:59 AM, an interview was conducted with CNA F. CNA F stated, Me and [CNA E] went in to .check on her [R27] .She was laying back over to the left side and it appeared that her eyes were rolled back. She was breathing labored and fairly slow. We both went and got [RN G] to come down and check her . On [DATE] at 4:23 PM, a phone interview was conducted with RN G. RN G stated R27's respirations were initially, really high. RN G reported he subsequently called the DON who directed him to call 911. RN G stated after he called the DON, he remembered R27 was diabetic which prompted him to check her blood glucose levels. RN G reported that the monitored read, Lo which indicated R27's blood sugar was less than 20 mg/dL. RN G reportedly administered Glucagon at that time. Shortly after, RN G said the CNAs informed him that R27 no longer had a heartbeat. RN G indicated that Emergency Medical Services (EMS) then arrived and initiated cardiopulmonary resuscitation (CPR) before transporting R27 from the facility. RN G verified there was no active order for blood sugar monitoring for R27. Review of R27's EMR revealed no record of RN G conducting an assessment after it was reported she felt unwell. Review of R27's EMR revealed no standing order for blood glucose monitoring following [DATE]. Review of R27's MAR did not indicate that physician ordered Glucagon Emergency Kit was administered on [DATE]. Resident #18 (R18) Review of R18's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, essential (primary) hypertension, and chronic kidney disease. Review of R18's MAR revealed physician orders with [DATE] start date, insulin glargine insulin pen; 100 unit/mL (3 mL); Amount to Administer: 20 units; subcutaneous, once per morning. Review of progress note dated [DATE] read, Received verbal order to discontinue Accu checks as blood glucose is stable, resident has had no s/sx (signs and symptoms) of hypo/hyperglycemia. Review of R18's blood glucose levels for approximately 60 days prior to the progress note to discontinue Accu checks ([DATE] to [DATE]) revealed blood glucose levels ranging from 164mg/dL to 483mg/dL. On [DATE] at 11:41 AM, an interview was conducted with the DON regarding stable blood sugar levels. DON considered R18's blood glucose levels to be, unstable. Review of R18's MAR revealed no orders, including frequency or method, to monitor blood glucose levels after [DATE]. On [DATE] at 10:08 AM, an interview was conducted with Registered Nurse (RN) D who confirmed R18 was diagnosed with type II diabetes with orders for insulin. RN D identified signs and symptoms of hypoglycemia and verified resident had no orders for hypoglycemic management. RN D reported in the event of a hypoglycemic episode, she would call the attending physician for glucagon orders, if needed, and EMS. RN D verified there was no glucagon located on the unit medication cart. RN D was unable to locate glucagon in medication contingency room and relied on DON for assistance. On [DATE] at approximately 8:27 AM, R18 was observed with brown sugar and syrup on their breakfast tray. R18's tray card read, SS (sugar substitute) diet. Review of facility policy titled, Dietary Manual: Suggested Diets for Long-Term Care Facilities, revised 4/21 read in part, Regular with Sugar Substitute: This diet should be ordered for those residents with unstable blood sugars. Examples of unstable blood sugar are Fasting BS (blood sugar) over 150mg/dL, non-fast BS over 180mg/dL. Review of R18's care plan read, Problem: Resident is at risk of complication R/T (related to) DX (diagnosis) diabetes mellitus and, Approach Start Date: [DATE]. Diet as ordered. Resident #3 (R3) Review of R3's EMR revealed admission to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease and moderate dementia. Review of R3's physician orders with a start date of [DATE] revealed, Farxiga (dapagliflozin propanediol); 10 mg; amt (amount): 10 mg; oral, once a morning with orders to, notify physician for blood glucose readings less than 70 mg/dL or greater than 300 mg/dL, as needed. Review of R3's care plan identified problem, Resident is at risk of complications r/t DX diabetes mellitus with a goal that read, Resident will have blood glucose WNL (within normal limits) and absence of signs of hypoglycemia or hyperglycemia. An approach with the start date [DATE] read, monitor blood glucose as ordered. Review of R3's MAR revealed no orders, including frequency or method, to monitor blood glucose levels nor orders for treatment of hypoglycemia. R229 Review of R229's partially completed MDS assessment, dated [DATE], revealed R229 was admitted to the facility on [DATE]. R229 was noted to be a Full Code and Diabetic. Review of R229's admission Record revealed the following, in part: Type I (insulin dependent) diabetes mellitus with diabetic neuropathy, Type 1 diabetes mellitus with ketoacidosis without coma (Admission), dehydration, and anoxic (lack of oxygen) brain damage, not elsewhere classified - r/t (related to) severe hypoglycemia. Review of R229's Care Plans revealed the following, in part: Problem: Resident is at risk of complications R/T DX (diagnosis) diabetes mellitus. Interventions included: [DATE] - Administer medications as ordered. [DATE] - Monitor blood glucose as ordered. [DATE] - Monitor for signs of hyperglycemia (blood glucose elevated; increased thirst; increase urination; increase appetite followed by lack of appetite; nausea, vomiting). [DATE] - Monitor for signs of hypoglycemia (low blood glucose; sweating; cold, clammy skin; numbness of fingers, toes, mouth; rapid heartbeat; nervousness, tremors, faintness, dizziness). Review of R229's Physician Orders revealed the following, in part: [DATE] - Insulin lispro solution; 100 unit/mL (milliliter); amt (amount); per sliding scale; subcutaneous Special Instructions . [Sliding Scale number of units to administer based on blood glucose levels]. [DATE] - Lantus U-100 Insulin (insulin Glargine) solution; 100 unit/ml; amt: 8 units; subcutaneous. Special Instructions: Give 8 units of Lantus Q (every) PM (evening). [DATE] - Lantus U-100 Insulin (insulin Glargine) solution; 100 unit/mL; amount 10 units; subcutaneous. Special Instructions: Give 10 units daily every AM . No order was present in Physician Orders or in the facility Standing Orders for administration of glucagon as a treatment for hypoglycemia for R229. Review of R229's Progress Notes revealed the following, in part: [DATE] 2:29 p.m. (CST), Res (resident) has a hx (history) of hypoglycemic/anoxic encephalopathy. Resident was currently in the hospital for diabetic ketoacidosis. Resident is a full code at this time . Res on Lantus, sliding scale insulin and scheduled Synthroid at this time . [DATE] 11:33 a.m. (CST), Resident blood sugar at 1100 (11:00 a.m. CST) = (equals) 582 (hyperglycemic) . [DATE] 2:31 a.m. (CST), Resident is receiving skilled nursing care r/t DM (diabetes mellitus) ketoacidosis, anoxic brain damage, cardiomyopathy . at around 2300 (11:00 p.m. CST), resident started using call light, asking for assistance but unable to state with what, c/o (complained of) all over body aches requesting Tylenol. Writer brought in PRN (as needed) Tylenol and noted resident was sweating profusely. Accu check was taken at this time was 51. Resident given 2 snacks. Accu-Chek redone at 2330 was 97 . [DATE] 6:55 a.m. (CST), MD updated about low blood sugar via phone call, MD aware of the low blood sugar reading and snacks provided. MD acknowledged, no new orders and MD to see resident in facility today, signed by the Director of Nursing (DON). [DATE] 4:46 p.m. (CST), MD contacted for blood sugar of HI (number unable to be registered) on meter at 4 PM check . During observation of the facility medication room on [DATE] at 8:30 a.m., the DON was asked to find any available back-up glucagon for administration to insulin-dependent diabetics for a severe hypoglycemic event. The DON looked through the back-up medication boxes and was not able to find the glucagon by the names of the medications on the back-up boxes. A medication named Gvoke was listed, and the DON was unsure of the type of medication it was. Upon searching through that specific medication back-up box, it was identified as an emergency dose of glucagon. When asked if the DON would have been able to find the glucagon in an emergency, the DON stated, No, because I didn't know what the Gvoke stood for. I didn't know it was glucagon. The nurse would not have been able to find it in an emergency. During an interview on [DATE] at 9:45 a.m., when asked if it was important for a newly admitted Type I diabetic to have an order for glucagon for treatment of severe hypoglycemia, Physician Q stated, Yes, I believe that is a policy here. They (residents with insulin-dependent diabetes) should have an order for glucagon when they are admitted . Physician Q aid he was unaware that R229 did not have an order for glucagon upon admission. Physician Q stated, I will make sure there is an order for glucagon for [R229] today. Physician Q agreed that there may not be time to call 911 with a severe hypoglycemic event. Observation of the [NAME] Hall medication cart on [DATE] at approximately 9:50 a.m. found no glucagon in the medication cart for administration to R229 in the event of a severe hypoglycemic event. Review of the Diabetic Management Program policy, reviewed 1/2022, revealed the following, in part: Procedure: All residents with orders for insulin or oral diabetic medications should have orders for blood glucose monitoring and treatment for hypoglycemia .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure a food preparation staff person washed their hands after being potentially contaminated. 2. Failing to demonstrate proper testing of the concentration of sanitizing chemicals in the three compartment sink and wiping buckets. 3. Failing to properly label and date food removed from the original packaging which was re-packaged and frozen. These deficient practices have the potential to result in food borne illness among any and all 26 residents of the facility. Findings include: (All times are reported in EST) 1. On 11/30/23 at approximately 11:45 AM, [NAME] B was observed wiping up something from the floor, with a paper towel, near the three compartment sink. [NAME] B disposed of the paper towel which was used to clean the floor, then donned a pair of gloves and began with food preparation duties without washing her hands. The FDA Food Code 2017 states: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in ¶ 2-403.11(B); (D) Except as specified in ¶ 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 2. On 11/29/23 at approximately 12:10 PM, Certified Dietary Manager (CDM) A was requested to demonstrate the procedure for testing the quaternary solution for the wiping cloths bucket. CDM A removed a strip from the roll of QT 40 test strips, placed it in the bucket and dragged it through the solution, and removed it after 7 seconds. CDM A read the color change of the strip to show nearly 400 PPM (parts per million). CDM A was then asked to review the dispenser of strips. CDM A acknowledged the directions for use included specific language to hold the strip in the solution without agitation, hold it still for 10 seconds. Following these instructions, CDM A conducted the test again and demonstrated the solution contained approximately 150 PPM. The FDA Food Code 2017 states: 2-102.11 Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by: (C) Responding correctly to the inspector's questions as they relate to the specific FOOD operation. The areas of knowledge include: 11) Explaining correct procedures for cleaning and SANITIZING UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT; 3. On 11/29/23 at approximately 11:45 AM, the upright freezer, located in the storage room adjacent to the dietary office, was observed to have six gallon sized zippered closure bags of food. The bags were not labeled with the food product. An interview with CDM A at this time revealed the bags contained chicken thighs, and had been separated from a larger container of fresh (not frozen) thighs, then frozen. Numerous bags of ground beef logs were observed in varying sizes in the freezer. CDM A reported a similar scenario in which the product came in unfrozen, was portioned, wrapped and frozen. None of the re-packaged foods was marked with original expiration date and date the product was placed in the freezer, to establish the length of time the product could be held once it was thawed. The FDA Food Code 2017 states: The FDA Food Code 2017 states: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (D) A date marking system that meets the criteria stated in ¶¶ (A) and (B) of this section may include: (1) Using a method APPROVED by the REGULATORY AUTHORITY for refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under ¶ (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under ¶ (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.

During an infection control interview on 11/30/23 at 11:30 PM, the Director of Nursing (DON) was asked about the system she used for surveillance of the facility infections and to present the 11/2023 data. The DON, who also functions as the Infection Preventionist, stated, I don't have the mapping ready. It is only 11/30/23. When asked about the tracking and trending of infections (also called mapping) the DON stated, The purpose of mapping is to find if there are clusters (of infected residents) and track infection and type of infection and monitor spread. I will present the mapping the first or second week of December and write the summary then. At this time, the DON revealed there were three Covid-19 positive residents in house. These residents had not been added to the November map as it had not been started. With this discussion, the DON said she understood the importance of continuous mapping (rather than waiting until the end of the month to track and trend infections) and that surveillance should be ongoing analysis and documentation of follow up. The facility policy titled Monitoring Infection Control Practices and dated as reviewed 3/2023, read in part: The facility's Infection Control Preventionist will conduct routine monitoring and surveillance to determine compliance with infection control policies and practices. The facility was asked to provide the policy for timely mapping, tracking, and analysis of infection. The Regional Clinical Director reviewed the manuals and responded there was not a policy for mapping and tracking of infection. Based on observation, interview, and record review, the facility failed to implement a complete infection control program by failure to ensure social distancing of residents in COVID-19 isolation during communal dining, and failure to complete real-time tracking and surveillance of facility infections. This deficient practice resulted in the potential spread of infectious organisms within the facility, including COVID-19, and had the potential to affect all 46 residents. Findings include: All reported times are Eastern Standard Time (EST), unless otherwise noted. During a dining observation on 11/29/23 at 1:13 p.m., R15 was viewed sitting in communal dining room with food in Styrofoam containers, plastic cups, a washable coffee cup, and regular silverware. R15 was sitting with his back less than two feet from the unknown resident directly behind him. Certified Nurse Aide (CNA) O, wearing a surgical mask was observed sitting within three feet of R15. During an interview on 11/29/23 at 1:24 p.m., Registered Nurse (RN) R, who had been assisting residents with their lunch meals, was asked if R15, who was in isolation due to exposure from his current roommate to COVID-19, was allowed to eat in close proximity to other residents in the communal dining room. RN R stated, I asked RN D is [R15] was allowed in the dining room, and she said yes. I was told that it was his right to come down to the communal dining room and eat. During an interview on 11/29/23 at 1:27 p.m., RN R stated, R15 was looking for his mother and he wanted to go and eat in the restaurant - the communal dining room. I could not redirect him back out of the dining room. He refused wearing a mask. Although R15 did not test positive for COVID-19 RN R agreed that he was presumed positive due to his close exposure and isolation in the same room with his roommate who was positive for COVID-19. RN R agreed the resident should be positioned six feet from other residents. RN R stated, I did not go down there (communal dining room) and see how he was positioned. I would say he is probably at a normal table (near other residents). RN R confirmed they were using Styrofoam dishes for residents in quarantine for COVID-19 and agreed the CNA should be wearing an N95 if she is within six feet of the resident. RN R said the Director of Nursing (DON) was above her in the Infection Preventionist (IP) position, and RN R was still learning. RN R directed this Surveyor to the DON for any further questions. During an interview on 11/29/23 at 1:34 p.m., the DON/IP was asked about allowing R15 to eat in close proximity to other residents in the communal dining room. The DON stated, He is in considered a presumed positive. CDC recommends he should stay in isolation. If he is six feet away from others, he can be in the dining room. I would have rather distanced him from others, before trying to feed him in another room. Staff should be wearing an N95 mask. I was told they were 6 feet apart. When the position of R15 to other residents and staff was described, the DON stated, No six feet is six feet. The DON said she understood the concern and agreed the resident should have maintained a six-foot distance from all residents or staff, and staff should be wearing N95 masks. Review of the Department of Health & Human Services Centers for Medicare & Medicaid Services (CMS), QSO-20-39-NH, revised 5/8/2023, revealed the following, in part: While the PHE (public health emergency) will end, CMS still expects facilities to adhere to infection prevention and control recommendations in accordance with accepted national standards . Nursing Home Visitation Frequently Asked Questions (FAQs) . 5. Should the facility pause communal activities and dining during an outbreak investigation? . Residents who are on TBP (i.e., isolation or quarantine) should not participate in communal activities and dining until the criteria to discontinue TBP has been met . A resident who is unable to wear a mask due to a disability or medical condition may attend communal activities, however they should physically distance from others . Review of the facility COVID-19 Visitation and Communal Activities/Dining, revised 10/2022, revealed the following, in part: . Residents who are on transmission-based precautions should not participate in communal activities and dining until the criteria to discontinue transmission-based precautions has been met .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** All times are Eastern Standard Time (EST) unless otherwise noted. Based on observation, interview, and record review, the facility failed to provide adequate ADL (activities of daily living) care for one Resident (#23) of two residents reviewed for ADL care. This deficient practice resulted in increased pain during functional transfers for Resident #23, and the risk of injury to the resident and caregivers. Findings include: Review of Resident #23's Minimum Data Set (MDS) assessment, dated 10/14/22, revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including cancer (unspecified), Parkinson's disease (a progressive neurological disorder), traumatic brain injury, left hip fracture, stroke, polymyalgia rheumatica (an inflammatory disorder causing stiffness), dementia, anxiety, and depression. Resident #23 required extensive two-person assistance with transfers, and extensive one-person assistance with bed mobility, dressing, toileting, and hygiene. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 6/15, which indicated Resident #23 had severe cognitive impairment. The pain assessment revealed Resident #23 received scheduled pain medication, and had not had pain during the look-back period (prior 5 days). During an interview on 11/29/22 at 12:33 p.m., Resident #23 was observed laying down in her bed. Resident #23 was interviewable, and reported she would like range of motion therapy due to stiffness. No contractures were evident per observation. During an observation on 11/30/22 at 08:44 a.m., Resident #23 was observed seated upright in a manual wheelchair. She was smiling and holding a large stuffed animal. No contractures were evident. During an interview on 11/30/22 at 01:48 p.m., the Activity Director, Staff L, reported they frequently offered Resident #23 participation in the group exercise class however Resident #23 refused much of the time. During an interview on 11/30/22 at 08:46 a.m., the Rehabilitation Director, Physical Therapy Assistant (PTA) DD, reported Resident #23 was discharged from therapy a couple months ago due to lack of participation, and a plateau in progress. PTA DD indicated Resident #23 was discharged at the level of using a mechanical standing lift for transfers, due to bilateral leg/knee pain which remained at the time of therapy discharge. PTA DD reported Resident #23's knees would twist during transfers (as she struggled to pick up her legs), so a two-person stand pivot transfer was unsafe. PTA DD reported they had educated nursing staff regarding Resident #23's level of assistance at discharge, per their usual process. PTA DD clarified they provided Resident #23 with an Exercise Program at discharge, which she completely independently, and referred her to the facility exercise group. Review of Resident #23's current ADL Care Plan revealed Resident #23 was designated to use a mechanical sit to stand lift with two-person assistance, was non-ambulatory, and used a wheelchair for locomotion in the facility. During an interview on 11/30/22 at 10:39 a.m., Certified Nurse Aide (CNA) Y was asked about Resident #23's range of motion and any functional decline for Resident #23. CNA Y reported they completed some range of motion with Resident #23 during cares, as it was tasked for Resident #23. CNA Y reported Resident #23 was a two-person stand pivot transfer assist and stated, We [two staff] do a pivot transfer. We have [Resident #23] hold onto the chair and help turn herself. CNA Y clarified [Resident #23's] left side (her weak side from a stroke) was the side she struggled to transfer towards, since her bed was against the wall, which Surveyor observed. CNA Y denied any contractures. During an observation on 11/30/22 at 10:52 a.m., the CNA tasks were viewed with CNA Y. CNA Y reviewed the task care designations, and stated, [Resident #23] is supposed to be a two-person transfer with a Mechanical Stand lift. CNA Y acknowledged they were not aware this was Resident #23's transfer status, and would need to clarify. The Director of Nursing (DON) walked by and was told about the discrepancy, and reported they would clarify Resident #23's transfer status. Review of the Electronic Medical Record (EMR) including Resident #23's falls revealed no falls occurred during staff transfers with Resident #23. The EMR was reviewed for any new injuries to Resident #23, and none were found. During an interview on 11/30/22 at 11:00 a.m., Resident #23 was asked about their transfers with nursing staff. Resident #23 responded she had no pain during the interview, however experienced leg/knee pain during the transfers, reporting a lot of pain. Resident #23 reported she had quit therapy due to the leg pain, and reported she was having trouble sleeping with the pain. Resident #23 clarified, I sure as heck didn't complain about it when they used the [standing] lift. Resident #23 stated she would prefer (CNA) staff would use the standing lift, but they had stopped using it, and she did not know why. When asked about her pain level during transfers, Resident #23 reported, It's a good '8' [with 10 being the highest and 0 being the lowest] when they transfer me. During a second interview on 11/30/22 at 11:09 a.m., CNA Y was asked if Resident #23 was having pain when they [two staff] were completing stand pivot transfers, per their earlier report. CNA Y responded, Yes, [Resident #23] does have pain, when they [CNA staff] completed two-person stand pivot transfers. CNA Y reported they tried to transfer Resident #23 away from her weak left side during the transfers. CNA Y reported the pain was at least moderate. CNA Y confirmed they had already received a reeducation today from the DON to transfer Resident #23 with the mechanical sit to stand lift, with two-person assistance, per tasks, Care Plan, and therapy recommendations at time of discharge from therapies in October, 2022. During an interview on 11/30/22 at 11:29 a.m., CNA CC was asked how they transferred Resident #23. CNA CC responded, I usually do extensive two-person assistance. I find another aide to help me. CNA CC reported Resident #23 was sometimes very weak, and needed extensive assistance to do a stand pivot transfer. CNA CC denied Resident #23 had pain during the transfers, and reported they did complete range of motion with cares. During an observation on 11/30/22 at 02:55 p.m., CNA Y and CNA CC were planning to transfer Resident #23 back to bed per Resident #23's request after lunch. Resident #23 agreed to Surveyor observation. CNA Y and CNA CC used the mechanical sit to stand lift to transfer Resident #23 back to bed, as both reported they had been educated to use the sit to stand lift by the DON on 11/30/22, after the discrepancy was noted by Surveyor. Resident #23 vocalized no pain during the transfer, and after the transfer denied any pain. Resident #23 reported she liked being transferred with the sit to stand lift, and wanted to transfer with the sit to stand lift going forward. During an interview on 11/30/22 at approximatley 3:05 p.m., Resident #23's nurse, Registered Nurse (RN) P, reported she had not been aware Resident #23 was having pain during the stand pivot transfers. RN P understood Resident #23 would be using the mechanical sit to stand lift with nursing staff going forward, per the DON. RN P clarified Resident #23 had scheduled Tramadol for pain, and had not needed any additional pain medication, as she was typically Resident #23's nurse during the day shift. During an interview on 11/30/22 at approximately 3:15 p.m., the DON reported they understood the concern, and had educated nursing staff to only use the mechanical sit to stand lift for Resident #23's transfers, per their own review of the Care Plan, CNA tasks, and therapy's most recent discharge recommendations from October, 2022. During an interview on 12/01/22 at 8:40 a.m., the Regional Operating Director, NHA S, and the current NHA were apprised of the concern with Resident #23 not being transferred correctly. Both understood the concern, and reported a staff education would be completed. Review of the policy, Activities of Daily Living, ADLs/Maintain Abilities, dated 11/20/21, revealed, Intent: It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values, and beliefs. Procedure: 1. Based on the comprehensive assessment of a resident, and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. 2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. 3. The facility will provide care and services for the following activities of daily living: b. Mobility - transfer and ambulation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00132859. All times are Eastern Standard Time (EST), unless otherwise noted. Based on observation, interview, and record review, the facility failed to provide adequate behavioral monitoring for one Resident (#25) of one resident reviewed for behavioral monitoring, related to completion of behavioral tracking logs. This deficient practice resulted in Resident #25's behavioral care logs not being completed, and the potential for resident to resident altercations, and abuse. Findings include: Review of the Resident #25's MDS assessment, dated 08/27/22, revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including heart failure, liver disease, dementia, bipolar disorder, psychotic disorder, delusional disorder, intellectual disability, and somatoform disorder (neurological symptoms without medical explanation). Resident #25 was independent with bed mobility, transfers, locomotion (wheelchair mobility), and toileting. The BIMS assessment revealed a score of 15/15, which showed Resident #25 had intact cognition. The Behavioral Assessment showed Resident #25 had physical behavioral symptoms directed at others four to six days during the assessment period, and verbal behavioral symptoms directed at others one to three days during the assessment period. Review of Resident #25's behavioral tracking logs (for 15 minute checks) showed no behavioral monitoring/tracking on 11/15/22 from 7:00 a.m. to 5:00 p.m., on 11/16/22 from 7:00 a.m. to midnight, and on 11/17/22 through 11/31/22. Review of Resident #25's current Care Plan and Care planning showed Resident #25 was care planned to have 15 minute checks completed, related to behavioral monitoring/tracking, beginning 5/19/22. During an interview on 11/30/22 at 12:43 p.m., Certified Nurse Aide (CNA) Y confirmed they typically completed Resident #25's behavioral tracking logs, and showed Surveyor a behavioral monitoring logbook, and reported she was unsure why there were no entries for Resident #25 for the past month, during November, 2022. During an interview on 11/30/22 at 12:47 p.m., RN P confirmed Resident #25's behavioral management tracking logs should have been completed by staff on the missing dates, as behavioral incidents were occurring, including a resident to resident verbal incident involving Resident #25, perpetrated towards Resident #21, a week ago [on 11/24/22], when RN P was working. Review of Resident #25's 11/24/22 behavioral tracking log was not completed. Review of Resident #25's progress notes confirmed a resident to resident verbal altercation had occurred on 11/24/22, perpetrated by Resident #25 to Resident #21. During an interview on 11/30/22 at 12:47 p.m., the NHA confirmed the behavioral management tracking logs for Resident #25 were accurate, including the missing entries during November, 2022. During an interview on 12/01/22 at 8:30 a.m., the Regional Operations Director, NHA S, and the NHA acknowledged the concern with the missing behavioral monitoring tracking during November, 2022. NHA S also confirmed Resident #25 was currently care planned to have 15 minute behavioral checks. Review of the policy, Behavior Intervention Program Management Process, revised 01/2022, revealed, It is the policy of the facility that residents who exhibit episodes of inappropriate behavior be reviewed by the facility's interdisciplinary team for contributing factors, underlying causes, and develop an individualized, person-centered plan of care .6. Behavior symptom tracking logs will be available for care staff to document observations of behaviors. Tracking logs will be reviewed by Social Services or designee .Any critical behaviors will be reported immediately to Director of Nursing and Administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00132859. All times are Eastern Standard Time (EST) unless otherwise noted. Based on observation, interview, and record review, the facility failed to provide adequate Social Services care for two Residents (#21, #25) of nine residents reviewed for medically related social services. This deficient practice resulted in the lack of social services supportive visits and effective interventions to prevent the verbal abuse of Resident #21 by Resident #25. Findings include. Review of Resident #21's Minimum Data Set (MDS) assessment, dated 06/20/22, revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including paraplegia (paralysis of lower extremities), pressure ulcer, kidney disease, anxiety, and depression. Resident #21 required extensive two-person assistance for bed mobility, and was dependent for transfers, toileting, and locomotion (bed dependent). The Brief Interview for Mental Status (BIMS) assessment revealed a score of 14/15, which showed Resident #21 had intact cognition. Review of the Resident #25's MDS assessment, dated 08/27/22, revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including heart failure, liver disease, dementia, bipolar disorder, psychotic disorder, delusional disorder, intellectual disability, and somatoform disorder (neurological symptoms without medical explanation). Resident #25 was independent with bed mobility, transfers, locomotion (wheelchair mobility), and toileting. The BIMS assessment revealed a score of 15/15, which showed Resident #25 had intact cognition. The Behavioral Assessment showed Resident #25 had physical behavioral symptoms directed at others four to six days during the assessment period, and verbal behavioral symptoms directed at others one to three days during the assessment period. Review of an investigation summary provided via email on 12/01/22, by the Nursing Home Administrator (NHA), revealed a Resident to Resident verbal altercation between Resident #21 and Resident #25, on 09/02/22. Resident #21 reported Resident #25 called her a derogatory name, which the facility administation confirmed occurred. Review of the Social Services Director, Licensed Practical Nurse (LPN) Zs interview/witness statement, dated 09/09/22, revealed the (former) NHA reported, [ .Resident #21] reported feeling unsafe as [Resident #21] is bedbound [bed dependent] and cannot move if [Resident #25] were to ever lay hands on her. [Resident #21] provided with a whistle she can keep at bedside to blow to alert staff if [Resident #25] were to enter [Resident #21's] room. On 09/03/22, [LPN Z] provided [Resident #21] with a whistle that is on a bracelet to wear on her wrist. There was no mention of psychosocial support provided during these social services visits, given Resident #21's report of feeling unsafe (fearful). Review of Resident #21's Electronic Medical Record (EMR) including nursing progress notes, and the 09/02/22 investigation summary revealed there were incidents of verbal aggression/abuse by Resident #25, to Resident #21, which occurred 11/24/22, 09/02/22, and 08/12/22. Per Resident #21's grievance form dated 08/12/22, there were several similar verbal incidents, on and prior to 08/12/22. Review of Resident #21's interview/witness statement, dated 09/02/22 at approximatley 4:30 p.m., revealed, .[Resident #21] doesn't understand why [Resident #25] won't leave her alone, but [sic] doesn't know what [Resident #25] is capable of. [Resident #25] said she has heard stories of [Resident #25] hitting other people, and [Resident #25] makes her nervous. [Resident #21] told me that she did not like that [Resident #25] had called her a big lady motor mouth [expletive]. [Resident #21] said that [Resident #25] had done this on numerous occasions. [Resident #21] said she doesn't know why [Resident #25] is after her and won't leave her alone. [Resident #21] has the feeling that [Resident #25] may do something to her, and [Resident #21] is incapacitated and unable to defend herself . During an interview on 12/01/22 at 9:09 a.m., Resident #21 reported Resident #25 had called her derogatory names when they were roommates, and had continued to call her a motor mouth [expletive] since Resident #25 moved down the hall, with two more incidents in the past week. Resident #21 reported Resident #25 had also used inappropriate gestures towards her, and she was afraid of a physical incident. She reported the whistle provided by LPN Z to use when Resident #25 approached her room did not make her comfortable with Resident #25, as she did not believe it would prevent a physical altercation. Resident #21 reported she remained fearful of Resident #25, which caused her to not sleep well, as Resident #25's room was two doors down from her, which Surveyor confirmed. Resident #21 reported she talked to facility management, the social services director, nursing staff, and her family, yet the incidents continued to recur, which caused her to feel upset and scared. During a phone interview on 12/01/22 at 09:41 a.m., FM AA reported they were concerned about Resident #25's behaviors towards Resident #21, which they had witnessed, which included giving her the finger and saying, I'm going to get you, motor mouth. FM AA stated Resident #21 was afraid Resident #25 would use a weapon, and that she couldn't defend herself. FM AA reported they had discussed these ongoing verbal incidents with administration, nursing, social services, yet the verbal incidents/behaviors continued to recur. FM AA' reported they did not believe the whistle was an effective intervention, as Resident #21 would not use the whistle, and they did not believe Resident #25 was redirectable, as the administration staff had told him, including this past week. FM AA reported they felt Resident #21 was being singled out by Resident #25, and were concerned for Resident #21's safety and well-being. Review of Resident #25's progress note, dated 08/12/22, revealed, .Asked resident [#25] if she called her roommate [Resident #21] 'motor mouth [expletive].' [Resident #25 replied 'Yes, but I won't do it again'. [Resident #25] also confirmed that she takes [Resident #21's] newspaper without asking 'but I give it back when I am done' .Inquired what [Resident #25] should do differently in these instances. [Resident #25] replied, ' .I should ignore [Resident #21] instead of calling her names .' Review of Resident #21's Grievance Complaint Form, dated 08/12/22, revealed, .[Resident #21] upset; reported that her roommate [Resident #25] called her a 'motor mouthed [expletive]' several times. Per [Resident #21], that is the last straw. Other complaints including her roommate taking her newspaper without asking. Keeping the bathroom door open when using the bathroom, and general rudeness.IDT [Interdisciplinary Team] met and decided to move the roommate [Resident #25] .[Resident #25] confirmed each complaint did occur. [Resident #5] moved to room [#] . The grievance was signed by LPN Z on 08/12/22, and addressed by 08/14/22. Review of the Electronic Medical Record (EMR) showed Resident #21 and Resident #25 had been roommates prior to this incident, which Resident #21 confirmed. Review of Resident #25's current Care Plan revealed, Problem: Resident is unable to make consistent daily decisions without cues/supervision for safety R/T [related to] DX [diagnoses] intellectual difficulties, bipolar disorder with restlessness and agitation at times .Approach: In new situation, provide support and reassure to reduce stress and potential agitation .Approach: Give feedback to resident when inappropriate decisions are made .Approach: Determine if decision made by the resident may be negative to the resident or others . Review of Resident #21's current Care Plan including the behavioral care plan revealed no interventions to address Resident #21's reported feelings of fear, helplessness, and vulnerability from the verbal incidents perpetrated towards her by Resident #25, or interventions to provide support, monitoring, or prevention of these occurrences. Review of Resident #25's Behavioral Care provider summary, dated 06/30/22, revealed, .[Resident #25] had a recent altercation with another resident and had to move rooms. [Resident #25] fixates on her new roommate [Resident #21, per census], says [Resident #21] talks on the phone a lot and it frustrates [Resident #25] at times . Review of Resident #25's Behavioral Care provider summary, dated 09/02/22, revealed, .[Resident #25] continues to fixate on other residents and their noises and lights at night. Says they irritate [Resident #25] . Review of Resident #25's Behavioral Care provider summary, dated 10/17/22, revealed, .[Resident #25] has been bothering her old roommate [Resident #21], will purposely go into [Resident #21's] room down the hall however says [Resident #25] wants nothing to do with her . Review of Resident #25's progress notes revealed Resident #25 had physical altercations where she was the perpetrator with another facility resident on 05/19/22, 06/10/22, and 07/12/22. Review of Resident #25's progress note, dated 11/24/22 at 3:23 p.m., by RN P , revealed, .I was informed by [Resident #21] as soon as her son left, [Resident #25] came to [Resident #21's] doorway, and called her a 'motor mouth'. I approached [Resident #25], who was at the nurses station at this time, if [Resident #25] had gone past [Resident #21's] room and [Resident #25] said, 'Yes'. I then repeated what [Resident #21's room] said and [Resident #25] said, I apologize; I don't want to be in trouble. I won't do it again .As I [RN P] am writing this, I heard [Resident #25] say to another resident, 'Get away from me', and as I turned, [Resident #25] pushed the handle on the back of the resident's chair as she [resident #25] made her way to her own room. Review of Resident #25's progress note, dated 06/09/22 at 7:08 a.m., revealed, [Resident #25] does have a hx [history] of verbal and physical behaviors particularly towards current and past roommates. Behaviors typically occur when she is upset with current and past roommates . Review of Resident #25's progress note, dated 03/08/22, revealed, .[Resident #25] does have a hx of verbal and physical behaviors towards current and past roommates . Review of Resident #25's behavioral tracking logs (for 15 minute checks) showed no behavioral monitoring/tracking on 11/15/22 from 7:00 a.m. to 5:00 p.m., on 11/16/22 from 7:00 a.m. to midnight, and on 11/17/22 through 11/31/22. During an interview on 11/30/22 at 12:47 p.m., RN P confirmed Resident #25's behavioral management tracking logs should have been completed by staff on the missing dates, as behavioral incidents were occurring, including a resident to resident incident involving Resident #25 towards Resident #21 a week ago [on 11/24/22], when RN P was working. Review of Resident #25's 11/24/22 behavioral tracking log showed it was not completed. During an interview on 11/30/22 at 12:47 p.m., the behavioral management tracking logs for Resident #25 were confirmed as accurate by the NHA, including the missing entries during November, 2022. Review of Resident #21's social services and nursing progress notes including interdisciplinary notes revealed no psychosocial support was provided to Resident #21 following the ongoing verbal abuse incidents perpetrated towards her by Resident #25. There was no mention of these incidents in Resident #21's progress notes, only in Resident #25's progress notes. During an interview on 12/01/22 at 10:37 a.m., the DON and LPN Z acknowledged verbal abuse had occurred to Resident #21, post review of the resident to resident incidents (which Resident #25 perpetrated towards Resident #21) . Both understood the need for increased supervision and effective interventions for Resident #25, as evidenced by the missing behavioral tracking logs and several resident to resident incidents towards Resident #21, which continued to recur. LPN Z reported she had discussed the incidents with Resident #21 when they occurred, stating, [Resident #21] has two whistles and she said to [Resident #21], 'You have to use them'. LPN Z reported Resident #21 was cognizant, and didn't understand why Resident #21 was not using the whistle when the events occurred. Both acknowledged Resident #21 would benefit from additional psychosocial support and monitoring when they understood Resident #21 experienced psychosocial harm as a result of the repetitive, multiple resident to resident verbal abuse incidents, and the whistle was not an effective intervention. During this same interview, the Social Services Director, LPN Z, was asked further about the lack of psychosocial support/visits for Resident #21 after these incidents, and appropriate interventions to prevent the multiple incidents of verbal abuse towards her by Resident #25, as reported during interview and review of the EMR and investigation summary dated 09/02/22. LPN Z confirmed Resident #21's Care Plan was not updated to include supportive interventions to address her feelings of fear, helplessness, and vulnerability. LPN Z reported they had not offered supportive visits post the incidents to address Resident #21's concerns, and understood the concern. LPN Z reported they believed the main intervention was to redirect Resident #25 to her room for a break, and for Resident #21 to use the whistle when Resident #25 was in her vicinity. Surveyor asked if Resident #25 had the mental capacity to understand her actions, and the cognitive capacity to carryover their instructions. LPN Z responded, No, I don't think [Resident #25] does. LPN Z explained Resident #25 scored 4/30 on the SLUMS assessment (a dementia assessment), which was in the dementia scoring range. LPN Z reported Resident #25 denied doing everything (towards Resident #21) but the incidents had been witnessed, and reported Resident #25 needed more to do, such as activities. LPN Z added, I need someone [to give guidance] who is familiar with nursing home rules for behaviors, and acknowledged they had reached out to another nursing home social worker for suggestions. LPN Z reported Resident #25' diagnoses (mental and intellectual) doesn't qualify with us, however other alternative placement options had been turned down, due to dementia was now the primary diagnosis, per the outside/community mental health assessments. LPN Z further clarified Resident #25's dementia diagnosis limited her ability to qualify for other programs and settings, and stated, [Resident #25] being here is a detriment to her in my opinion. LPN Z added they were not a social worker, but a nurse, and had done all the interventions they knew to do. During an interview on 12/01/22 at approximately 11:00 a.m., the DON confirmed Resident #21 would benefit from additional social services for support and visits, and to address Resident #21's psychosocial outcome of feeling scared and vulnerable from Resident #25's repetitive, ongoing verbally abusive behaviors towards her. The DON acknowledged the building was developing staff, as they were a newer team, and hiring additional staff including activities staff, which they believed would help staff to address these concerns. The DON reported they understood the concerns. During an interview on 12/01/22 at approximatley 12:25 p.m., the Regional Operations Director, NHA S, and the NHA acknowledged the concern with the multiple resident to resident verbal abusive altercations (which Resident #25 perpetrated towards Resident #21), and the lack of supportive visits, Care Plan updates, and follow up by Social Services related to Resident #21's adverse psychosocial outcome. Both understood LPN Z would benefit from additional training related to the behavioral management of facility residents. Review of the policy, Social Services Department, revised 01/2022, revealed, Social Services department will ensure the resident has medically related social services needs are continually met. Social services will assure to meet the physical, mental, and psychosocial well-being of teach resident, and to assist in attaining or maintaining the highest practicable level of functioning .Medically-related social services means services provided by the facility's staff to assist residents maintaining or improving their ability manage their everyday physical, mental, and psychosocial needs. The social service department is responsible for services or participation in the following: .Identifying individual social and emotional needs. Assisting to providing corrective action for the resident's needs by developing and maintaining individualized social services care plans, maintaining regular progress and follow-up notes indicating the resident's response to the plan and adjustment to the institutional setting .Making supportive visits to residents and performing needed services ( .i.e. services to meet the resident's needs .Finding options to most meet the physical and emotional needs of each resident . Review of the document, [Facility Organization] Job Description, undated, revealed, Position Title: Social Services Director .General Purpose: Responsible for developing, planning, implementing, and evaluating social services programs and services in accordance with state and federal regulations. To identify and provide for residents. social, emotional, and psychological needs. To aid in the development of the resident is [sic] full potential .to provide family counseling as needed .Performs all duties using independent judgment and discretion to implement regulations and policy .Licensed Social Worker preferred. Qualifications: Must, at a minimum, have a bachelor's degree in a human services field and one year of supervised social work experience in a health care setting .Social Work Functions: Duties .Provide or arrange for needed counseling services . Find options that most meet the physical and emotional needs of each resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all professional staff were licensed, certified, or registered in accordance with applicable State laws for one Licensed Practical Nurse (LPN) out of six licensed nurses whose qualifications were reviewed. This deficient practice resulted in the provision of skilled nursing care by an unlicensed LPN, and the potential for the provision of skilled care services that did not meet standard of practice requirements for all facility residents. Findings include: This deficiency pertains to Intakes MI00129273 and MI00132598. Multiple complaint allegations were investigated that alleged the facility allowed a nurse to work with a suspended nursing license. During a telephone interview on [DATE] at 4:40 p.m., regarding the employment of a nurse with a suspended nursing license, confidential Complainant E stated, . For [LPN C] the 12 hour midnight shifts went without a nurse (a licensed nurse) when she was suspended. I want to know if families were informed that their loved one was provided care by a nurse with a suspended license. Complainant E said the information had been provided to the facility, LPN C had been terminated in July of 2022, but had recently been rehired by the facility. Review of a copy of a Licensing and Regulatory Affairs ([NAME]) online review of [LPN C's] disciplinary actions revealed the following: Suspended Applied [DATE] Fine Imposed Applied [DATE] Limited/Restricted Applied [DATE] Probation Applied [DATE] Review of the facility Past Noncompliance/Action Plan, developed [DATE], revealed the following, Description of deficient Practice: The facility administrator was notified by an outside source that a nurse who works the night shift at [the facility] had a suspended license. The administrator validated that the nurse's license had been suspended. The Administrator subsequently notified and suspended the nurse, on [DATE], from employment pending investigation. Review of an Employee Memorandum revealed [LPN C] was Suspended Pending Investigation beginning [DATE], Violation No. HR-306-1.4, Description of Violation: Failure to follow the Company's Professional Standards of Conduct . Discharge Effective [DATE] . Upon completion of investigation, [LPN C] was terminate. She received the notification by phone . During a telephone interview on [DATE] at 6:58 a.m., the Director of Nursing (DON) confirmed she was aware of the [State Name} Bureau of Professional licensing Board of Nursing disciplinary action that placed LPN C on nursing license probation as of [DATE]. The DON said that the former facility nursing home administrator was responsible for submitting quarterly reports to the State Board of Nursing. The DON stated, We found out that the quarterly reports (detailing LPN C's nursing competency in the position) were not being done once we called the State of . The DON also confirmed [LPN C] was clearly noted in the Board of Nursing Disciplinary documents as responsible for ensuring the submission of the quarterly reports, payment of a $250.00 fine within 90 days of the effective date of the disciplinary order, signed [DATE] (effective 30 days later), and multiple other conditions of employment. The DON and LPN C have a familial relationship, and both were terminated in [DATE] related to supervision and continued employment of a licensed nurse with a suspended license. LPN C worked from [DATE] through [DATE] as an unlicensed nurse, often working the night shift as the only nurse in the building. The facility self-identified the deficiency on [DATE], and implemented the following detailed interventions delineated in their Past Noncompliance Action Plan, dated [DATE], How and why deficient practice occurred: The nurse had actions taken against her nursing licensure that resulted in probationary nurse licensure. The nurse reported the probationary status to the previous facility administrator. The previous Administrator did not follow up with the terms of the nurses' probation or notify Atrium Centers of a nurse who had probationary licensure. The terms of probation were not met, and the nurse's license was subsequently suspended for not meeting the terms of probation. Upon investigation it was identified that the actions taken against the nurse were due to the lack of inaction (sic: action) by the nurse to notify a physician when a resident had a change of condition . Plan of Correction/Plan to Address: Action for Nurse Involved: The nurse was suspended on [DATE]. The [State Name] Consent Order and Stipulation for disciplinary action was reviewed and indicates the nurse cannot work in home health care. The nurse was placed on probation. The nurse was instructed to contact the licensing agency to obtain any change of licensure status in writing. Per the nurse, she was told that no changes will be made to the status of her license until the monetary fine as required as a condition of her probation is received. The nurse reports that she has submitted the payment for fees. The nurse's personnel file, fingerprints, background check, and references were reviewed. Identification of residents/Facility Actions: Residents in the facility are identified as being at potential risk. The following actions were taken on [DATE]: - The progress notes for residents who expired in the facility from [DATE] - current were reviewed to determine any concerns with physicians not being contacted timely with resident changes of condition. - Resident incident reports generated by the suspended nurse were reviewed from [DATE] - current to determine if actions taken by the nurse were appropriate and physicians were notified of the incidents. - Medication Error reports from [DATE] - current were reviewed to determine if the suspended nurse was involved and to ensure appropriate actions were taken in response to the errors, including physician notification. - The nursing licenses of all nurses employed at {Nursing Facility] were audited to ensure active licensure. During the audit it was identified that one nurse has her license under a different last name than the name on her social security card. The nurse has been asked to submit a request to the licensing board to amend the last name on her licensure to match the name she has on her social security card. - The certifications of CENAs (Certified Nurse Aides) were reviewed to ensure active CENA certification. There was 1 PRN (as needed) CENA identified whose certification presents as lapsed. The CNA was informed and will not be allowed to work until valid, active certification is presented. The CENA was also instructed to notify her current full-time employer of the lapsed certification. {Medical Association] was notified to determine a potential delay in transition of information from [the CENA licensure source]. - The electronic health record was reviewed to ensure employee licensed names are the same name that is in the electronic health record for documentation purposes. - Review of CENA certification identified 1 CENA whose last name on her certification is different than the last name on her social security card. The CENA has been asked to submit a request to {the CENA licensure source] to change the last name on her certification to match the last name on her social security card. - Contracted employees and employees of [Facility Corporation] who visit [the Facility] and who are required to have professional licensure or certification were contacted to provide current, updated proof of licensure. - Licensures and certifications were audited to determine any other employees on a probationary or restricted license or certification. - The Board of Nursing will be contacted within 30 days to report the nurse's employment at [the Facility] while on a suspended license. - Residents were interviewed to determine any potential concerns regarding nurse care rendered on the night shift. - Upon further investigation the Director of Nursing was suspended. Measure to ensure deficient practice will not recur: - Licensed Nurses will be educated on reporting any actions or pending actions with professional licensure. CENAs will be educated on reporting any actions or pending actions against their certifications. - All staff, including but not limited to nurses and CENAs, will be educated on notifying the facility administrator of any knowledge of pending legal issues, any arrests, or any concerns with licensure's or certifications. - The Administrator was educated to report any nurses on probation to the parent company . The company will verify that stipulations of probation including submission of quarterly reports if required as a condition of probation, are being submitted and conditions of probation are being met. - The VP (Vice President) of clinical services provided education to the facility Administrator, Director of Nursing, and Human Resource Representative on reporting to the company when concerns arise regarding licensure or certification. - The Facility Human Resources Representative was educated to audit the licensure of employees on restricted licensure/probation every 2 weeks to ensure licensure remains active and the employee is working within licensure restrictions and conditions of probation. - The Administrator will complete a timeline, full root-cause analysis, and investigation for submission to the facility QAPI Committee. Monitoring of corrective actions to ensure deficient practice will not recur: - The Human Resource Representative or designee will audit nursing licenses and CENA certifications every 6 months to verify active licensure and certification. Identified concerns will be addressed immediately. Audit results will be submitted to the QAPI Committee twice yearly. - A Human Resource Representative or designee from [Facility Corporation] will review monthly to ensure any employee conditions of probation/restrictions are being met, including any reports required to be submitted by the employee. Identified concerns will be addressed immediately. Findings will be provided to the company QAPI Committee monthly. - The facility Human Resources Representative will audit licensure/certifications every 2 weeks for nurses or CENAs who are on probation or who have restricted licensure/certification to ensure licenses/certification remains active. Identified concerns will be reported immediately to the Administrator for follow up. Audits will be submitted to the QAPI Committee monthly. Person responsible for attaining and sustaining substantial compliance: Administrator. Date substantial compliance achieved: [DATE]. Signed by the facility Administrator. As the facility self-identified the deficiency, implemented interventions to correct, educated, and monitored for resolution and prevention of further deficiency, past non-compliance was determined corrected, and no deficiency will be cited.

All times reported in Eastern Standard time (EST). This citation pertains to intake: MI00129665 Based on observation and interview, the facility failed to provide a safe environment for residents as evidenced by the lack of functional night lighting in six of 15 observed resident rooms. This deficient practice has the potential to result in residents unable to safely navigate their rooms during the dark hours. Findings include: On 11/30/22 between 9:15 AM and 9:40 AM resident rooms were observed for the purpose of establishing the functioning of wall mounted recessed night light fixtures. It was determined a wall switch at the nurses' station was required to be turned on to activate all night lights in resident rooms. Once activated, the following rooms were observed without functional lights: 100, 111, 112, 113, 115, 118. Not all resident rooms were able to be observed due to privacy issues. An interview with Environmental services director (ESD) K was conducted on 11/30/22 at 9:55 AM. ESD K acknowledged knowing some of the lights were out, and stated they had just received a box of bulbs. ESD K was not aware of all rooms without functional night lights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . This deficiency pertains to Intakes #MI00131669. All times are recorded in Eastern Standard Time (EST) unless otherwise noted. Based on observation, interview, and record review, the facility failed to offer a binding arbitration agreement that provided for the selection of a neutral arbitrator agreed upon by both parties and provided for the selection of a venue that was convenient to both parties for 5 of 6 residents (R4, R8, R19, R30, and R35) with signed binding arbitration agreements. This deficient practice failed to provide a neutral and fair arbitration process and had the potential to affect all residents and responsible parties entering into this agreement. Findings include: A complaint was received by the State Agency (SA) on 9/21/22 regarding the binding arbitration agreement for Resident 35 (R35). A call was placed to the complainant on 11/30/22 at 8:24 AM to clarify the details of the complaint regarding the facility's use of a binding arbitration agreement. During an interview on 11/30/22 at 10:03 AM, the Social Services Director, Licensed Practical Nurse (LPN) Z stated she did the admission paperwork for residents. She presented an arbitration agreement stating, It is part of the paperwork that is explained upon admission but not all residents sign it. LPN Z explained, It does expedite the grievance process, and said signing the agreement was not a condition of admission. The binding arbitration agreement for R35 was received for review on 11/30/22 at 11:32 AM from the Business Office Manager (Staff T). The Agreement to Resolve Legal Disputes Through Arbitration for R35 had been signed on 5/26/22 for the initial admission with the error of the Durable Power of Attorney (DPOA) listed as the Resident and R35 written into the agreement as the Representative. R35 was readmitted [DATE] and the same arbitration agreement was again signed 8/12/22 with the Resident R35 and DPOA listed in the proper blanks. Upon review of the Agreement to Resolve Legal Disputes Through Arbitration form there were multiple blanks and typographical errors including: B. an (sic) judgement . B. This paragraph ends as follows: . The decision of the arbitrator shall be binding on all of the parties to the arbitration, and also on their successors and assigns, including the agents (multiple blank lines followed) and then continued and employees of [Name of facility] , and all persons whose claim is derived through or on behalf of Resident, including, but not limited to, that of any parent, spouse, child, guardian, executor, administrator, legal . The sentence ends without conclusion or period punctuation. A space follows under this paragraph which appears to have been erased or whited out. C. Who Wil (sic) Conduct Arbitration . C. will be resolved through arbitration administered by the American Health Layers (sic) Association (AHLA) . C. or AHLS is unwilling tor (sic) unable . C. This paragraph ends as follows: . If the parties are unable to agree on an alternative organization, The sentence ends without conclusion or period punctuation. A space follows under this paragraph which appears to have been erased or whited out. D. Where the Arbitration Will Take Place. The parities (sic) . D. then at (Name of Facility) s (sic) option . During an interview on 11/30/22 at 12:16 PM, Regional Operations Director S and Nursing Home Administrator (NHA) reviewed the signed Agreement to Resolve Legal Disputes Through Arbitration for R35. The Regional Operations Director S stated, It appears there would be a missing rest of the sentence in (paragraph) B and C. On 11/30/22 at 12:22 PM, the Regional Operations Director S invited Staff T to join the discussion. Regional Operations Director S stated the form signed was the wrong form and there was a computer form that was supposed to be used from the corporate office. Staff T explained for admissions, LPN Z made copies and did not use electronic forms. Regional Operations Director S said, I did not realize that he (DPOA for R35) signed an agreement with missing sentences. Staff T said, We both have been making copies of that form for over a year. Regional Operations Director S questioned the validity of the form and invited LPN Z into the discussion. LPN Z confirmed and said, This is the original that he (DPOA for R35) signed. LPN Z stated, I have been making copies of the same copies for the last year. The conversation continued with Regional Operations Director S and the NHA. The required clauses: (iii) The agreement provides for the selection of a neutral arbitrator agreed upon by both parties; and (iv) The agreement provides for the selection of a venue that is convenient to both parties. were not found in the Agreement to Resolve Legal Disputes Through Arbitration. Paragraph C stated a national dispute resolution service would be used as a neutral arbitrator, but went on to state, If the parties are unable to agree on an alternative organization. Here the paragraph ends, and the selection of a neutral arbitrator is not provided for. Paragraph D read: The parities (sic) will mutually agree to a location where the arbitration will take place. If the parties cannot agree to a location, then at (Name of Facility) s (sic) option, the arbitration will take place at (Name of Facility), or at a location affiliated with (Name of Facility). The clause states the parties will mutually agree, but if they cannot, it will be the choice of the facility. This agreement did not provide for the selection of a venue convenient to both parties. Regional Operations Director S stated, That regulation did not go into effect until October 24, 2022, and so the agreements did not have to have those clauses. This surveyor invited presentation of further information to fulfill the regulation. On 11/30/22 at 2:15 PM, a list of residents who had entered into a binding arbitration agreement on or after September 16, 2019, was requested. A list of 22 current residents who had signed binding arbitration agreements was presented. A review of the arbitration agreements for R4, R8, R19, and R30 revealed the same form with errant, missing, and incomplete paragraphs had been signed. These Agreements to Resolve Legal Disputes Through Arbitration also failed to offer a binding arbitration agreement that provided for the selection of a neutral arbitrator agreed upon by both parties and provided for the selection of a venue that was convenient to both parties. .

All times reported in Eastern Standard time (EST) unless otherwise noted. Based on interview and record review, the facility failed to implement its abuse policy including: 1. Thoroughly screening working eligibility in 7 of 20 staff members (Certified Nursing Assistants [CNA] Q, R and O, Registered Nurses [RN] P and A, Licensed Practical Nurse [LPN] D, and the Nursing Home Administrator [NHA], and 2. Providing abuse training and education for all new and existing employees (LPN D). This deficient practice resulted in the potential for risking all 29 resident's safety. Findings include: Review of the employee files for CNA Q, R and O, RN P and A, LPN D, and the NHA, failed to reveal the facility attempted to contact at least two previous employers prior to being hired. During an interview on 11/30/22 at 4:24 PM, Regional Operations Director (S) stated she had filled out one reference check obtained from a previous facility for the NHA. This reference was dated 10/11/22 while the employee gave authorization and dated the same form on 10/17/22. While other places of employment were listed on the application, no other reference checks for the NHA were provided. During an interview on 12/01/22 at 12:33 PM, Human Resources (T) stated the NHA did the reference checks and the employee files had been searched to provide all references that were available. The review of the employee files also revealed LPN D had been hired 11/22/22 and had worked several shifts. Her file included a return demonstration test titled Abuse and Neglect policy/procedure test with the date on the form left blank. Only three true/false questions had been answered and the questions including essay questions and fill in the blank questions were left unanswered. When asked about the review of the abuse tests and answers for the new employees, the Director of Nursing stated this must have been missed. The facility policy EMPLOYMENT APPLICATION PROCEDURE dated as effective 12/2002 and last revised 10/2014 read in part: Each applicant for employment must complete and sign an application for employment and all references provided by an applicant must be checked prior to employment of the applicant . A. all applicants for employment must complete a (Company specific) Application including two applicant reference check forms prior to the extension of an offer of employment, regardless of whether the applicant has also submitted a resume . E. The human resource representative or department head will diligently attempt to contact all references listed by the applicant, using the telephone and written reference check forms PG-204. The representative must make contact and receive a favorable or neutral reference from at least two of the references listed prior to an offer of employment being extended to the applicant. Records of all reference checks, whether successful or not, must be retained with the employment application. The facility policy ABUSE PREVENTION PROGRAM dated as reviewed 1/2022 read in part: SCREENING The facility will conduct thorough investigations of histories of prospective staff . The facility will obtain verification of screening prior to employment . The facility should maintain documentation of the screening that has occurred . All applicants for employment will be checked from previous and/or current employers and make reasonable efforts to uncover information about any past criminal prosecutions. Applicants will be asked to supply references of previous work history. TRAINING The facility will ensure that all staff, new and existing are trained and knowledgeable of facility's Abuse Prevention Program . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a phone interview on 12/01/22 at 09:41 a.m., FM AA stated there were several verbal incidents towards his mother by Resident #25. FM AA reported Resident #25 would give Resident #21 inappropriate hand gestures, including the finger, and yelled at Resident #21, saying, I'm going to get you, motor mouth. FM AA clarified they had heard Resident #25 say this to Resident #21, and staff gave Resident #21 a whistle to alert staff, which Resident #21 declined to use. FM AA reported this caused Resident #21 to be upset and fearful of Resident #25, including of a physical altercation. FM AA reported they had spoken to current and past administrators, nursing management staff, and social services staff, with no change in Resident #25's behaviors, as staff told them Resident #25 was redirectable. FM AA reported they did not agree, as Resident #25's verbal behaviors towards his mother had continued. FM AA stated sometimes they [nursing management] have one aide working in the whole place, and cannot provide adequate supervision of Resident #25, when they are short staffed. FM AA reported they told an unnamed staff [who they declined to name] they were going to file a report them (to the State Agency), and the staff asked them not to report, stating they would face retaliation. FM AA reported these incidents towards Resident #21 by Resident #25 had been going on for months, as well as towards other facility residents. FM AA reported they spoke to the NHA a few days ago with their concerns, and were told Resident #25 was redirectable. FM AA asked to continue the interview to discuss Resident #21's care needs not being met, and related it was hit or miss. FM AA reported sometimes Resident #21 laid in wet urine for up to 14 hours (until the next shift), more than once. FM AA reported recently when they were present Resident #21 waited from 2:00 p.m. until 6:30 p.m. to be changed, despite their requests. FM AA reported they told the nurse who said, The aides can do it. It's not my job. FM AA reported this upset both him and Resident #21. FM AA reported their biggest concern was Resident #25 approaching and upsetting Resident #21. FM AA stated All I can tell [Resident #21] is to blow the whistle, and said they didn't think that was an adequate intervention to stop Resident #25's behaviors, and the potential for verbal and physical altercations. FM AA clarified they had discussed their concerns with facility administration. During an interview on 12/01/22 at 10:08 a.m., Resident #21 was asked about nursing care. Resident #21 reported she had been frequently left in a wet brief, and stated, I'm afraid to say anything as I want to stay here [at the facility]. Resident #21 reported this had occurred in the past two weeks. Resident #21 reported she and her roommate had both been left in their wet briefs for six hours, and stated, They [nursing staff] shut the door on us, and didn't come back. Both of us were in there with COVID [an infectious viral illness]. We both pushed the call light, and it was not answered for six hours. Resident #21 reported they had waited for hours to be changed on other occasions, and stated, That's why my sore [pressure sore] didn't heal; these last couple months have been terrible [with long call light wait times]. Resident #21 stated the longest she has had to wait was from 6 p.m. at night until 4:00 to 5:00 a.m. in morning, and it was a month ago. Resident #21 reported they [nursing staff] had to change the bed [which was wet]. Resident #21 reported they typically wait one to two hours to be changed, on all shifts, and stated, There is nobody here. [FM AA] came in one day and said, 'Where are the staff?' Resident #21 stated, My rear end starts to sizzle. When asked if their pressure ulcer was healing, Resident #21 reported it had healed, however their back was sore and stated, Another sore may have started. Resident #21 reported they were going to the wound clinic on 12/02/22 for follow-up. Resident #21 confirmed the verbal incidents perpetrated towards her by Resident #25 were ongoing, causing her to feel scared and afraid of a physical incident, as she was vulnerable and helpless being in her bed. Resident #21 confirmed she considered them verbally abusive, and did not know why Resident #25 continued to call her names and make inappropriate gestures towards her, as she and her son had told staff including administration and nursing staff on multiple occasions, yet the incidents recurred. All times are Eastern Standard Time (EST) unless otherwise noted. This deficiency pertains to Intakes #MI00129665 and #MI00129273. Based on observation, interview, and record review, the facility failed to ensure sufficient staff to provide for resident's care needs, based on acuity and the Facility Assessment. This deficient practice resulted in Resident dissatisfaction with the timeliness of care provided and unmet care needs. This deficiency has the potential to affect all facility residents. Findings include: During an interview on 11/28/22 at 2:43 p.m., with Resident #5 stated, The nurses rush and they don't talk to me. I can see that is because there are a half dozen (call) lights on . days (day shift CNAs) are short (staffed) . Last week I could not get a shower because the girl was working by herself down here . with all these heavy (care needs) people, and it was the same on the [NAME] (hall). Wednesday and Saturday are my shower days, and I didn't get one. During an interview on 11/29/22 at 7:10 a.m., Registered Nurse (RN)B was asked about documentation of which staff worked on the nursing schedule. RN B stated, Well I don't think the Director of Nursing (DON] or any of the administrative nurses that worked the floor are on the schedule. We don't put that on the nursing schedule. RN B said the DON, Social Services Designee/LPN Z' or RN/MDS B filled in as floor nursing staff. When asked how this Surveyor would know who worked, as those administrative staff members were not identified on the nursing staff list, RN B stated, Well, I suppose you wouldn't (know). During an interview on 11/29/22 at 9:43 a.m., Resident #21 stated, (There are} not enough CNA's. Two weeks or (maybe) a week ago there was a nurse and one CNA during the day. I don't want to be called a liar. Saturday (there were three nurses) and they had no CNAs. In the last six months there have been nights where there were no CNAs. We get the short end of the stick . [CNA Y] is the only one working on this side. The office help are running around here making like CNAs. They have done this to me - if I complain too much then they totally ignore me period and then what do you do. They don't walk past - they just don't show up . I got called on the carpet yesterday . every morning when I go to therapy, they are supposed to give me a Xanax and two Tylenol so I can get through therapy. [Therapy Staff] came in and I told [them] that I had not had my pills yet. There wasn't a blessed soul around except three residents . I was yelling for the nurse. I waited by that desk for one hour and I did not see one fricken nurse for one hour . During a telephone interview on 11/30/22 at 7:01 p.m., CNA GG said she began work at the facility in March of 2022. CNA GG said the first night she was training in as a CNA, the day shift nurse aides both called in and she had to work the floor alone as a CNA without even really knowing the residents. CNA GG said that there were multiple times when she was the only CNA working the floor during shifts and would be the only one when carried over to other shifts. CNA GG stated, It was like that all the time. CNA GG confirmed that resident showers would not get completed because there was not enough staff to do all the showers on the schedule. Review of the facility Daily Staffing Sheets (postings) on 11/29/22 at 12:45 p.m., revealed administrative staff, including the Director of Nursing (DON), MDS (Minimum Data Set) assessment/Registered Nurse (RN) B, and Licensed Practical Nurse/Social Services Designee Z worked multiple shifts to cover for the unavailability of a floor nurse. The Daily Staffing Sheets also documented the following shifts, where staffing appeared insufficient to meet resident needs, based on the Facility Assessment between 10/4/22 and 11/28/22: 11/28/22 Day Shift One LPN, one RN, and 2 CNAs (Certified Nurse Aides). 11/13/22 One RN and 2 CNAs Day Shift; Night Shift one LPN Night shift and 1.5 CNAs. 11/9/22 One LPN and one CNA on night shift. 10/30/22 Night shift one LPN and one CNA. 10/26/22 Night Shift one LPN and one CNA. 10/24/22 Night Shift one LPN, and CNA. 10/23/22 Night Shift one RN and one CNA. 10/7/22 Night Shift one LPN and one CNA. 10/4/22 Afternoon shift 1 RN 8 hours, no CNAs. Night shift one RN 12 hours no CNAs documented. Review of the Facility Assessment, dated 9/6/22, revealed the following staffing information: [The Facility] is licensed to provide care for :35 . Staffing Plan: 3.2. Based on the resident population and their identified needs for care and support, we have determined the following approach to staffing to ensure that facility has sufficient staff to meet the needs of the residents at any given time . Position: Licensed Nurses (Direct Care Staff) 2-3 FTE/12-hour shifts (Total Number of FTE's Needed on Daily Basis) .Certified Nursing Assistants 6-8 FTE/7.5/12-hour shifts . Other Nursing Personnel (e.g., those with administrative duties) 2FTE/8-hour shifts . State of Michigan criteria for minimum staff requirements found in the Facility Assessment from 1980 (old information) that did not include the acuity of facility residents in determination of required staffing levels. 11/29/22 2:45 PM [NAME] provided copies of the requested Staffing sheets for July, although three pages were missing for the dates reported when there were no CNA's present in the building. No evidence was provided to show evidence of adequate staffing in the building on 7/22/22 night shift. During an observation on 11/30/22 at 11:15 a.m., upon entry into the business office manager's (Staff) T's office this Surveyor observed Staff T quickly move her pen from a stack of papers that she was filling out. Nursing Assignment Sheets with July 2022's date were in clear sight. Staff T was asked about documentation on the almost blank July 2022 Nursing Assignment sheets. Staff T said she was filling them out, because they did not have the originals, so they were being recreated. Recreated documentation has not been requested, but rather payroll documentation for hours worked on the days where the Nursing Assignment sheets, and the Nurse Staffing Postings were missing in the documentation required for review. Regional Operations Director S entered the room and stated that she had previously received permission to recreate documents from the previous and current section manager. This Surveyor again requested the payroll information for the specified days as previously requested, and Regional Operations Director S said they (payroll documentation) would not be accurate because the administrative nursing staff that worked would not necessarily be documented on the payroll sheets because they were salaried. Regional Operations Director S added the payroll would not be accurate because she had brought up several staff from the facility where she was the Nursing Home Administrator (NHA). Payroll documentation was provided for one CNA from another corporate facility; however, review Assignment Sheets and Staff postings for days provided no documentation of the identified CNA being in the facility during the dates in July when the Nursing Assignment sheets were missing (July 18, 22 through July 22, 22). On 11/30/22 at 1:03 p.m., telephone contact with the identified CNA from another corporation facility was attempted. The telephone call was not answered, and the message stated, Not available at this time, please try your call again. A repeat attempt that same day resulted in the same message. During an interview on 11/30/22 at 2:35 p.m., CNA Y confirmed she had worked in the facility on Friday 7/22/22 with RN P and CNA FF on Day shift. CNA Y said both afternoon shift CNAs had called off (not worked) for the day. CNA U had walked off the floor during day shift and there was only one aide on each hall during Day shift. CNA Y confirmed she had worked alone, as the only aide on both halls during afternoon shift and was relieved by a night CNA. One CNA worked the whole night. When specifically asked if any other corporate facility CNA staff had worked as a CNA on days, afternoons, or nights, on that Friday 7/22/22. CNA Y said she was sure there were no staff from any other facility working in the building as a CNA that day. During a telephone interview on 11/30/22 at 2:47 p.m., RN EE stated, Yes, I do recall having to work with no CNA's while we were waiting for somebody to come in. I had one CNA at the start of the night - I got called in for night shift, and the CNAs that were on afternoons all called off. Somebody from day shift stayed over, then she left, and the midnight shift came in. When asked if she had worked without any CNAs on night shift, RN EE stated, I could have - I just am not sure. Depending on what is going on - even having two (CNAs) can be challenging at times. When I was in the [administrative] role they struggled to have coverage - because they only had two CNAs scheduled for night shift. There was one that stayed over for day shift - she left and there was nobody. RN EE confirmed there was no other corporation CNAs that worked that specific night. RN EE stated, (It is) absolutely not adequate to have 2 CNAs on day shift, nor on afternoons. The two on nights will do the wet checks together. Review of the Facility Assessment, dated 10/28/22, revealed the following staffing levels identified by the facility for sufficient based on the facility census: [Facility Name] is licensed to provide care for: 35 (Residents). 1.2 [Facility name] has a daily average census June-August 31st. Total Avg. (average) Residents = 26. 1.2a. In an effort to help our facility determine staff needs we also took into account the average number of residents admitted /discharged on weekdays & weekends. Weekdays: 2 . Assistance with Activities of Daily Living - As of September 6, 2022, included: 1-2 residents were independent in dressing, transfers, toileting, and mobility. 22 to 31 residents required Assist of 1-2 staff for those same ADLs. 2-7 residents were totally dependent upon staff for those same ADLs. The Facility Assessment Staffing Plan included: 3.2 Based on the resident population and their identified needs for care and support, we have determined the following approach to staffing to ensure that facility has sufficient staff to meet the needs of the residents at any given time. Staffing Tool 1: Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff is available to meet each resident's needs. Refer to the guidance in the various tags that have requirements for staffing to be based on/in according with the facility assessment .Enter number of staff needed or an average or range: Licensed Nurses (Direct Care Staff), Total Number of FTE's (full time equivalents) Needed on Daily Basis: 2-3/12-hour shifts. Certified Nursing Assistants, 6-8 FTE/7.5/12 hr. (hour) shift. The facility also included the [State Name} Staff Requirements, dated January 1, 1980 in their facility that detailed patient ratios and the number of patients to nursing care that included: The ratio of patients to nursing care personnel during a morning shift shall not exceed 8 patients to 1 nursing care personnel; the ratio of patients to nursing care personnel during an afternoon shift shall not exceed 12 patients to 1 nursing care personnel, and the ratio of patients to nursing care personnel during a nighttime shift shall not exceed 15 patients to 1 nursing care personnel, and there shall be sufficient nursing care personnel available on duty to assure coverage for patients at all times during the shift . No reference to acuity consideration was noted in this portion of the Facility Assessment. During an interview on 12/01/22 at 1:48 p.m., the NHA and Regional Operations Director S agreed the Facility Assessment CNA levels did not provide adequate staffing levels to meet resident care needs based on the lowest level identified in the Facility Assessment document. Both the NHA and Regional Operations Director S agreed the facility had been struggling with short staffing.

All times reported in Eastern Standard time (EST) unless otherwise noted. Based on interview and record review, the facility failed to verify the appropriate competencies and skills sets to provide nursing services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by facility policy and facility assessment for six Certified Nursing Assistants (CNAs U, V, O, W, X, and Y) of twelve CNAs reviewed for competency evaluations and one Registered Nurse (RN A) of four RNs reviewed for competency evaluations. This deficient practice resulted in the likelihood for nursing personnel to lack training and skills needed to care for all 29 residents who reside in the facility. Findings include: On 11/30/22 employee files were reviewed and revealed: - CNA U was hired 1/29/22 and had an orientation checklist signed as completed on 3/4/22. There was no nursing signature indicating completion. A Nursing Assistant Orientation was incomplete with all skills from day two, day three, and day four blank and not completed although the Director of Nursing signature was affixed to the form. While the orientation checklist was not signed until 3/4/22, the employee completed more than 25 shifts prior to the signed completion of the orientation checklist and no skills from 3 of the 4 days of orientation were ever checked off indicating completion. CNA U terminated employment 5/26/22 and was rehired 6/14/22. The clinical skills competency checklist for this rehire was completely blank except a signature by the employee dated on 7/1/22. CNA U then again terminated employment 7/22/22. No completed skill competency demonstration was found or presented for CNA U for either date of hire. - CNA V was hired 9/24/20 and had only seven points signed off on 6/5/22 on the clinical skills competency checklist. No other skill competency demonstration was found or presented for CNA V. - CNA O was hired 10/10/22 and no skill competency demonstration was found or presented for CNA O. - CNA W was hired 12/28/16. A clinical skills competency review dated 7/26/21 was presented. A current annual skill competency demonstration was not found or presented for CNA W. - CNA X was hired 5/23/21. A clinical skills competency review dated 10/12/20, with no full name printed on the form but only listed a first name, was presented, but the skill review date preceded the hire date. A current annual skill competency demonstration was not found or presented for CNA W. - CNA Y was hired 10/11/17. A clinical skills competency review dated 7/26/21 was presented. A current annual skill competency demonstration was not found or presented for CNA Y. - RN A was hired 8/19/22. A License Nursing Skills Competency Checklist which indicated the purpose was for new hire was dated as the skills were observed 11/28/22 (three months after RN As hire date. The form was signed by RN A but had no signature or date of the Observer. During an interview on 11/30/22 at approximately 4:00 PM, the Business Office Manager (Staff T) reviewed the requested competencies and employee files. Staff T stated she had presented the most current competencies she had in the files. Staff T stated several of the staff were hired by a previous Director of Nursing (DON) and said, I do not know if the DON at the time was doing competencies. Our new DON is doing them. During an interview on 12/01/22 at 1:08 PM, the DON stated, I have given (Staff T) all of the competencies I have done. The nurses are done, and I have three CNAs to do. CNA O hired 10/10/22 and was scheduled as working 9 shifts every two weeks. CNA O was listed as an employee the DON had not yet evaluated for competency. When asked about CNA Y, the DON stated, I did her last year. The competency was dated 7/26/21. The DON stated, I do not have it. I will do it immediately. I am sorry they do not have it. When the DON was asked about CNA Xs competency evaluation, the DON said, If she (Staff T) does not have it, I will re-do it. She (CNA X) was on my list as crossed off. I figured previously to leaving I did it. It must of got lost in the shuffle. The DON stated she would have to re-check her list. The Facility assessment dated as reviewed 10/28/22 read in part: Staff training/education and competencies Outlined below are the various education, training and competencies that are necessary for our staff to provide the level and types of support and care needed for our resident population. A non-inclusive list of training topics and Annual competencies were listed. .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure frozen food, removed from its original packaging and placed in plastic zippered bags, was properly labeled. 2. Failing to replace a torn, damaged and ill fitting gasket on an upright refrigerator. 3. Failed to maintain the steamer cooking appliance in a sanitary manner. This deficient practice has the potential to result in food borne illness among any or all 39 residents in the facility. Findings include: (All reported times are in EST) 1. On 11/28/22 at 4:30 PM, two plastic zippered bags were observed in the upright freezer in the rear adjacent storeroom. Both plastic bags were absent of any labeling which identified the product, the date it had been removed from the original packaging, or an expiration date. On 11/29/22 at 12:30 PM, this same observation was made. on 11/30/22 at 8:15 AM, an interview was conducted with Kitchen Manager (KM) F, who acknowledged that the bags should have been labeled with the above information. The FDA Food Code 2017 states: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (D) A date marking system that meets the criteria stated in ¶¶ (A) and (B) of this section may include: (1) Using a method APPROVED by the REGULATORY AUTHORITY for refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under ¶ (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under ¶ (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. 2. On 11/28/22 at 12:45 PM, the upright single door Delfield refrigerator, located in the food preparation area, was observed to have a door gasket which was torn on the lateral edge, and an installation which prevented the door from sealing. The upper and lower corners of the gasket were twisted and did not provide a seal, and was further supported by cold air exiting the unit when the door was closed. At this time, an interview with Dietary Aide (DA) J was conducted who stated the unit has a difficult time maintaining temperatures. 3. On 11/29/22 at 8:40 AM, Dietary [NAME] (DC) G was observed using the mechanical steamer. Excessive steam was exiting through the door when it was closed. Further observations of the cooking equipment revealed the door handle was corroded. DC G stated the steamer door is supposed to be closed and prevent the exit of steam until the door is opened, and the unit had been in this condition for a few months. The FDA Food Code 2017 states: 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.

All times are Eastern Standard Time (EST) unless otherwise noted. Based on observation, interview, and record review, the facility failed to provide sufficient staff based on the Facility Assessment to provide the care required by the resident population considering the types of diseases, conditions, physical and cognitive abilities and overall acuity within the population. This deficient practice resulted in resident dissatisfaction with the timeliness of care provided and unmet care needs. This deficiency has the potential to affect all facility staff. Findings include: Review of the Facility Assessment, dated 10/28/22, revealed the following staffing levels identified by the facility for sufficient based on the facility census: [Facility Name] is licensed to provide care for: 35 (Residents). 1.2 [Facility name] has a daily average census June-August 31st. Total Avg. (average) Residents = 26. 1.2a. In an effort to help our facility determine staff needs we also took into account the average number of residents admitted /discharged on weekdays & weekends. Weekdays: 2 . Assistance with Activities of Daily Living (ADL) - As of September 6, 2022, included: 1-2 residents were independent in dressing, transfers, toileting, and mobility. 22 to 31 residents required Assist of 1-2 staff for those same ADLs. 2-7 residents were totally dependent upon staff for those same ADLs. The Facility Assessment Staffing Plan included: 3.2 Based on the resident population and their identified needs for care and support, we have determined the following approach to staffing to ensure that facility has sufficient staff to meet the needs of the residents at any given time. Staffing Tool 1: Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff is available to meet each resident's needs. Refer to the guidance in the various tags that have requirements for staffing to be based on/in according with the facility assessment .Enter number of staff needed or an average or range: Licensed Nurses (Direct Care Staff), Total Number of FTE's (full time equivalents) Needed on Daily Basis: 2-3/12-hour shifts. Certified Nursing Assistants, 6-8 FTE/7.5/12 hr. (hour) shift. The facility also included the [State Name] Staff Requirements, dated January 1, 1980 in their facility that detailed patient ratios and the number of patients to nursing care that included: The ratio of patients to nursing care personnel during a morning shift shall not exceed 8 patients to 1 nursing care personnel; the ratio of patients to nursing care personnel during an afternoon shift shall not exceed 12 patients to 1 nursing care personnel, and the ratio of patients to nursing care personnel during a nighttime shift shall not exceed 15 patients to 1 nursing care personnel, and there shall be sufficient nursing care personnel available on duty to assure coverage for patients at all times during the shift . No reference to acuity consideration was noted in this portion of the Facility Assessment. During an interview on 12/01/22 at 1:48 p.m., the Nursing Home Administrator (NHA) and Regional Operations Director S agreed the Facility Assessment Certified Nursing Assistant levels did not provide adequate staffing levels to meet resident care needs based on the lowest level identified in the Facility Assessment document. When asked how the minimum staffing levels were calculated, Regional Operations Director S was unable to describe or provide the method of calculation of sufficient staff determination based on resident acuity.

All times are Eastern Standard Time (EST) unless otherwise noted. Based on interview and record review, the facility failed to ensure the required members attended the quarterly QAPI (Quality Assurance Performance Improvement) meetings. This deficient practice had the potential to affect all facility residents, given the required members (staff) responsibilities were to ensure the utmost quality care was being provided to the facility residents. Findings include: Review of the QAPI meeting attendance sheets for the past year, reviewed with the Regional Operations Director, Nursing Home Administrator (NHA) S, and the NHA, revealed the Medical Director, Physician BB had not attended any QAPI meetings since June, 2022. The NHA could not confirm their attendance, as Physician BB''s signature was not on the attendance logs. Surveyor reviewed the concern with NHA S, and the current NHA, regarding the Medical Director, Physician BB, not being in attendance for over one quarter, per the unsigned meeting attendance pages. NHA S and the NHA understood the concern. During an interview on 12/01/22 at 12:24 p.m., Physician BB could not confirm they had attended any of the QAPI meetings since July, 2022. Review of the policy, Quality Assurance and Performance Improvement Plan [QAPI], dated 10/24/22, revealed, The QAPI Plan [facility name] is designed to establish and maintain an organized facility-wide program that is data-driven and utilizes a proactive approach to improving quality of care and services throughout the facility .Establish a facility-wide process to identify opportunities for improvement through continuous attention to quality of care, quality of life, and resident safety. Establish clear expectations around safety, quality, rights, choices, and respect. Continually improve the quality of care and services provided to our residents. Vision: Our vision is to create an exceptional person-centered environment where people are loved, valued for their contributions both past and present, and where individuality and independence is nurtured. Mission: Our Mission is to create a culture of ongoing performance improvement to support a life worth living for those entrusted in our care. Purpose: Our purpose is to provide excellent quality care and services to our residents. Our facility has a performance improvement program which systematically monitors, analyzes, and improves its performance to enhance resident quality of care and quality of life. Our QAPI program focuses on systems and processes. We strive to identify gaps within these systems and processes, rather than placing blame on an individual. QAPI committee: The QAPI committee provides the backbone and structure for QAPI, the core members are the Medical Director or his/her designee, the Director of Nursing (DON), the Infection Preventionist, and/or at least three other team members, one who is the Administrator, Owner, or Board Member .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency pertains to Intake #MI00129273. All times are recorded in Eastern Standard Time (EST) unless otherwise noted. Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices for: 1) Donning and doffing of Personal Protective Equipment (PPE); 2) Proper disinfection of PPE; 3) Performance of hand hygiene; 4) Complete surveillance for infection control tracking; 5) Complete surveillance/audits for infection control tracking; 6) Proper disposal of biohazardous materials; 7) Ensure resident compliance with source control measure to hinder the spread of infection of Covid-19; and 8) Ensure visitors adhered to infection control practices during visitation in the facility. These deficient practices had the potential to result in the transmission of infectious organisms and the development of new or recurring infections in all 29 facility residents. Findings include: During an initial observation on 11/28/22 at 12:30 PM, signage outside the facility's entrance vestibule posted: Covid positives - 4 residents and 3 staff dated 11/28/22. Per the Nursing Home Administrator (NHA), who greeted the survey team upon entry, stated the last Covid positive was a resident tested on [DATE] and the facility was currently in an outbreak mode. There were Transmission Based Precautions (TBP) rooms located on both [NAME] and South Halls. Staff and visitors were directed to wear PPE while providing care or entering TBP rooms. During on observation on 11/28/22 at 2:17 PM, Registered Nurse (RN) B was standing in the [NAME] Hall outside of a TBP room for Covid-19. RN B wore an N-95 mask improperly with both straps around the base of her neck. RN B repeatedly adjust her N-95 mask on her face prior to entering the TBP room without sanitizing her hands. RN B exited the TBP room and failed to sanitize her eye protection and change out her mask. RN B assisted an unidentified resident in a wheelchair in the hall to the nurse's station. On 11/29/22 at 8:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) D. LPN D was asked who her Certified Nurse Aides (CNA's) were and responded a name of her coworker and another down the South Hall and third that was a float. LPN D further responded that all the CNA's help down both halls when providing care for residents. Indicating there was not dedicated staff to care for residents under TBP for Covid-19. During an observation on 11/29/22 at 9:12 AM, RN B was pushing a two-tiered cart down the [NAME] Hall with Covid-19 rapid testing supplies on the top, on the bottom there were tests waiting to be resulted, and a regular clear trash bag tied to the side of the cart with disposed used dirty tests. On 11/29/22 at approximately 10:30 AM, an interview was conducted with RN B. RN B was asked where staff complete their Covid-19 tests. RN B took this Surveyor to a small room near the front entrance. In the small room where staff completed Covid-19 testing daily there was a regular trash can, a biohazard trash can, a used Covid-19 test on top of a counter and an old dirty Covid-19 test discarded in the regular trash. When asked if the old dirty Covid-19 test was disposed of in the regular trash RN B responded, No. That should not be in the regular trash. All the old Covid-19 tests are to be placed in a biohazard trash bag. During an observation on 11/29/22 at 11:28 AM, Staff L exited a TBP Covid-19 room down the South Hall. Staff L failed to sanitize her hands after she cleaned off her eye protection and changed her dirty mask. During an interview on 11/29/22 at 2:30 PM, Infection Control Preventionist / Director of Nursing (DON) and Regional Clinical RN M, were asked who the remaining residents were on TBP related to Covid-19. The DON responded, one resident was in room [ROOM NUMBER] down the [NAME] Hall and one was in room [ROOM NUMBER] down the South Hall. This Surveyor questioned the room assignment to 119 as there were two residents in that room. The DON and Staff M, were asked how much longer the resident in room [ROOM NUMBER] was to be on quarantine for and when the other came off quarantine, and they responded, The one came off of quarantine yesterday and the other resident has six more days of quarantine. When asked if it was possible to move either resident from the TBP room so that isolation could be lifted from the Covid-19 recovered resident, they responded, We did not even think about that. On 11/29/22 at approximately 2:45 PM, the DON was asked what types of Covid-19 mitigation for new admissions were in place and if they were being followed. The DON responded, The new admissions are tested for Covid-19 during the first 24 hours after arriving to the facility, then on day three and again on day five. They are also to wear a face mask after admission for ten days. The DON was asked if Resident #20 who was admitted on [DATE] wore or was encouraged to wear a face mask, and responded, We tried, but he just would not wear one. R20 contracted Covid-19 on 11/11/22 and was the first resident to contract Covid-19 during the outbreak. After R20 there was further spread of Covid-19 to seventeen other residents between 11/15/22 until 11/24/22 and five other facility employees between 11/9/22 through 11/22/22. No documentation was provided to support a mask was offered to or refused by R20 to mitigate the spread of Covid-19. On 11/30/22 at 8:10 AM, an interview was conducted with Resident #19. R19 was asked about being in quarantine and Covid-19 recovered. R19 stated that she was not aware that her roommate was under quarantine and the staff never told her. R19 also stated that she thought it was her that was still on quarantine and further expressed that she was glad that the other resident was moved to a different room as she liked the door open, and it was a lot quieter now that the TV was not on all night. R19 said she was to have a shower yesterday and did not get one and was not sure why. On 11/30/22 at 8:20 AM, an interview was conducted with the DON. The DON was asked if she knew why R19 did not get a shower yesterday, and responded, I will find out. The DON was asked if it was related to her being on TBP, and responded, I am not sure. The DON was unable to determine the reason R19 did not receive a shower by the end of the survey. During an observation on 11/30/22 at 12:10 PM, down the [NAME] Hall at the end in the resident lounge. The resident lounge door was shut. Inside the resident lounge, there was a resident who sat in her wheelchair, and a staff member Occupational Therapist (OT) N sat in a chair adjacent to one another. They were talking and the OT N had her mask below her mouth and nose. The OT N made eye contact with this Surveyor looking through the closed door and immediately place her mask on her face correctly. On 11/30/22 at approximately 12:30 PM, the facility mappings, and line listings were reviewed along with other infection control documents related to the current Covid-19 outbreak in the facility. Review of the mapping and line listing for October 2022 revealed a monthly summary which indicated there were audits and education provided to staff regarding urinary tract infections on peri care. The DON was asked to provide the documentation for these audits and education and stated that she did not know where the education and audits had been placed or gone and even looked through the shred box. Further review of the infection control mapping and line listing for November 2022 revealed a line list but lacked any Covid-19 or other facility line listed infections to track trends during a Covid-19 outbreak that began in the facility on 11/2/22 when the first employee tested positive. The DON confirmed that there was not a map that was started yet for infections acquired in November 2022 and this was reviewed on 11/30/22 by this Surveyor. The audits for November 2022 were reviewed and started on 11/16/22 and stopped on 11/22/22. No audits were provided to the surveyor prior to the 11/16/22 date and the outbreak was noted to start on 11/2/22. Review of facility documents (three pages) for Covid-19 surveillance and contact tracing, dated 11/17/22 on the top and titled Infection Control Covid-19 Timeline, revealed incomplete contact tracing. The contact tracing lacked any documentation of the prior three days as to who the Covid-19 positive employee or resident had. The contact tracing did not identify who the employee or resident was, nor provide a specific hall or other individuals they had contact with. Furthermore, lacked employee specific times that were worked in the facility during the outbreak. The DON confirmed the contact tracing should have included more evidence and had a hypothesis of how the Covid-19 outbreak started during an interview on 12/1/22 at approximately 11:15 AM. On 12/1/22 at 12:45 PM, an interview was conducted with Maintenance Director K. Maintenance Director K was asked about increased cleaning during the outbreak, and responded, Cleaning is done daily. Maintenance Director K was then asked about cleaning audits and logs, and responded, I do not have any audits or logs. Review of communications from the Department of Health and Human Services, dated 11/15/22 and 11/22/22, read in part, .Facility approved for .CR (Covid Relief) Facility designated beds for retention purposes only. Acceptance of this designation constitutes agreement to: .Maintain dedicated staff to serve only the COVID-positive residents . During the time of the survey between 11/28/22 through 12/1/22 none of the 29 residents were seen wearing a mask while in the facility, nor in the communal dining area, and nor in the dining room where activities were being held. Review of facility policy titled, Monitoring Infection Control Practice, date reviewed 01/2022, read in part, Policy: The facility's Infection Control Preventionist will conduct routine monitoring and surveillance to determine compliance with infection control policies and practices. Procedures: Residence Surveillance If suspicion or evidence of an infection is detected within the resident population the following should be done: .8.) The Infection Control Preventionist shall review and analyze data monthly (or more frequently if warranted) for trends, rates of infections, clusters of infections, causes of infections and to evaluate the effectiveness of the facility's infection control program .Employee Surveillance: .4.) The Infection Control Preventionist will utilize logs, reports to assist in potential causes of infections and to evaluate the effectiveness of the facility infection control program .Facility Surveillance: 1.) Surveillance of the workplace to ensure that established infection control practices are observed and protective clothing and equipment are available and properly used . Review of facility policy titled, Covid-19 Prevention and Response, date revised 10/2022, read in part, Policy: This facility will respond promptly upon suspicion of illness associated with a SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus .22.) Managing admissions and residents who leave the facility: .b.) Residents should be advised to wear source control for 10 days following their admission . Review of facility policy titled, Covid-19 Visitation and Communal Activities/Dining, date revised 10/2022, read in part, Policy: This facility will allow visitation of all visitors and non-essential health care personnel and can be conducted through different means based on the facility's structure and resident's needs, such as in resident rooms, dedicated visitation spaces, and outdoors .Policy Explanation and Compliance Guidelines: .4.) .f.) A face covering or mask (covering the mouth and nose) in accordance with CDC guidance .18.) Communal activities (including group activities, communal dining, and resident outings): a.) Communal activities and dining may occur while adhering to the core principles of COVID-19 infection prevention. The safest approach is for everyone .to wear a face covering or mask while in the communal areas of the facility . Review of facility policy titled, Isolation-Categories of Transmission-Based Precautions, date updated 09/2022, read in part, Policy: To provide care to residents documented or suspected to be infected or colonize with highly transmissible microorganisms that require additional precautions beyond Standard Precautions, in order to reduce transmission of these microorganisms .Trash and Soiled Linens .Items that meet the criteria of biohazard medical waste must be disposed of in .a red bag [biohazard] . Review of facility policy titled, COVID-19 Testing Policy, dated 10/2022, read in part, .Testing of Staff and Residents in Response to an Outbreak Investigation 1.) An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed .5.) Contact tracing is recommended immediately . Review of facility policy titled, COVID-19 Surveillance Policy, date revised 10/2022, read in part, Policy: This policy will implement heightened surveillance activities for coronavirus illness .8.) The Infection Preventionist, or designee, will track the following information: .d.) Employee compliance with hand hygiene. e.) Employee compliance with standard and transmission-based precautions. f.) Employee compliance with cleaning and disinfection policies and procedures . On 11/28/22 at 1:34 PM, the clean laundry was observed being delivered on the [NAME] wing by Staff EE. When Staff EE came to room [ROOM NUMBER], a designated Covid-19 positive room, she donned PPE and entered the room. Moments later, Staff EE was observed to exit the room and continue down the hall wearing a face shield. She was asked if her face shield was the same shield worn in the quarantine room and said, Oh yes, I forgot that part. Staff EE then disposed of her face shield, took goggles out of her pocket, and donned them. On 11/28/22 at 2:40 PM, Family Member FF was observed entering a room in the middle of South Hall. Family member FF came into the room after entering at the front door, past the front office, and past the nursing station occupied by one nurse. Family member FF came in the room and placed a large bag of Christmas decorations in the room. Family member FF exclaimed, Oh my, I am not even wearing a mask. I always wear a mask. Family member FF explained they had come in the front door, and no one had even reminded her to wear a mask. .

Based on interview and record review, the facility failed to include training on effective communications as mandatory training for direct care staff including six Certified Nurse Aides (identified as CNAs O, Q, R, U, V, and W) out of eight CNAs whose in-service training files were reviewed. This deficient practice resulted in the potential for unmet resident care needs due to ineffective communication. Findings include: All times are recorded in Eastern Standard Time (EST) unless otherwise noted. On 12/05/22 at 12:37 PM, the employee records were reviewed. Individual staff education was requested but was not organized per employee, but chronologically per month. No employee had a current list of education hours or courses completed. During an interview on 12/05/22 at 3:00 PM, the DON stated there was a binder in the nursing station and each staff member was to read the information and take a test. Specific education training on effective communications with residents was requested. While a sheet indicating one in-service on customer service was held in 2022 with 19 staff from varying departments in attendance, all of the direct care staff had not attended the presentation and were not offered education to promote skills to master understanding of resident communication and ensure information provided to the resident would be delivered in a form and manner that the resident could access and understand. The Clinical Skills Competency Checklist, General Orientation Checklist, and the Temporary Nurse Aide Skills Competency Checklist were presented and the category of effective communication with residents was not listed as a skill taught on any of these checklists. During a follow-up interview on 12/05/22 at 3:45 PM, Regional Operations Director S stated the new education which included effective communication has not been rolled out yet for staff but will begin in December. On 12/5/22 at 4:05 PM, an email communication from the facility's corporate Director of Professional Services was presented by the Regional Clinical Director M. The email dated 12/2/22 read in part: Topics for this month are: - Effective Communication, - Grief, Loss and Bereavement - QAPI (Quality Assurance Performance Improvement) . Review of the Facility Assessment dated 10/28/22, revealed the following: Staff training/education and competencies 3.4 . Listed below are current training topics (this is not an inclusive list): - Communication - effective communications for direct care staff. Completed upon General Orientation . .

Based on interview and record review, the facility failed to include education that outlined and informed staff of the elements and goals of the facility's QAPI (Quality Assurance Performance Improvement) program as mandatory training for all staff including eight Certified Nurse Aides (identified as CNAs O, Q, R, U, V, W, X, and Y) out of eight CNAs whose in-service training files were reviewed. This deficient practice resulted in the potential for unmet resident care needs due to an ineffective performance improvement program. Findings include: All times are recorded in Eastern Standard Time (EST) unless otherwise noted. On 12/05/22 at 12:37 PM, the employee records were reviewed. Individual staff education was requested but was not organized per employee, but chronologically per month. No employee had a current list of education hours or courses completed. No education on Quality Assurance or Performance Improvement was found. The Clinical Skills Competency Checklist, General Orientation Checklist, and the Temporary Nurse Aide Skills Competency Checklist were presented, and the category of quality assurance or performance improvement were not listed as a skill taught on any of these checklists. During a follow-up interview on 12/05/22 at 3:45 PM, Regional Operations Director S stated the new education which included QAPI had not been rolled out yet for staff but would begin in December. The facility assessment was discussed, but a reference to the QAPI program education including the goals and various elements of the program, implementation of the program, and the staff's role in the facility's QAPI program with communication of concerns, problems, or opportunities for improvement to the facility's Quality Assurance Committee was not found as part of this facility assessment. On 12/5/22 at 4:05 PM, an email communication from the facility's corporate Director of Professional Services was presented by the Regional Clinical Director M. The email dated 12/2/22 read in part: Topics for this month are: - Effective Communication, - Grief, Loss and Bereavement - QAPI (Quality Assurance Performance Improvement) . .

. Based on interview and record review, the facility failed to implement an effective in-service training program for nurse aides that supported mandatory nurse aide attendance, tracked participation, and ensured continuing competence for eight Certified Nurse Aides (identified as CNAs O, Q, R, U, V, W, X, and Y) out of eight CNAs whose in-service training files were reviewed. This deficient practice resulted in the potential for unmet resident care needs. Findings include: All times are recorded in Eastern Standard Time (EST) unless otherwise noted. During an interview on 12/05/22 at 12:29 PM, Business Office Manager (Staff T) stated she handled the business office and kept the employee records after others completed the forms. A list of employee records had been requested from Staff T for review. Staff T stated the facility previously had an electronic means of offering education and training was totaled and tracked, but that program was no longer available. During an interview on 12/05/22 at 12:31 PM, the Director of Nursing (DON) stated, Education is a tag team effort. I do most of it, but I have other staff members who help. On 12/05/22 at 12:37 PM, the employee records were reviewed. The individual Certified Nursing Assistant (CNA) education was not filed per employee, but available in large binders filed per month. Education was requested for a list of CNAs. A stack of papers was received with signature sheets containing many different classifications of employees attending. One sheet was titled: Education Sign in Sheet and listed Subject Matter: Hand Hygiene and included a line: Date of Education which was blank, and Educator: which was also blank. No CNA had a current list of education hours or courses completed. During an interview on 12/05/22 at 3:00 PM, the DON stated she did not keep track of all of the in-service education hours, and Staff T also did not track those hours. The DON stated there was a binder in the nursing station and each staff member was to read the information and take a test. The DON stated she had not been tracking the hours or time spent on education and agreed she did not know if the CNAs had 12 hours of education per the regulation. The DON stated she gathered the tests, but there was no tracking tool or log to see who had gone to which training or how long it took. The DON said, I will have to follow up with that. Review of the Facility Assessment dated 10/28/22, revealed the following: Staff training/education and competencies 3.4 . Required in-service training for nurse aids. In-service training must: - Be sufficient to ensure the continuing competence of nurse aids, but must be no less than 12 hours per year . - Address areas of weakness as determined in nurse aides' performance reviews and facility assessment . .