**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to position a urinary catheter collection bag to facilitate drainage for 1 resident (Resident #20) of 2 residents reviewed for urinary catheter care. Findings include: Review of an admission Record revealed Resident #20 (R20) admitted to the facility on [DATE] with pertinent diagnoses which included flaccid neuropathic bladder and retention of urine. Review of a Minimum Data Set (MDS) assessment for R20, with a reference date of 10/11/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R20 was cognitively intact. Review of a current urinary catheter Care Plan intervention for R20, initiated 4/16/2024, directed staff to position her urinary catheter bag below the level of the bladder. In an observation and interview on 10/21/2024 at 3:28 PM in R20's room, R20 was sitting in her wheelchair with her urinary catheter collection bag hanging from the back of her wheelchair level with her middle and upper back and above the level of her bladder. R20 reported her urologist instructed her at an appointment that same day that she needed to store the bag below the level of her bladder. In an observation on 10/22/2024 at 8:15 AM in the dining room, R20 was in her wheelchair with her urinary drainage tube going over the back of her wheelchair and the urinary catheter collection bag hanging from the back of her wheelchair level with her middle and upper back and above the level of her bladder. Urine was visible backed up in the drainage tube and unable to empty into the urinary catheter collection bag. In an interview on 10/22/2024 at 10:16 AM, Certified Nursing Assistant (CNA) P reported staff had been storing R20's urinary catheter collection bag on the back of her wheelchair for months because this was R20's preference. In an interview on 10/22/2024 at 10:20 AM, CNA T reported staff had been storing R20's urinary catheter collection bag on the back of her wheelchair for months because it was being pulled on when it was stored under the wheelchair. In an interview on 10/22/2024 at 10:26 AM, Registered Nurse (RN) E reported R20's urinary catheter collection bag was being stored on the back of her wheelchair because it was leaking when under her chair. RN E reported the bag should be placed under the wheelchair to prevent urine from going back into the bladder and causing possible infection. In an interview on 10/22/2024 at 10:41 AM, the Director of Nursing (DON) reported R20's urinary catheter collection bag was being stored on the back of her wheelchair because it was getting caught up under the wheelchair and leaking. The DON reported keeping the bag above the level of the bladder could cause urine to reflux back into the bladder. In an interview on 10/22/2024 at 4:05 PM, R20's community Urologist M reported he noticed R20's urinary catheter collection bag was on the back of her wheelchair and above the level of her bladder at her appointment with him the previous day. Urologist M reported he educated R20 that the bag and tubing must be below the level of the bladder to allow the bladder to empty and prevent reflux of urine back into the bladder. Urologist M reported the bladder remaining full of urine and urine reflux can cause urinary tract infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to date and discard an outdated-for-use biological medication and failed to discard two insulin pens kept in active storage past the manufacturer's recommended expiration date and after the medication had been discontinued. Findings: On [DATE] at 7:55 AM a review was conducted of the facility medication room with Licensed Practical Nurse (LPN) J. Review of the medication refrigerator revealed an opened and entered multidose vial of purified protein derivative (PPD) solution. It was observed that the vial was not dated when it had been placed in service. LPN J noted that the box in which the undated vial was contained was dated [DATE] but that the vial itself was not dated. LPN J indicated she did not know the date the vial had been placed into service and reported that the vial expiration date would be the manufacturer's expiration date on the vial. On [DATE] at 8:10 AM the North unit medication cart was reviewed with Registered Nurse (RN) E. Review of the top drawer revealed a [NAME] insulin pen dated as placed in service [DATE] and an Admelog insulin pen dated as placed in service [DATE] for Resident #15 (R15). RN E reported that all nurses are responsible for maintaining an orderly medication cart. RN E reviewed the electronic medical record for R15 and reported no current Doctor's Orders were in place for the insulin pens and that both should have been discarded. The policy provided by the facility titled Medication Storage in the Facility last revised [DATE] was reviewed. The document reflected, Policy. Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier . The policy reflected Procedures ., H. Outdated, contaminated or deteriorated medications .are immediately removed from inventory . And Expiration Dating, C .1).b. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: 1. In a multidose injectable vial. 2. An item for which the manufacturer has specified a usable life after opening. And D. When the original seal of a manufacturer's vial is initially broken, the vial will be dated. 1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial will be 30 days unless the manufacturer recommends another date . G. All expired medication will be removed from the active supply .regardless of the amount remaining. Review of the Manufacturer's instructions for the Admelog insulin pen reflected Only use your pen for up to 28 days after its first use. Throw away .after 28 days even if it still has insulin in it. Review of the Manufacturer's package insert for the Lantus insulin pen reflected the device was to be discarded 28 days after it was placed in service. Review of the Manufacturer's package insert for the PPD solution reflected Storage . A vial of (PPD solution) which has been entered and in use for 30 days should be discarded. On [DATE] at 11:01 AM an interview was conducted with the Director of Nursing (DON) in her office. The DON acknowledged the PPD solution should have been discarded. The DON also reported that the insulin pens discovered in the North medication cart that were outdated and without a current order should have been tossed a long time ago.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper use of Personal Protective Equipment (PPE) for residents in Enhanced Barrier Precautions (EBP) for 1 resident (Resident #22) of 12 residents reviewed for infection control. Findings include: Review of an admission Record revealed Resident #22 (R22) admitted to the facility on [DATE] with pertinent diagnoses which included pressure ulcers. Review of R22's Physician's Orders, active 10/23/2024 at 9:00 AM, revealed he required multiple daily dressing changes. Further review revealed no order for EBP's. In an observation and interview on 10/23/2024 at 9:30 AM in R22's room, Registered Nurse (RN) E performed several dressing changes without donning a gown. There was no signage on the door indicating the need for PPE. RN E reported R22 should have EBP's in place because of his wounds. In an interview on 10/23/2024 at 10:04 AM, the Director of Nursing (DON) reported R22 should have had EBP's in place since admitting to the facility because of his wounds that required dressing changes. Review of facility policy/procedure Enhanced Barrier Precautions, reviewed 3/2024, revealed .EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) . High-contact resident care activities include . Wound care: any skin opening requiring a dressing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain cleanliness and general repair of equipment, plumbing, the onsite waste water system, and other aspects of the physical environment. This deficient practice has the potential to affect all residents in the facility. Findings Include: During a tour of the dry storage room, at 10:22 AM on 10/21/24, it was found that an odor resembling sewer gas was present upon entering the room. When asked if they knew what the odor was, Dietary Manager R and Regional Dietitian U were unsure. Upon further evaluation of the room, it was found that a slowly leaking sewer pipe was observed in the back left corner with totes underneath it to catch the leak. The sewer pipes were observed covered in duct and electrical tape in some spots, with no adequate fix to the line. No food storage was under this area. During a tour of the facility, at 1:40 PM on 10/21/24, observation of the Ice Machine room with Regional Dietitian U, found a black rubber insulated seal was dangling down on the backside of the white plastic shield that hangs over the bottom bin portion of the ice machine. Further observation of the unit found increased amounts of black debris accumulation on the side wall of the unit, between the plastic shield and the wall. Observation of the room found an accumulation of brown crusted debris on the underside of the ice machine with a dozen plastic lids that had fallen behind the unit onto the floor. The unit was observed draining water from three different water lines into the stainless steel preparation sink next to the ice machine. When asked if that is the sink where hydration pass is filled, Regional Dietitian U stated she believes so. The sink was found with heavy rust staining on the inside compartment and walls. Two of the three discharge lines, hanging over the sink, were from a water-cooled compressor, the third line was from the ice that melts in the bottom bin, drains to a condensate pump (where it stays stagnant in an enclosed container that doesn't get cleaned) until the pump fills to the level to be discharged into the sink (where residents receive hydration pass). During a tour of the east hall spa room, at 1:50 PM on 10/21/24, it was observed that one of the two light ballasts in the room was not working and left the shower area dim and hard to see. Observation of the central supply room, at 2:23 PM on 10/21/24, found a leaking sewer line in the back left corner of the room that was falling onto old files and records the facility had in storage. The files and records were observed with black spotted mold looking accumulation with numerous water lines and marks from consistent leaking and drying in this area. During an interview with Environmental Services Manager (ESM) G, at 2:40 PM on 10/21/24, it was found that he has been at this facility less than a month and has been trying to play catch up on some of the repairs that the facility needs. When asked about the sewer line in dry storage. ESM G stated that they have reached out to a vendor to fix the issues and are just waiting on them to come and complete the project. When asked about the leaking sewer line in central supply ESM G stated he was not aware about that leak. During a tour of the laundry room, at 3:30 PM on 10/21/24, it was found that one of two washers and one of two dryers were not operational. When asked if there was progress on getting repairs or new equipment, ESM G stated it has been going through the purchase order process, but he's not sure where it's at currently. When asked if staff can keep up with demand, ESM G stated that they have been, but it's harder on staff as they work longer hours in order to make it happen. ESM G wasn't sure how long the machines have been down, but mentioned staff told him its been this way for a while. Last annual survey, in December of 2023, these pieces of equipment were down and not operational. In an interview with ESM G, at 3:05 PM on 10/21/24, the surveyor questioned the operation of the facilities' onsite wastewater treatment plant and found that they have been having issues staying in compliance with the Michigan Department of Environment Great Lakes and Energy ([NAME]) regarding the wastewater treatment plant. ESM G stated that since coming on board the last few weeks he has started to take over ensuring their vendor wastewater operator is fulfilling the obligations of his position. Previously the reports and samples were not received by the facility and would just go to the vendor. ESM G stated that [NAME] was out last week and had discharge concerns with numerous violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI00145786 Based on observation, interview, and record review, the facility failed to effectively implement interventions for effective communication for one resident (R2) of four reviewed for care plans, resulting in the miscommunication of care needs. Findings include: Review of a Face Sheet for R2 revealed she originally admitted to the facility on [DATE] with pertinent diagnosis of hemiplegia and hemiparesis (one sided weakness), aphasia (may be unable to comprehend or unable to formulate language because of damage to specific brain regions), and cognitive communication deficit. In an interview on 7/24/24 at 8:28 AM, the Designated Power of Attorney (DPOA)/husband of R2 reported that R2 cannot speak or say words like that because she has expressive aphasia. He works with her every day using word cards and a computer program to encourage her to speak in the mornings. He said the facility staff does not know how to communicate with her like he does. In an interview on 7/24/24 at 12:37 PM, R2 had no communication board in her room or any other modes for R2 to communicate verbally, nonverbally, or any means to reinforce words she was trying to express. Review of the Electronic Medical Records for R2 revealed no communication board or communication devices were available and no baseline communication/cognitive status established. In an interview on 7/29/24 at 9:15 AM, the Director of Nursing (DON) reported R2's husband usually comes to visit 2-3 times a day and will work with her doing therapy in the gym, help work on her speech, and some gardening. The NHA (Nursing Home Administrator) and DON were not aware of any baseline communication or communication devices for R2. In an interview on 7/29/24 at 11:00 AM, Speech Therapist (ST) S reported he is not at the facility often and is not given the autonomy to screen the residents himself but does get referrals. He reported he has made several attempts to see R2, but she was either sleeping and difficult to arouse, or another time he tried, and she backed herself up in a corner. There was a time ST S thought R2 may have been sick when he attempted to see her approximately in May/June 2024 and was asked to not attempt to try at this time. When asked about R2 saying si (si, C, or see) when she communicated, ST S reported it could have been an utterance without any value to it. Like a pattern of talking and may not have communication value. Nonverbal communication may be more effective when she is nodding her head. ST S reported that knowing the communication pattern would be valuable. Based on her record review, ST S could not figure out what her baseline communication was. He would have to assess more for her ability to identify pictures from verbal commands, yes or no questions, or even a communication board. Review of a Secure Conversation note for R2 dated 4/12/24 revealed: husband/guardian is requesting a letter be written stating that (name of R2) is cognitively intact and can make decisions but has difficulty communicating due to aphasia. Will one or both of you please evaluate her cognition? Her BIMS has been a 14 or 15 since I started using a picture board so she can point to her answers (with the exception of the November assessment when she was not interacting with staff). Review of a Social Service Progress Note dated 5/20/24 for R2 revealed, During the resident's quarterly PHQ-9 assessment, the resident expressed she has thoughts of suicidal ideation/self-harm almost daily. A Columbia Suicide Screening assessment was completed. Social worker and administrator do not feel the resident is an immediate threat to herself. Will attempt communication device as resident is frustrated that she is not able to communicate after her stroke. Review of a Practitioner Progress note dated 5/23/24 for R2 revealed: Cognitive communication deficit, continue supportive care and monitoring. Could be contributing to anxiety and depression. Review of a Practitioner Progress note for R2 dated 6/10/24, 6/13/24, 6/20/24, and 7/2/24 revealed: Cognitive communication deficit, continue supportive care and monitoring. Could be contributing to anxiety and depression. Review of the Care Plan for R2 revealed: I will be able to communicate needs daily by Yes/No answers, initiated 5/17/22. Monitor/document communication skills. Document baseline. If resident is presenting problems with cognitive function and communication, obtain an order for Speech Therapy consult to evaluate and treat, initiated 5/17/22. Monitor/document mobility status. If resident is presenting with problems or paralysis, obtain order for Physical therapy and Occupational therapy to evaluate and treat, initiated 5/17/22. Reinforce any cognitive programs put in place by therapy services, initiated 5/17/2022. Discuss with me/Guardian concerns or feelings regarding communication difficulty, initiated 5/27/22. Encourage me to continue stating my thoughts even if I am having difficulty making sense. Focus on a word or phrase that makes sense and help me elaborate from that word/thought. Allow me time to try to formulate my thoughts without feeling rushed to do so, initiated 5/27/22. Help me to develop a communication tool that I can utilize to communicate my needs, initiated 5/27/22. Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/document frustration level. Allow me time before providing me with words. Review factors affecting underlying cause of communication deficit, recent onset, chronic or recurrent conditions, success of attempted remedial actions, ability to compensate with nonverbal strategies, understanding in particular situations etc. Validate my spoken message by repeating aloud, initiated 5/27/24. Record/report to MD for [signs and symptoms] of UTI: pain, burning, no output, increased pulse, increased temp, urinary frequency, fever, chills, altered mental status, change in behavior, change in eating patterns. Social worker will collaborate with therapy to develop a communication board to help ease my frustration with not being able to communicate, initiated 5/20/24. Review of the Care Plan for R2 revealed: I have the potential for impaired cognitive function [related to] history of cerebral infarction with residual deficits/communication problems initiated 11/30/22 and no revision date. Goal: Will maintain current level of cognitive function through the review date, initiated 11/30/22 and no revision date. Interventions: -Ask me yes/no questions in order to determine my needs. Date Initiated: 11/30/2022 -Report to Social Services and Nurse any changes in cognitive function, specifically changes in: decision making ability, memory, recall, or confusion. Date Initiated: 11/30/2022

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI00145786 Based on observation, interview, and record review, the facility failed to effectively manage care for one resident (R2) of four reviewed for quality of care, resulting in unmet care needs. Findings include: Review of a Face Sheet for R2 revealed she originally admitted to the facility on [DATE] with pertinent diagnosis of hemiplegia and hemiparesis (one sided weakness), aphasia (may be unable to comprehend or unable to formulate language because of damage to specific brain regions), and cognitive communication deficit. In an interview on 7/24/24 at 8:28 AM, the Designated Power of Attorney (DPOA)/husband of R2 reported he saw her Friday morning on 7/19/24 and she was timid and didn't want to communicate which was abnormal for her, because she is usually cheery. He left and came back in the afternoon and R2 was having some pain in her abdominal/vaginal area. He had the nurse assess R2 and did not see any concerns. The next morning on 7/20/24, the DPOA came to visit, and his wife still had pain in her vaginal area. He asked the nurse to do a urinalysis because she was having symptoms similar to a urinary tract infection as she had in the past. The nurse told him they would do it for R2. When he came back to the facility at 1:30 PM, the nurse told him the strip indicated there was bacteria in the urine and the doctor ordered the urine sample to be sent out to the lab. In an interview on 7/23/24 at 3:34 PM, the Nursing Home Administrator (NHA) said they are waiting for labs to be done. A urinalysis (U/A) was collected on Saturday but was not picked up or sent out and needed to be redone. She began to refuse medications which was not normal for her. She had recently been sent to the hospital for behaviors and was diagnosed with a UTI. During multiple observations on 7/23/24 at 1:43 PM, 2:56 PM, and 4:22 PM, R2 was in bed with the lights out and would not engage or acknowledge this surveyor, visitors, and had limited staff interaction. She would open her eyes briefly and quickly close them. Review of a Behavior Notes dated 7/19/24 at 1:04 PM for R2 revealed: Resident spent the entirety of this shift in bed. When asked if she wanted to get up, she refused. Resident very quiet and appears to be sad. Review of a Behavior Notes dated 7/19/24 at 9:40 PM for R2 revealed Registered Nurse (RN) D documented: At the start of this shift, resident's husband approached this staff and he said that his wife was in pain, and she was pointing at her genital area. Went to this resident's room and checked. This staff observed this resident was crying and she was pointing at her genital area. This staff assessed the area and her bottom. She did not have any skin condition. Her skin in the genital area and bottom was intact. Asked this resident if she wanted her pain medication. She nodded. This staff gave her (as needed) Tylenol and milk of magnesia for she was on the BM (bowel movement) list. After a few minutes, she was seen in bed and asleep. In an interview on 7/24/24 at 3:37 PM, RN D reported he was working second shift on Friday 7/19/24 when R2's husband approached him about 2:10 PM with concerns about his wife having complaints of pain in the general area of her lower abdomen and vaginal area. The day shift nurse thought her pain was from constipation, but the husband told them she had a bowel movement the previous day. R2 was observed laying flat on her back and visibly crying. RN D asked R2 if it hurt down there, and she said si and pointed to her vagina. RN D was thinking she may have a yeast infection. RN D assessed the resident's vaginal area and noticed a discharge similar to a yeast infection and thought that may be the problem. He pressed on her suprapubic area, and she grimaced. R2 could not communicate well so he asked her pertinent questions. RN D then said he did not have any assessment concerns and convinced R2 to take a Tylenol and she then went to sleep. R2 was fine the rest of the night. When asked if he documented the assessment, RN D reported he did not. When asked if he notified the physician, he reported he did not. In an interview on 7/24/24 at 11:42 AM, Licensed Practical Nurse (LPN) H reported R2s husband approached her in the morning of 7/20/24 with concerns his wife having complaints of burning in her genitals. LPN H asked the resident if it burns when she is dribbling urine and said yes or si. LPN H asked if she had a urinary tract infection (UTI) in the past and if it felt the same and she said yes. LPN H collected a urine sample after R2s husband left that morning via straight catheter collection method and noticed the edge of the outer vagina (labia majora) looked raw and the resident hurt when she moved positions. LPN H did not notice any concerns inside the labia (labia minora) when she straight cathed the resident. LPN H reported she did not document her assessment findings. LPN H did a urine dipstick that resulted in the resident having 70+ bacteria in her urine and called the physician who ordered a urinalysis with a culture. LPN H reported she is new and did not know how to send out a urinalysis (UA), so she put the urine on ice and talked to oncoming RN I who did not know how to send it out either but was going to find out and take care of it. LPN H reported she later found out it was not sent out. LPN H reported there was nothing abnormal about R2 this day and her behavior was normal, she was just in pain and uncomfortable. A thorough pain assessment was not completed or documented. In an interview on 7/24/24 at 7:00 PM, CNA M reported she was familiar with R2 and reported she could communicate her needs but not verbalize them. Staff could usually guess or figure out what R2 wanted or needed. On Saturday 7/20/24 R2 was checked to see if she needed incontinence care after dinner and R2 said no. CNA M reported she checked her brief anyway and it was dry. About 45 minutes later R2 put on her call light to be changed and her brief was wet. When CNA M put the head of the bed down, she was making noises like she was aggravated. CNA M reported she was told in report R2 was being checked for a UTI. R2 was breathing heavy and CNA M asked her if she hurt when she pees and R2 said no. When CNA M removed her brief R2 inhaled like it hurt and asked her if it hurt. She thought the brief grazed over the sore area. R2 replied no but si. CNA M noticed a bright red lump on her inner right labia similar to an abscess and a milky white fluid coming from her vagina. She folded R2s brief back up and got RN I. RN I came in and got some Nystatin cream and applied it to R2. In an interview on 7/24/24 at 3:20 PM, RN I reported she worked the second shift on 7/20/24 and started around 2:00 PM. She was told in report from the day shift nurse (LPN H) that R2 was having some abdominal pain and burning in her genital area. LPN H told her that she obtained a urine sample for a urinalysis to be sent out but did not know which lab to send it out to. RN I told LPN H she would take care of it. RN I reported she texted the DON (Director of Nursing) to find out which lab to send the urinalysis to and was instructed to find out when the urine was collected because it was at room temperature with no date or time of the collection marked on the sample. CNA M (Certified Nursing Assistant) approached RN I to tell her that R2 was having pain in her genital area and CNA M saw bruising. RN I said she assessed R2 and saw some redness and an abrasion inside her labia that was not real red and some discharge but did not document any assessment. RN I reported it could have been from her brief. RN I asked RN L to assess R2 because she thought there were abrasions, and she was the only nurse on duty from 2-6 PM and wanted a second opinion. In an interview on 7/25/24 at 1:33 PM, RN L reported she started her shift on 7/20/24 at 6:30 PM. When she arrived, RN I was the only nurse at the time and was passing medications to other residents. She was informed by CNA M about a rape allegation involving R2 and her husband. RN I then gave report that they were concerned earlier about R2 having a UTI, RN L did an assessment of R2's vaginal area and saw some bruising and redness. A circular abrasion was on her left inner labia and a small area was on her right. It was similar to a rug burn or an irritation with some inflammation that looked like it would have been from the last couple of hours. She did have some discharge and it could have been a yeast infection. R2 could scratch her genitals if she had any itching. R2 was incontinent. Review of a Practitioner Progress note dated 7/20/24 at 9:32 PM for R2 revealed: Nurse called [8:16 PM]. Pt had been complaining of pain around genitalia. I gave verbal order to transfer her immediately to ED (emergency department). Review of a Nurse Practitioner Note dated 7/22/24 for R2 revealed .ROS reveals concerns for potential UTI, reviewed with patient, she denied firmly to have straight cath (catheter) for eval of UTI. She denies any other concerns at this time. In an interview on 7/24/24 at approximately12:15 PM, LPN/Unit Manager J reported there has been some ups and downs with labs recently and named several labs the facility uses. She was not clear at first which labs and forms the facility is to use for a urinalysis then named a couple options. UM J reported she communicates with staff by cheat sheets in a binder that has snap shots of how to put in orders based on the lab. UM J said there is one lab that provides a urinalysis collection kit with instructions the staff could use. In an interview on 7/24/24 at 12:30 PM, LPN H reported she did not use the UA collection kit that the UM J reported was available. In an interview on 1/24/24 at 1:00 PM LPN C reported she was informed that week on where to send a urinalysis. In an interview on 7/29/24 at 9:15 AM the Director of Nursing (DON), reported they were able to collect another urine sample on 7/23/24 and sent to the lab. The urinalysis resulted on 7/26/24 and R2 was positive for a UTI.

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience for four residents who required assistance to be fed (Resident #10, Resident #14, Resident #18, and Resident #26), of 4 residents reviewed, resulting in staff standing over the residents to assist with feeding in an undignified manner and providing intermittent feeding assistance with the potential for the residents' food to get cold. Findings include: Resident #10 (R10) Review of the Care Plan for R10 revealed she has dysphagia with a general diet with 4-pureed textured foods, thin liquids and is allowed a regular texture meal when alert. Her independence with meals fluctuates and is to be provided assistance as needed. She does better with finger foods at meals, initiated 4/29/19. She is also care planned for being dependent for feeding initiated 2/3/22. Resident #14 (R14) Review of the Care Plan for R14 revealed she is dependent for eating, initiated on 1/27/21. The feeding techniques she requires is to be fed by staff, she has a history of pocketing food, initiated 2/3/22, and diet orders are a general diet, 4-pureed texture, and thin liquids, initiated 2/1/21. Resident #18 (R18) Review of the Care Plan for R18 revealed she requires the assistance of one-to-one feeding, at times independent cut up meals into small bites, initiated 11/25/20. She needs supervision, encouragement, and cueing to eat. Her husband will be in daily to assist with lunchtime feedings, initiated 2/23/21. Resident #26 (R26) Review of the Care Plan for R26 revealed her diet orders are pureed with mildly thickened liquids, I need to be fed, initiated 2/16/23. She is to be assisted with eating and offer cueing as needed, initiated 7/14/23. During an observation on 1/8/24 at 12:11 PM in the North Unit dining room, R10, R14, R18 and R26 were sitting at the dining room table with food trays sitting in front of them and were not able to feed themselves. Other residents in the room were eating their meals. Certified Nursing Assistant (CNA) C was the only staff member in the room meeting the needs of all the residents that were in the dining room. CNA C was observed providing beverages, utensils, cutting up residents' food, and satisfying meal change requests for the residents in the dining room. CNA C was walking to the different tables R10, R14, R18, and R26 were sitting at and stood over them while providing them 1-2 bites of food at a time while rotating between them and assisting the other residents in the dining room. After some time had passed by, CNA C sat down next to two of the residents who needed assistance. Other staff were observed entering the dining room and leaving and assisted briefly and intermittently. During an observation and interview on 1/9/24 at 8:26 AM, CNA C was observed assisting the residents with their breakfasts in the North Unit dining room. R4, R10, R14 and R18 were sitting at different tables waiting for assistance with their meals that was placed on the table in front of them. Other residents in the room were eating their meal. There were 13 residents total in the dining room and CNA C was the only staff member in the dining room assisting all the residents by providing coffee and other requests for the residents. CNA C was observed rotating between the four residents who required assistance with meals, standing over them when providing 1-2 bites at a time until their meal was finished. CNA C reported the other aides will usually come in and help when they get done with the needs on the floor. At this time a nurse came into the dining room to give medications to a resident who was eating independently. Another CNA brought a resident to dining room via wheelchair and left the resident at a table with her meal and no silverware and walked away. At 8:41 AM there was still no other staff in the dining room assisting the residents consistently. The atmosphere was not relaxing as CNA C kept trying to meet the needs of all the residents. One staff member observed randomly entering the dining room and would randomly assist residents who did not require feeding assistance for approximately a few minutes at a time and leave the room. .

Based on observation, interview and record review, the facility failed to ensure medications were stored and administered according to professional standards, resulting in the potential for significant medication errors and clinically adverse consequences. Findings include: Review of the Medication Administration policy dated June 2019 revealed, B. Administration: 3. Medications are administered at the time they are prepared. Medications are not pre-poured in advance of the medication pass or for more than one resident at a time. During an observation and an interview on 1/10/24 at 9:35 AM, Licensed Practical Nurse (LPN) I had two medication cups with medications in them for two different residents in her hand. LPN I reported the one resident was not ready for his medications yet, so she put his name on the cup and placed it back into the locked medication cart and proceeded to the other resident's room to administer his medications. This surveyor told her when she was done with that medication pass, the next medication pass will need to be observed from the beginning. When LPN I came back to her medication cart, the top drawer had 4 medication cups with preset medications. She reported they were for R1, R2, R15 and R186. One cup had crushed medications that LPN I reported there were two different medications in that cup. She said one resident was still on his CPAP when she went to see if he wanted them and could not administer them, another resident was busy with the aides and could not give medications, and another resident told her he was not ready for his medications. When queried if she asks or checks on the residents to see if they are ready for their medications before she prepares them, LPN I reported it would take all day to give them their medications if she did that. In an interview on 1/10/24 at 3:08 PM, the Director of Nursing (DON) reported her expectations from the nurses are to not preset medications without administering them right after.

Based on observation, interview, and record review the facility failed to: 1. Ensure sufficient hot water at the hand sink; 2. Properly datemark food product; 3. Properly store food product; and 4. Ensure cleanliness of food and non-food contact surfaces. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 30 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, starting at 9:05 AM on 1/8/24, it was observed that the hand sink, located to the right of the dish machine, was not providing hot water to achieve the required 100F. At this time, the hot water was checked with a rapid read digital thermometer and found to only reach 61F. An interview with Dietary Aide F found that the hand sink never seems to get hot, but the one compartment wash sink (next to the hand sink on the dish machine line) gets hot. Further observation found that the hot water line under the hand sink passes through a mixing valve. According to the 2017 FDA Food Code section 5-202.12 Handwashing Sink, Installation. (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 38C (100F) through a mixing valve or combination faucet . 2. During the initial tour of the kitchen, at 9:15 AM on 1/8/24, an interview with Dietary Manager (DM) E found that food is dated for six days out. Observation of the three-door true cooler found an open thickened dairy beverage with no discard date (manufacture states the product is good for four days after opening), an open container of thickened lemon water with no discard date (manufacture states the product is good for seven days after opening). Further review of the cooler found a three-gallon container with a large ham wrapped in saran wrap and pieces of ham chunks stored in a plastic bag. When asked if there was a discard date on either of the ham items, DM E stated it was not dated. During the initial tour of the kitchen, at 9:28 AM on 1/8/24, observation of the two-door cooler found an open package of sliced ham with no discard date. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . 3. During the initial tour of the kitchen, at 9:30 AM on 1/8/24, it was observed an open container of less sodium soy sauce was found stored underneath the preparation table on the cook line. Further review of the product found that the manufacture states to Refrigerate After Opening. According to the 2017 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: .(2) At 5ºC (41ºF) or less . 4. During the initial tour of the facility, at 9:27 AM on 1/8/24, it was observed that the top gaskets of the two door cooler were found with an accumulation of debris. During the initial tour of the kitchen, at 9:35 AM on 1/8/24, an interview with DM E found that staff use the stand up mixer a couple times a week. The mixer was found covered in a plastic bag which DM E indicated meant it was clean and ready to be used. Observation of the underside arm of the mixer found an accumulation of white and yellow stuck on splatter debris. During the initial tour of the kitchen, at 9:37 AM on 1/8/24, observation of the underside corners of the juice machine found an accumulation of sticky orange, brown debris. During a tour of the North hall pantry, at 11:22 AM on 1/8/24, it was observed that a dried spill occurred on the top of the refrigeration unit and into the crevice of the top gasket seal. When asked if kitchen staff use this area, DM E stated the PM cook comes down daily. During the tour of the facility, at 11:25 AM on 1/8/24, it was observed that the ice machine was found with an accumulation of black debris on the corners and sides of the inside plastic lip. When asked who services the machine, DM E stated a vendor comes out and cleans it quarterly and they were here in December. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate nursing staffing to provide 1 Resident (R202) with care as needed, resulting in R202 sitting in urine past the standard 2-hour check and change and experiencing discomfort and potential for skin breakdown. Findings include: Review of R202's face sheet dated 9/28/23 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had diagnoses that included: Schizoaffective disorder, epilepsy, chronic pain, anoxic brain damage (loss oxygen causing brain damage), aphasia (loss of the ability to understand or express speech caused by brain damage), bipolar disorder, anxiety disorder and muscle weakness, R202 was not her own responsible party and was currently in hospice care. On 9/28/23 at 12:35 PM R202 was up in her chair at the Nurse's Station and Registered Nurse (RN) E was feeding her ice cream. R202 was asked if she liked ice cream and she did not respond. R202 began sliding and lifting her buttock off the seat of her chair. R202 did not respond to questions of did she have pain or did her bottom hurt. RN E was asked if he saw her buttock or skin today and he responded, No. When asked how long she had been up in the chair and when she had last been changed, he responded, she had been up in her chair since she fell out of bed this morning and he was not sure when her brief had last been changed. R202 than began yelling she wanted her bottom checked. On 9/28/23 at 12:45 PM, RN E and Certified Nurse Aide (CNA) F transferred R202 back to bed with a canvas full body sling and an electronic lift. When R202 was lifted out her chair the canvas sling that had been in the chair was wet over the entire bottom and up past both hips. Her sweatpants and brief were totally saturated. CNA F said she had not provided any care for R202 today and thought CNA G had provided care. During an interview with CNA G on 9/28/23 at 1:05 PM, she confirmed she did R202's morning care around 9:00 AM and changed her incontinent brief at that time. CNA G said R202 wanted to get up at that time but someone else needed assistance to get another resident out of bed so she left and R202 fell before she could get back to her to assist her out of bed. CNA G said she did not change R202 since prior to the fall that morning. CNA G said 2 CNA's called in and she and CNA F were assigned to all 35 residents. CNA G said the nurses and other staff were assisting when they could, but she had not had time to get back to do incontinence care with R202. During an interview with the Nursing Home Administrator (NHA) on 9/28/23 at 2:00 PM, the Surveyor reported the observation and interviews that R202 had not received her incontinence care for the greater than 3 hours today and was found soaked in urine. The NHA said she would start investigating and verifying all residents were getting the care they needed. During an interview with UM (Unit Manager) B on 9/28/23 at 2:45 PM, UM B was asked who the CNA was that was assigned to R202 today. UM B said they had 2 CNA's call in and when that happens, she went to the nurse's station and pulled a resident list by room off the board. All but 3 residents listed were highlighted in yellow or green. R202 was in the yellow group. The yellow group had 16 residents and there were 3 residents that were not assigned to either group. UM B was not sure which CNA had the yellow group today. During an interview with the NHA at 3:45 PM the NHA confirmed that she spoke with the scheduler and there was confusion as to who was providing care for R202 and other residents. The NHA said the scheduler was a CNA and they had a driver that was also a CNA, both were doing some care, however, there was confusion as to who was responsible for which residents' care. The NHA said the driver had to leave and the scheduler was also doing her job duties along with assisting with care when she could.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document and communicate a resident's advanced directive (Code status) to the interdisciplinary team and to staff responsible for the resident's care for one resident (Resident #24), resulting in the potential for failing to follow advanced directives. Findings: Review of a facility policy Residents' Rights Regarding Treatment and Advanced Directives last reviewed 12/2020 reflected It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advanced directive. The policy specified 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for resident's care. 11. If a Do-Not-Resuscitate (DNR) order is desired, the Michigan General Procedures, Medical Treatment Decision Form and/or Michigan Physician Order for Scope of Treatment (MI-POST), will be followed. Resident #24 (R24) Review of an admission Record reflected R24 admitted to the facility on [DATE]. The section of the record Advanced Directives reflected CPR (cardiopulmonary resuscitation)-Full Resuscitation; + Blood Transfusions; + Hospitalization; + Intravenous Fluids for Acute Condition Treatment; + Intravenous Fluids for Hydration; + Intravenous Fluids for Pain Control; + Oxygen Therapy; + Pain Management. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15/15. Review of a Statement of Ability/Inability for Decision Making-V 2.0 dated [DATE] reflected a physician and a psychologist determined R24 was profoundly cognitively impaired and it is in his/her best interest to activate a Durable Power of Attorney for Healthcare decisions at this time. Review of a Durable Power of Attorney (DPOA) signed on [DATE] reflected R24 designated an individual to act on her behalf in the event she was deemed unable to do so. Review of a Medical Treatment Decision Form (MTDF) dated [DATE] was signed by R24 and specified DNR Do Not Resuscitate. Other treatment options specified that R24 did not wish to have artificial feeding. R24 did wish to receive Intravenous fluids for hydration, acute condition treatment & pain control. R24 also wished to have pain management, antibiotic treatment, blood transfusions and oxygen therapy. Review of an Order Recap Report for the date range [DATE]-[DATE] reflected a phone order, active as of [DATE] CPR - Full Resuscitation. Review of the profile detail banner in the Electronic Medical Record (EMR) on [DATE] at 10:10 AM reflected R24's Code Status was CPR - Full Resuscitation. During an interview on [DATE] at 1:48 PM, Registered Nurse (RN) E reported that nurses review the MTDF with the resident or responsible party upon admission. After the MTDF is signed, the form is placed in the Doctor Book for the physician's signature and is then scanned into the EMR. During an interview on [DATE] at 2:05 PM, the Director of Nursing reviewed R24's clinical record and said the physician order and code status reflected on R24's profile was not consistent with the Medical Treatment Decision Form and directives set forth in the DPOA paperwork. The DON said she would expect a conversation with the DPOA to confirm the advanced directive and then change the order to reflect R24's wishes. The DON said there is an audit process via an admission checklist that is intended to prevent errors or omissions. Review of a blank (Facility Name) New Admission/readmission Checklist provided by the DON reflected Complete the Medical Treatment Decision Form (MTDF) and enter the advanced directive information as physician orders in (EMR). Ensure the correct responsible party provides the directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Comprehensive Significant Change Minimum Data Set (MDS) assessment for 1 resident (Resident #7), resulting in the potential for unmet care needs. Findings: Resident #7 (R7) Review of an admission Record reflected R7's Primary Payer was Hospice Medicaid. Review of a Hospice Certification and Plan of Care for certification period 11/14/2022 to 2/11/2023 reflected R9 started on hospice care 11/14/2022. Review of a quarterly MDS assessment dated [DATE] reflected that R7 was receiving hospice care. The prior assessment (annual) was dated 9/28/2022. A significant change MDS assessment was not transmitted within 14 days following the significant change in prognosis and treatment goals. During an interview on 1/20/2023 at 1:32 PM, the Director of Nursing (DON) reported that the facility shares an MDS coordinator with a sister facility and the DON conducts the interviews and reviews the MDS assessments prior to submission. According to the DON, transitioning to Hospice care is a significant change and should have prompted a comprehensive significant change assessment. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Nursing centers must comply with the Omnibus Budget Reconciliation Act of 1987 and its minimum requirements for nursing facilities to receive payment from Medicare and Medicaid. Government regulations require that staff members in nursing centers comprehensively assess each resident and that care planning decisions be made within a prescribed period. A resident's functional ability (such as the ability to perform activities of daily living and instrumental activities of daily living) and long-term physical and psychosocial well-being are the focus. A nursing facility must complete the Resident Assessment Instrument (RAI) for each resident. The RAI helps nursing facility staff gather definitive information on a resident's strengths and needs, which must then be addressed in an individualized care plan (CMS, 2015b) .The components of the RAI yield information about a resident's functional status, strengths, weaknesses, and preferences, as well as offering guidance on further assessment once problems have been identified (CMS, 2015b). The MDS Version 3.0 is an initial overview of a resident's health care needs. It is a preliminary assessment to identify the resident's potential problems, strengths, and preferences. The CAAs are triggered by individual MDS item responses that reveal the need for additional assessment. These item responses identify problems, known as triggered care areas, which form a critical link between the MDS and decisions about care planning. CAAs enable facilities to identify and use tools that are grounded in current clinical standards of practice, such as evidence-based or expert-endorsed research, clinical practice guidelines, and resources. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 21). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 1 resident (Resident #9) reviewed for accuracy of assessments, resulting in an inaccurate reflection of the resident's status and the potential for inaccurate care plans and unmet care needs. Findings: Resident #9 (R9) Review of an admission Record reflected R9 admitted to the facility in 2010 with pertinent diagnoses that included End Stage Renal Disease, other disorders of phosphorus metabolism, and dependence on renal dialysis. Review of the previous 12 months of Minimum Data Set (MDS) assessments reflected the following pertaining to Section O - Special Treatments and Procedures: -A discharge MDS assessment dated [DATE] did not reflect R9 was receiving dialysis. -Annual MDS assessment dated [DATE] did reflect R9 was receiving dialysis. -Quarterly MDS assessment dated [DATE] did reflect R9 was receiving dialysis. -Discharge-return anticipated MDS assessment dated [DATE] did not reflect R9 was receiving dialysis. -An entry tracking record dated 8/5/2022 did not reflect R9 was receiving dialysis -A discharge assessment-return anticipated, dated 9/9/2022, did not reflect R9 was receiving dialysis. -Entry tracking record dated 9/11/2022 did not reflect R9 was receiving dialysis -A quarterly review dated 11/2/2022 did not reflect R9 was receiving dialysis but did indicate R9 was receiving transfusions. During an interview on 1/20/2023 at 1:32 PM, The Director of Nursing (DON) reported that the facility shares an MDS coordinator with a sister facility and the DON conducts the interviews and reviews the MDS assessments prior to submission. According to the DON, R9 should have been coded as receiving dialysis. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Long-term health care settings include skilled nursing facilities (SNFs), in which patients receive 24-hour-a-day care, including housing, meals, specialized (skilled) nursing care, treatment services, and long-term care facilities, in which patients with chronic conditions receive 24-hour-a-day care, including housing, meals, personal care, and basic nursing care. Requirements for documentation in these facilities are governed by individual state regulations, TJC, and CMS. CMS mandates use of the Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) and the Care Area Assessment (CAA) to document data in long-term care facilities. MDS assessment forms are completed on admission and then periodically within specific guidelines and time frames for all residents in certified nursing homes (Ahn et al., 2015). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 377). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to ensure 1 of 5 Nurse Aides (Non-Certified Nurse Aide D) reviewed for nurse aide certification 1.) became certified within four months of nurse aide training 2.) successfully completed a NATCEP/CEP, and 3.) demonstrated proficiency and was determined to be proficient for the tasks they were assigned before continuing to provide resident care, resulting in the potential for unmet care needs, and serious harm and/or injury from an uncertified and untrained staff member providing direct patient care. This deficient practice had the potential to affect all residents that resided within the facility. Findings: Review of the facility Certified Nurse Aide (CNA) Position Summary last revised 4/23/20 revealed, .Required/Desired Qualifications: Education, Training, and Experience: Must possess a current Michigan Certified Nurse Aide Certification or have completed a Michigan approved CNA training program and are eligible to test. Must be certified within 4 months of hire . During an interview on 01/20/2023 at 9:01 AM, Human Resources (HR) F reported that Non-Certified Nurse Aides (NCNA) did not provide direct patient care. HR F reported that NCNAs could not bathe, toilet, or transfer residents. During an interview on 01/20/2023 at 9:11 AM, Nursing Home Administrator (NHA) reported that NCNAs did not provide direct patient care but could pass waters, pass meal trays, provide reassurance to residents, and notify nursing staff of resident needs. NHA reported that NCNAs could assist with holding residents in position while certified/licensed staff provided care (brief changes, wound care, linen changes, etc). NHA reported that NCNA D was enrolled in a State approved Certified Nurse Aide (CNA) course and worked as a facility CNA. NHA reported that NCNA D failed the clinical portion of the certification test and is scheduled to retake the test February 9, 2023. NHA reported that due to the federal minimum competency requirements, November 22 was the last day she was qualified to work at the facility as a CNA and should have worked with a certified CNA in the capacity of a NCNA after failing the CNA certification test. Review of NCNA D's employee file on 01/24/2023 at 11:26 AM with HR F revealed a hire date of 6/28/22. NCNA D did not have an orientation checklist or competency evaluation completed to ensure she possessed the skills and techniques necessary to care for residents' needs. HR F reported that an orientation checklist was to be completed within 30 days of hire. Review of the Michigan Registry for Certified Nurse Aides revealed NCNA D did not have an active certification as of 1/24/23. Review of the Staffing Log and the Nursing Department Daily Staffing revealed NCNA D worked the following shifts (2nd shift) in the capacity of a CNA despite not having the required certification and competency to do so safely on the following dates: 11/23/22, 11/24/22, 11/25/22, 11/28/22, and 11/29/22 12/1/22, 12/2/22, 12/4/22, 12/5/22, 12/6/22, 12/7/22, 12/8/22, 12/9/22, 12/12/22, 12/13/22, 12/15/22, 12/16/22, 12/17/22, 12/18/22, 12/19/22, 12/21/22, 12/22/22, 12/23/22, 12/26/22, 12/27/22, 12/29/22, 12/30/22, and 12/31/22 1/1/23, 1/2/23, 1/4/23, 1/5/23, 1/6/23, 1/9/23, 1/10/23, and 1/12/23 NCNA D was removed from the schedule beginning 1/13/23

Based on observation, interview and record review, the facility failed to ensure expired medication was discarded in 1 of 2 medication carts reviewed, resulting in the potential for less than therapeutic effects of medications, decreased effectiveness of medications, and the potential for adverse drug reactions. Findings: Review of a facility policy Storage of Medications dated June 2019 reflected A. Medications will be considered acceptable for use until the stated expiration date on the individual product. The date will be the lesser of the manufacturer's expiration date indicated by (name of pharmacy). B. Medications dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date. C. Once any drug or biological package is opened, manufacturer/supplier guidelines regarding expiration dating will be followed. (no D. specified in the policy); E. All expired medications will be removed from the active supply and destroyed in the facility or returned to (name of pharmacy) for destruction. F. Disposal of any medications prior to the expiration date will be required if contamination or decomposition is apparent. G. Nursing staff should consult with (name of pharmacy) for any questions related to medication expiration dates. During a medication administration observation on 1/19/2023 at 12:51 PM, Registered Nurse A drew up and administered two units of Humulin R 100U/mL for a resident's (R20) blood glucose reading of 185. The vial of Humulin R was dated as opened on 12/13/2022. When asked, RN A said she thought opened vials of insulin were stored for 30 days prior to disposal. Review of a pharmaceutical company Instructions for Use web page for Humulin R reflected After vials have been opened: Store opened vials in the refrigerator or at room temperature up to 86 degrees Fahrenheit for up to 31 days. Keep away from heat and out of direct light. Throw away all opened vials after 31 days, even if there is still insulin in the vial. (Accessed on 1/24/2022 at 10:02 AM from https://uspl.lilly.com/humulinru100/humulinru100.html#ug)

Based on interview and record review, the facility failed to honor resident food preferences for 1 resident (Resident #9) and as reported during a Confidential Group Interview and by the Resident Council meeting attendees in October, November and December 2022. Findings: During a confidential group interview on 1/18/2023 at 10:37 AM, 3 of 8 respondents reported dissatisfaction with menu choices not being honored. Review of Resident Council Minutes December 2022 reflected Dietary: (How is the food, any issues, ticket items on the tray, is the food hot, etc.) Food tastes good. Don't always receive what they ordered/what's on the menu/Resident Choice meals are not being added to the schedule/menu. Review of Resident Council Minutes for November 2022 reflected Food tastes good, remember to look at dislikes on tickets, no other issues, occasionally food is too cold (not often) . Review of Resident Council Minutes for October 2022 reflected Food tastes good, remember to look at dislikes on tickets, no other issues, occasionally food is too cold (not often), provide menu option lists more regularly (weeks' worth at a time). During an interview and observation on 1/18/2023 at 12:16 PM, Resident #9 (R9) reported that she is often served food specifically listed as a dislike on her meal ticket. R9 specified she does not care for potatoes and is frequently served potatoes. During the interview, a staff member delivered the noon meal to R9. The meal was a Sheppard's Pie, the meat base of the entree covered in mashed potato. Along side the plate of food was R9's meal ticket. Review of the meal ticket reflected a list of foods R9 Dislikes that included potatoes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for medication administration for 5 residents (Resident #14, #30, #15, #9 and #20) reviewed for provision of nursing services, resulting in the withholding of medications without a physician order, medications administered outside of physician ordered parameters, and the potential for less than therapeutic effects of medications, decreased effectiveness of medications, and the potential for a delay in treatment and the worsening of medical conditions. Findings: Resident #14 (R14) Review of an admission Record revealed R14 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes. Review of R14's Physician Order dated [DATE] revealed, Lantus SoloStar Solution Pen (long acting insulin) .Inject 10 unit subcutaneously in the evening for DM (diabetes mellites) to be administered in the evening. No parameters were ordered to hold (not administer) the Lantus. Review of R14's January Medication Administration Record (MAR) revealed R14 did not receive the ordered insulin on the following days: *[DATE] due to 11=Outside of Parameters *[DATE] due to 11=Outside of Parameters *[DATE] due to 11=Outside of Parameters *[DATE] due to 11=Outside of Parameters *[DATE] due to 11=Outside of Parameters *[DATE] due to 11=Outside of Parameters *[DATE] due to 11=Outside of Parameters *[DATE] due to 11=Outside of Parameters Review of R14's Progress Notes revealed no documentation that the physician was notified that the Lantus was held nor that an order was obtained to hold the medication. During an interview via email dated [DATE] at 8:07 AM, Director of Nursing (DON) verified that R14 did not have parameters ordered to hold the Lantus. DON stated, I called (name omitted) Hospice last evening and got an order for HOLD parameter for (R14's) Insulin. Resident #30 (R30) Review of an admission Record revealed R30 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: heart failure. Review of R30's Physician Order dated [DATE] revealed, Midodrine HCl Tablet 2.5 MG Give 1 tablet by mouth two times a day for orthostatic hypotension hold if sbp >140mmHg (hold if systolic blood pressure/top number is greater than 140). R30's January MAR revealed the Midodrine was to be administered in the AM (morning) and HS (hour of sleep). This order was discontinued on [DATE] following the morning dose of the medication. Review of R30's Blood Pressure Summary and January MAR revealed no documentation that R30's blood pressure was assessed prior to the administration of the medication to ensure the ordered parameters were followed on the following days: *[DATE] for the AM dose and the HS dose *[DATE] for the HS dose *[DATE] for the AM dose *[DATE] for the AM dose and the HS dose *[DATE] for the AM dose and the HS dose. The AM dose was documented as being held due to 11=Outside of Parameters without documentation of the blood pressure in a Progress Note or on the Blood Pressure Summary. *[DATE] for the AM dose and the HS dose. The AM dose was documented as being held due to 11=Outside of Parameters without documentation of the blood pressure in a Progress Note or on the Blood Pressure Summary. *[DATE] for the AM dose and the HS dose *[DATE] for the AM dose Review of R30's Physician Order dated [DATE] revealed, Midodrine HCl Tablet 2.5 MG Give 1 tablet by mouth two times a day for orthostatic hypotension hold if sbp >140mmHg -Start Date [DATE]. R30's January MAR revealed the Midodrine was to be administered at 8:00 AM and 5:00 PM. The first dose was to be administered at 5:00 PM. Review of R30's Blood Pressure Summary and January MAR revealed no documentation that R30's blood pressure was assessed prior to the administration of the medication to ensure the ordered parameters were followed on the following days: *[DATE] for the 5:00 PM dose *[DATE] for the 8:00 AM dose. The 5:00 PM dose was held due to 3=Absent from home without further documentation in the Progress Notes of R30's blood pressure assessment following the missed dose of the medication. *[DATE] for the 8:00 AM dose and the 5:00 PM dose. The PM dose was documented as being held due to 11=Outside of Parameters. *[DATE] for the 8:00 AM dose Review of R30's January MAR revealed the Midodrine order was modified to require the assessment/documentation of R30's blood pressure at the time of the medication administration. Beginning [DATE] R30's blood pressure was documented on the MAR as well as the Blood Pressure Summary. Resident #15 (R15) Review of an admission Record revealed R15 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes. Review of R15's Physician Order dated [DATE] revealed, Tresiba Solution (long acting insulin) Inject 16 unit subcutaneously in the evening for DM II (diabetes mellitus type 2). No parameters were ordered to hold (not administer) the Tresiba. Review of R15's January Medication Administration Record (MAR) revealed R15 did not receive the ordered insulin on the following days: *[DATE] due to 11=Outside of Parameters *[DATE] due to 11=Outside of Parameters *[DATE] due to 11=Outside of Parameters *[DATE] due to Tresiba ONLY 4U (units) remaining. Given. On order. Indicating an incorrect dose of insulin was administered without a physician order. *[DATE] due to ON order (Medication was not available for administration.) Review of R15's Progress Notes revealed no documentation that the physician was notified that the Tresiba was held, was unavailable, nor that an order was obtained to hold the medication. During an interview on [DATE] at 10:32 AM, Registered Nurse (RN) E reported that if there are no ordered parameters for a medication, the physician would be notified if there is a need to hold the medication and an order would be obtained to hold the medication. RN E reported that if vital signs are out of range and a medication is unsafe to administer, the physician would be notified, and an order would be obtained to hold the medication. RN E reported that if a resident is too lethargic or unable to take medications, the physician would be notified. During an interview on [DATE] at 1:27 PM, DON reported that if a medication is held a progress note should be written. Resident #9 (R9) Review of an admission Record reflected R9 admitted to the facility in 2010 with pertinent diagnoses that included End Stage Renal Disease, Type 2 diabetes with diabetic chronic kidney disease, Chronic diastolic (congestive) heart failure, non-ST elevation (NSTEMI) myocardial infarction, cardiac arrhythmia, hypertension, other disorders of phosphorus metabolism, and dependence on renal dialysis. Review of a [DATE] Medication Administration Record (MAR) reflected the following order: Midodrine HCl Tablet 2.5 MG Give 1 tablet by mouth two ties a day for orthostatic hypotension Hold if SBP (systolic blood pressure) > (greater than) 140mmHg and notify provider !!! (sic). The MAR reflects that on [DATE] R9's SBP was 148. A check mark on the MAR indicates the medication was given. On [DATE] R9's SBP was 138 and the medication was marked as held as evidenced by the number 11 (outside of parameters) Further review of the [DATE] MAR reflected an order Insulin Glargine Solution 100 UNIT/ML Inject 15 unit subcutaneously two times a day for diabetes. The MAR did not specify parameters for the order. The MAR reflects the medication was held as evidenced by the number 11 (outside of parameters) documented for the evening (8:00 PM) dose on [DATE], 16, 19, 23, 26, 28 and 30. Resident #20 (R20) Review of an admission Record reflected R20 admitted to the facility with pertinent diagnosis of Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene. During a medication administration observation on [DATE] at 12:51 PM, Registered Nurse A drew up and administered two units of Humulin R 100U/mL for R20's blood glucose reading of 185. The vial of Humalin R was dated as opened on [DATE]. When asked, RN A said she thought opened vials of insulin were stored for 30 days prior to disposal. Review of a pharmaceutical company Instructions for Use web page for Humulin R reflected After vials have been opened: Store opened vials in the refrigerator or at room temperature up to 86 degrees Fahrenheit for up to 31 days. Keep away from heat and out of direct light. Throw away all opened vials after 31 days, even if there is still insulin in the vial. (Accessed on [DATE] at 10:02 AM from https://uspl.lilly.com/humulinru100/humulinru100.html#ug) Review of the R20's [DATE] Medication Administration Record (MAR) reflected an order Insulin Regular Human Solution 100 UNIT/ML Inject as per sliding scale: if 71-150 = 0; 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10; 401-450 = 12; 451+ call physician, subcutaneously before meals and at bedtime for dm (diabetes mellitus). The vial of Humulin R dated as opened on [DATE] would have been expired on [DATE]. The MAR reflected R20 had been given the expired insulin 13 of 26 opportunities for administration. Review of the facility policy Medication Administration-General Guidelines dated [DATE] revealed the following highlighted by the DON .If two consecutive doses of a vital medication are withheld or refused, the physician is notified; a nurse documents the notification and the physician's response. The policy did not contain a list of medications that would be considered vital. Review of the Facility Assessment last reviewed/revised [DATE] revealed, Policies and procedures for provision of care .Any baseline clinical sills (sic) that are not specified by (facility corporation) policy are adapted from [NAME] and [NAME] Clinical Fundamentals of Nursing . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, If a patient refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason that a medication was not given in the nurses' notes .notify the health care provider when a patient misses a dose. Be aware of the effects that missing doses may have on a patient (e.g., with hypertension or diabetes). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 614). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Responsibilities of medication administration include knowing medication therapeutics, assessing a patient before administration, calculating doses, administering medications using the seven rights, monitoring and evaluating medication effects, and assessing a patient's ability to self-administer medications .Before administering medications, perform a physical assessment, which will reveal physical findings for any indications or contraindications for medication therapy. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 672). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Health care provider- initiated interventions are dependent nursing interventions that require an order from a health care provider. The interventions are based on a physician's or nurse practitioner's choices for treating or managing a medical diagnosis .As a nurse you intervene by carrying out the health care provider's written and/ or verbal orders. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 246). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 resident (Resident #15) reviewed for comprehensive and accurate medical records, resulting in an inaccurate reflection of the resident's medical condition and needs and the potential for providers to not have an accurate picture of resident status and condition. Findings: Resident #15 (R15) Review of an admission Record revealed R15 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia. Review of R15's admission Skin Assessment dated 12/26/22 revealed R15's left buttock had a healing open wound (no measurements or description) and right buttock shoulder pain, knee (no measurements or further description). Review of R15's Physician Assessment Form dated 12/26/22 revealed, .Impression/Treatment Plan .Partial thickness shear of sacrum -Appears to be healing, no pressure related wounds noted -Desitin cream q (every) shift and offloading . No wound measurements or description documented. (Review of the National Pressure Injury Advisory Panel revealed, Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis .These injuries commonly result from adverse microclimate and shear in the skin .) Review of R15's January Treatment Administration Record (TAR) revealed an order Partial thickness shear of sacrum: Clean sacrum with normal saline, apply desitin cream to sacrum and offload. Ensure overlay mattress is in place. every shift for Wound care, prevention. Start Date 12/27/22. Review of R15's Weekly Skin Sweep dated 1/2/23 revealed that R15 had rash/excoriation on her sacrum. Review of R15's Weekly Skin Sweep dated 1/9/23 revealed that R15 had rash/excoriation on her sacrum. Review of R15's Physician Assessment Form dated 1/12/23 revealed, .Impression/Treatment Plan .Partial thickness shear of sacrum -Appears to be healing, no pressure related wounds noted -Desitin cream q (every) shift and offloading . No wound measurements or description documented. (Indicating a current open wound requiring treatment). Review of R15's Weekly Skin Sweep dated 1/16/23 revealed that R15 had rash/excoriation on her sacrum. Review of R15's Progress Notes revealed no documentation of measurements/description/resolution of R15's Partial thickness shear of sacrum or left buttock had a healing open wound as documented in the Physician Assessment and Nursing admission Assessment. As of 1/24/23 at 12:04 PM, R15's January TAR revealed a current order Partial thickness shear of sacrum: Clean sacrum with normal saline, apply desitin cream to sacrum and offload. Ensure overlay mattress is in place. every shift for Wound care, prevention. Start Date 12/27/22. Indicating R15 was being treated for a current open wound on her sacrum.) During an interview on 01/20/23 at 12:51 PM, Director of Nursing (DON) reported that R15 was not being followed for a sacral wound and the area Partial thickness shear of sacrum identified on admission had resolved. Review of the Facility Assessment last reviewed/revised 10/26/22 revealed, Policies and procedures for provision of care .Any baseline clinical sills (sic) that are not specified by (facility corporation) policy are adapted from [NAME] and [NAME] Clinical Fundamentals of Nursing . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The health care record is a valuable source of data for all members of the health care team. Data entered into the health care record serve many purposes, including facilitating interprofessional communication among health care providers, providing a legal record of care provided, justification for financial billing and reimbursement of care. Data are also used to audit, monitor, and evaluate care provided to support the process needed for quality and performance improvement. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 366). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The health care record provides a way for members of the interprofessional health care team to communicate about multiple aspects of patient care, including patient needs and response to care and therapies; clinical decision making; and the content and outcomes of consultations, patient education, and discharge planning. Information communicated in the health care record allows health care providers to know a patient thoroughly, facilitating safe, effective, timely, and patient-centered clinical decision making. The health care record is the most current and accurate, continuous source of information about a patient's health care status, allowing the plan of care to be clear to anyone who accesses the record .The health record is an important means of communication because it is a confidential, permanent, legal documentation of information relevant to a patient's health care. The record is an ongoing current and accurate account of a patient's health care status and is available to all members of the health care team. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 366). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Documentation is a key communication strategy that produces a written account of pertinent patient data, clinical decisions and interventions, and patient responses in a health record. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 365). Elsevier Health Sciences. Kindle Edition.

Based on observation and interview the facility failed to keep kitchen equipment in a state of repair that would allow for regular use and operation of the machines. This deficient practice has the potential to increase delayed mealtimes and frustration of residents and staff. During the initial tour of the kitchen, at 10:14 AM on 1/18/23, an interview with Dietary Manager (DM) B found that the facility ovens have not been working very well. When asked what has been going on with the ovens, DM B stated that the dials get stuck and are all worn so they cant be read, the ovens don't have a great set point and will run too hot or too cold unless you know all of their quirks. [NAME] Q, who has been here for 27 years, is the only one who has a good handle with them. DM B went on to state that she has new staff she is training in the kitchen, and its been difficult to teach staff how to use them. DM B went on to state that one of the new cooks burnt her meal the other week due to the oven running too hot. Observation of the kitchens cooking equipment, found a flat top burner that doesn't work, burners for the range top, and three under burner ovens. During a revisit to the kitchen, at 11:50 AM on 1/18/23, an interview with [NAME] Q found that when she uses the ovens, she cant use specific temperatures for cooking, its either over 250F for meats and cooking or under 250F for baking, most of the dials don't give you much to go by.

This citation pertains to intake MI000131812 Based on observation and interview, the facility failed to clean and maintain flooring in the North Shower room. This resulted in an increased odor, accumulation of sludge debris, and a possible decrease in the satisfaction of living affecting all residents who use the North Shower room. Findings include: During a tour of the facility, at 1:25 PM on 1/18/23, it was observed that a stagnant musky odor was found upon entrance of the north hall spa room. Observation of the spa room found the room clean and tidy, but with sheet metal covering over the floor drain and the shower area portion of the floor. Both sheets of metal were screwed to the floor and were not able to be easily accessed at this time. An interview with Environmental Services Manager (ESM) G, at 2:02 PM on 1/18/23, found that the odor in the north hall spa room might be because the ventilation stopped working over the Holiday break and the facility is waiting for the new ventilation fan to come in next week. ESM G went on to say that the metal sheets in the North Spa are to help even out the floor, without the sheets, it was hard to use a shower chair safely in that area with the floor sloping so steep to the drains. The surveyor stated that he would like the metal sheets pulled up today in order to look underneath. During a revisit to the north hall spa room, at 2:50 PM on 1/18/23, the surveyor asked ESM G if the odor is usually like this, ESM G stated that the odor is worse than normal. At this time ESM G was asked how often portions of the floor, that are covered by the sheet metal, get unscrewed from the floor and cleaned. ESM G stated that they get done about every six months, and that it had been a good six months since the last cleaning, and the cleaning was due. Upon ESM G removing the sheet metal coverings from the floor drain and shower floor area, it was observed that a heavy accumulation of sludge and dirt was found underneath.

This citation pertains to intake MI000131812 Based on interview and record review, the facility failed to ensure a fire monitoring system was functional for 15 days (10/25/2022-11/09/2022) without a report to the State Agency and without a Fire Watch implemented, resulting in the potential for serious harm, injury and/or death from smoke and fire. Findings: Review of a fire monitoring system audit/activity report for the date range 1/01/2022-1/24/2022 reflected the following: 10/20/22 at 14:11:31 (3:11:31 PM) Account was set inactive on 10/20/2022 out of service-pending cancellation 14:11:33 (3:11:33 PM) Audit details for Subscriber Information ACTIVATE FLAG CHANGED FROM Y (Yes) to N (No) Out of Service - Pending Cancellation Inactive date changed from (space left blank) to 10/20/2022 10/21/22 at 12:31:26 From: (email address of employee at fire monitoring company); Reply to: no-reply@ (name of fire monitoring company); To: (email address of employee at fire monitoring company); Subject: CANCEL; Message:; Attachment: email12210211230.doc 7279 bytes. 10/25/2022 at 10:55:37 AM Account number changed to CANCxxxxx (cancelled/account number). Further review of the report reflected 11/09/22 16:19:36 (4:19 PM) Account was set Active on 11/09/22. During an interview on 1/20/2023, the Nursing Home Administrator (NHA) reported the facility learned the fire alarm system was not communicating with the security/monitoring company when a routine fire drill was conducted on 10/27/2022. The reason for the system failure was due to non-payment to the fire monitoring/security company and was not known prior to the fire drill. The NHA reported she did not call the State Agency to report the outage and a Fire Watch was not implemented nor was she directed to do so by corporate environmental services staff. Review of an educational document (Name of fire monitoring company) Security System Outage/Disconnection dated 10/27/2022 reflected the Issue Identified: Fire Alarm System not communicating with our (name of monitoring company). Need for manual Emergency (911) communication in the event of a fire. The education indicated All residents at risk. The Root Cause Analysis: Communication Outage/Disconnect of (fire monitoring system) with (name of community) fire system. The process implemented to prevent further occurrence was In the event of an emergency where the fire alarm sounds, a designated employee must call 911 to alert first responders there is a need for assistance. Once 911 had been called, designee is to call Administrator immediately following. The section of the form for Monitoring indicated Manual call to 911 until further notice as long as the outage of the (fire monitoring company) system continues. Review of NFPA 101 Life Safety Code 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. A.9.6.1.6A A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. Such individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the fire safety situation for public education purposes. (Also see NFPA601, Standard for Security Services in Fire Loss Prevention.) The term out of service in 9.6.1.6 is intended to imply that a significant portion of the fire alarm system is not in operation, such as an entire initiating device, signaling line, or notification appliance circuit. It is not the intent of the Code to require notification of the authority having jurisdiction, or evacuation of the portion of the building affected, for a single nonoperating device or appliance.

This citation has 2 Deficient Practice Statements (DPS) DPS 1 Based on interview and record review, the facility failed to ensure a sufficient number of Administrative/Managerial Nursing staff to 1.) monitor nursing staff for compliance with nursing standards of practice (medication administration, documentation) and complete evaluations, 2.) oversee and supervise development and delivery of in-service education, 3.) ensure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services and 4.) ensure the ICP (Infection Control Preventionist) had the time necessary to properly assess, develop, implement, monitor, and manage the Infection Prevention and Control Program. Findings: Director of Nursing Duties During an interview on 01/20/23 at 12:54 PM, Director of Nursing reported that she had assumed the DON role in October 2022. DON reported that she was the facility Wound Care Nurse and was responsible for weekly monitoring of wounds which included documentation of wound measurements, characteristics, and treatment decisions and ensuring treatment changes were reflected in the resident Treatment Administration Record. DON reported that if a resident wasn't being followed by the contracted wound consultants, she would consult with the facility provider and make treatment changes as need. DON reported she was not Wound Care Certified. DON reported that she was the Infection Control Preventionist for the facility. DON was responsible for surveillance (system for prevention, identifying, reporting, investigating, and controlling infections diseases for residents, staff, volunteers, and visitors), implementing isolation protocols, antibiotic stewardship (monitoring antibiotic use in the facility), resident/family/staff infection control education, and the immunization (flu/pneumonia/Covid) program for staff and residents. DON reported that Unit Manager (UM) V was working on becoming Infection Control certified to assist with the Infection Control Program duties, but had not yet completed the training. During an interview on 01/20/23 at 01:32 PM, DON reported that there was a recent change with the MDS Nurse (Minimum Data Set is a core set of screening, clinical & functional status elements that forms the foundation of the comprehensive assessment) and the new MDS Nurse's first day is today. DON reported that she was responsible for the in-person resident interviews in relation to the MDS assessments. DON reported that she was accountable for the oversight of the resident MDS assessments as well as ensuring that resident Care Plans were reviewed, revised, and implemented. DON reported that because of the licensed nurse shortage at the facility, she also worked as the direct care nurse when there were no other licensed nurses to cover a shift. Review of the January 2023 Staffing Schedule revealed the DON worked the following shifts: (1st shift) 1/6/23 and 1/9/23 (2nd shift) 1/3/23, 1/12/23, 1/16/23, 1/21/23, 1/22/23, and 1/23/23 During an interview on 01/20/23 at 01:32 PM, DON reported that she was the Staff Educator for the facility. DON reported that during direct care and licensed staff evaluations, areas for improvement are identified and is what drives the yearly education and the education provided during the mandatory monthly meetings. During an interview on 01/24/2023 at 11:26 AM, HR F reported that DON signs off on all Initial Competency Checklists to ensure the new employees have met the requirements and then turns the completed Initial Competency Checklist. During an interview on 01/24/2023 at 10:47 AM, [NAME] President of Human Resources (VPHR) J reported that new hire Initial Competency Checklists were completed by DON. VPHR J reported that because this is a smaller facility the DON was to observe the skills and sign off on each of the items listed in the Initial Competency Checklist for the licensed nurses and direct care staff and submit the completed form to the Human Resources Coordinator. VPHR J reported that weekly meetings were held to discuss staffing needs for all Mission Point facilities, and they had been working at the corporate level to fill these holes with the focus on CNA and licensed nurse positions. VPHR J reported that staffing needs were identified at the facility. VPRH J reported that the DON duties varied based on the facility census and the facility budget. VPHR J reported there was no designated Corporate/Regional Wound Care Nurse, Staff Educator, or MDS Nurse. VPHR J reported that the Regional/Corporate Nurse would educate on Infection Control and changes made with policies and procedures, however, there was no designated Regional/Corporate Infection Preventionist. Confirming that DON simultaneously served as the Director of Nursing, Infection Control Preventionist, Wound Care Nurse, Staff Educator (including new hire orientation competency evaluation), MDS oversight (including resident Care Plan revision and implementation), and as a direct care nurse. It was identified during the onsite survey that the facility did not ensure there were sufficient administrative and/or managerial staff which resulted in the following deficiencies: 1. Failed to complete a Comprehensive Significant Change Minimum Data Set (MDS) assessment for 1 resident (Resident #7) and failed to accurately complete Minimum Data Set (MDS) assessments for 1 resident (Resident #9). (Refer to noncompliance cited at F637-Comprehensive Assessment After Significant Change and F641-Accuracy of Assessments). 2. Failed to ensure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs, resulting in medication errors for Resident #14, #30, #15, #9 and #20 and incomplete/inaccurate medical records for R15. (Refer to noncompliance cited at F658-Services Provided Meet Professional Standards, F726-Competent Nursing Staff, and F842-Resident Records). 3. Failed to implement an effective and current system of surveillance of resident and staff illnesses to identify possible communicable diseases and infections for all residents and staff to prevent the spread of an illness/outbreak and failed to ensure a complete and accurate outbreak investigation for a COVID-19 outbreak and document follow-up activity in response to the outbreak. (Refer to noncompliance cited at F880-Infection Prevention and Control). 4. Failed to 1.) ensure a complete and comprehensive assessment was completed .3.) determine staff training, education, and competencies required to care for residents in the facility, and 4.) ensure the facility assessment was reviewed annually and updated to reflect administrative staff. (Refer to noncompliance cited at F838-Facility Assessment). Review of the State Operations Manual revealed, IP (Infection Preventionist) Hours of Work- Designated IP hours per week can vary based on the facility and its resident population. Therefore, the amount of time required to fulfill the role must be at least part-time and should be determined by the facility assessment, conducted according to §483.70(e), to determine the resources it needs for its IPCP, and ensure that those resources are provided for the IPCP to be effective. Based upon the assessment, facilities should determine if the individual functioning as the IP should be dedicated solely to the IPCP. A facility should consider resident census as well as resident characteristics, types of units such as respiratory care units, memory care, skilled nursing and the complexity of the healthcare services it offers as well as outbreaks and seasonality of infections such as influenza in determining the amount of IP hours needed. The IP must have the time necessary to properly assess, develop, implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees such as QAA. Review of the facility policy Antibiotic Stewardship Program last reviewed/revised December 2020 revealed, .1. The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the Antibiotic Stewardship Program: a. Infection Preventionist-coordinates all antibiotic stewardship activities, maintains documentation, and serves as a resource for all clinical staff. b. Director of Nursing-serves as back up coordinator for antibiotic stewardship activities, provides support and oversight, and ensures adequate resources for carrying out the program . Review of the facility policy Infection Prevention and Control Program last reviewed/revised December 2020 revealed, .6. Antibiotic Stewardship .The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program . Review of the facility Director of Nursing job description dated 4/27/20 revealed, .Principal Duties and Responsibilities: *Responsible for ensuring proper Policies, Procedures, and Protocols for care are in place to include the entire nursing process (assessment, plan, implementation, and follow up) for use of antibiotics in the care of the residents. The role of the DON includes adequate education and monitoring to ensure the process is implemented, communication, evidence-based standards of practice vs perceptions, and expectations of staff in their respective roles. *Develops, maintains, and implements nursing policies and procedures that conform to current standards of nursing practice, facility philosophy, and operational policies while maintaining compliance with state and federal laws and regulations. *Communicates and interprets policies and procedures to nursing staff, and monitors staff practices and implementation. *Participates in all admission decisions and may visit prospective residents before admission to assess overall health status. *Participates in daily or weekly management team meetings to discuss resident status, census changes, personnel, or resident complaints or concerns. *Evaluates the work performance of all nursing personnel, assists in the determination of wage increases, and implements discipline according to operational policies. *Ensures delivery of compassionate quality care and nursing supervision as evidenced by adequate services and staff coverage on unit, absence of odors, general cleanliness, prevention of pressure wounds, and apparent maintenance of optimal resident functions. *Demonstrates knowledge of and application of Key Clinical Quality Indicators, and proactively monitors and implements systems to achieve and/or surpass company thresholds. *Exercises overall supervision of resident assessments and care plans. Assures resident care conferences are conducted. *Reviews 24-hour report from every unit daily to monitor and ensure timely, effective responses to significant changes in condition, transfers, discharges, use of restraints, unexplained injuries, falls, behavioral episodes, and medication errors. *Collaborates with physicians, consultants, community agencies, and institutions to improve the quality of services and to resolve identified problems. *Coordinates nursing services with all other departments including Therapy and Pharmacy consultants. *Oversees nursing schedules to assure they meet resident needs and regulatory and budgetary standards. *Oversees and supervises development and delivery of in-service education to equip nursing staff with sufficient knowledge and skills to provide compassionate, quality care and respect for resident rights. *Proactively develops positive employee relations, incentives, and recognition programs. Promotes teamwork, mutual respect, and effective communication. *Performs rounds to observe care and to interview staff, residents, families or other interested parties. *Monitors staff for compliance with OSHA mandates and facility policies on workplace safety. *Proactively develops procedures and incentives to promote workplace safety and safe work practices. *Establishes, implements, and monitors the infection control program designed to provide a safe, sanitary, and comfortable environment designed to prevent the development and transmission of disease and infection. *Prepares or reviews infection control surveillance reports to identify trends and to develop effective actions to control and prevent infections. Submits an infection control report to the QA Committee. *Participates in budget development for the nursing department, and for medical, nursing, and central supplies. Assures nursing staff properly charges out ancillaries used. *Helps the Administrator prepare staff for inspection surveys, instructing staff on matters of conduct and disclosure, being interviewed by inspectors, immediate corrections of problems noted by surveyors, etc. *Reviews and reinforces important standards previously cited. *Participates in the preparation of the Plan of Correction response to an inspection survey and implements any follow-up QA required for any nursing allegations. *Communicates directly with residents, families, medical staff, nursing staff, interdisciplinary team members, and Department Heads to coordinate care and services, promote participation in care plans, and maintain a high quality of care and life for residents. *Promotes customer service and hospitality and responds to and adequately resolves complaints or concerns from residents or families about nursing services. *Monitors facility incidents and complaints daily to identify those defined as unusual occurrences by State policy and promptly reports such occurrences to Administrator for appropriate action. *Monitors complaint reports daily for allegations of potential abuse or neglect, or the loss or misappropriation of resident property, and participates in these investigations. *Promotes compliance with accident prevention procedures, safety rules, and safe work practices to prevent employee injury and illness and control worker's compensation costs. *Responsible for surveillance, infection definition based on standards of practice, education, tracking, data management, analysis of data, communication with the Medical Director and Consultant Pharmacist, and ongoing system review. *Responsible for ensuring proper Policies, Procedures, and Protocols for care are in place to include the entire nursing process (assessment, plan, implementation, and follow up) for use of antibiotics in the care of the residents. The role of the DON includes adequate education and monitoring to ensure the process is implemented, communication, evidence-based standards of practice vs perceptions, and expectations of staff in their respective roles. *Assures staff is trained in fire and disaster and other emergency procedures and evaluates performance during drills. *Acts in an administrative capacity in the absence of the Administrator. *Conduct staff meetings and in-services as requested. *Answer incoming calls when necessary and direct calls appropriately. *Assists in the dining room during assigned meals. *Perform other tasks as required . DPS 2 Based on observation, interview, and record review, the facility failed to ensure a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical condition, and plan of care, resulting in the potential for staff burnout, neglect, unmet care needs, and serious adverse physical, mental, and psychosocial harm. This deficient practice has the potential to affect all residents residing in the facility. Findings: Facility Assessment During an interview on 01/20/2023 at 9:11 AM, NHA reported that based on the Facility Assessment and the resident acuity level, the Certified Nursing Assistant (CNA) to resident ratio should be 1:10 to 1:12 (1 CNA for 10-12 residents) and a ratio of 1:8 would be ideal. NHA reported that staffing 3 CNAs on 1st shift, 2.5 CNAs on 2nd shift, and 2 CNAs on 3rd shift is the goal. NHA reported that the facility is not consistently staffed based on the Facility Assessment staffing plan. Review of the Facility Assessment last reviewed/revised on 10/26/22 revealed: Staffing plan 3.2. Our facility is relatively small in size making the staffing plans unique to ensure appropriate staffing is provided to meet the needs of all patients. The table listed below describes the basic facility staffing needs required to care for patients within our average census patterns. In relation to direct care staffing of nurses and nursing assistants, we staff with consideration of our daily census and flex staff up or down in relation to patient acuity. Our facility uses a basic guideline as below in relation to direct care staffing. Adjustments are made in relation to acuity and census. Licensed Nurses (LN): RN, LPN providing direct care- DON (Director of Nursing): 1 DON RN (Registered Nurse) full-time Days Clinical Care Coordinator/MDS: 1 RN full-time days RN or LPN (Licensed Practical Nurse) Charge Nurse: 2 for each shift am, pm, 1 nurse noc (night) shift 1:x 17 ratio Days and Evenings 1:x 35 ratio Nights An RN is scheduled 8/24 hours daily to meet the RN coverage requirement. Certified Nurse Aide (CNA): providing direct care- 1:8 ratio Days (total licensed or certified) 1:12 ratio Evenings 1:15 ratio Nights These numbers are baselines and are adjusted as needed in relation to patient acuity. During an interview on 1/20/2023 at 9:18 AM, the NHA reported that Corporate was aware of the staffing concerns at the facility but would not approve the use of agency CNAs and licensed nurses. During a confidential group interview on 1/18/2023 at 10:37 AM, 3 of 8 participants reported they feel like staffing at the facility could be improved. According to the residents, the facility counts the nurse in its staffing considerations but believe the nurse does not have time to answer call lights. Residents reported that the facility can't keep staff and that the afternoons are the worst time of day for call light response times. Residents reported having to wait for an hour and up to an hour and a half for staff to meet their needs. Residents reported staff are good about leaving the call light on until their need can be met. Residents also reported that there are not enough staff working in the kitchen. Review of Resident Council Meeting Minutes from August 2022 to December 2022 reflected the residents reported concerns with staff call light response times on the second shift during meetings held in September, October and November. In September 2022 residents specifically reported wanting more than one nurse aide on each hall. During an interview on 1/19/2023 at 7:50 AM, Staff R reported that one nurse is not enough for 33 (census at the time of the interview) residents. Staff R said they had a hard time getting treatments done and have to stay late. Staff R said Certified Nurse Aides (CNA's) are mandated frequently and it causes burnout and the facility does not use agency staff due to cost. During an interview on 1/19/2023 at 8AM, Staff S reported that there are only 2 CNAs on duty today (day shift), This is not enough help, the majority of residents are two person assist. Staff S said a shower needed to be completed later in the day and that would leave 1 CNA and 1 nurse to attend to residents. Review of a Resident Roster dated 1/19/2023 provided by the facility identified 15 of 33 residents required 2 people for transfers. When asked, the Nursing Home Administrator (NHA) reported that 3 residents were totally dependent on staff for feeding assistance. Review of PBJ (Payroll Based Journal) Staffing Data Report [NAME] Data Report 1705D FY (Fiscal Year) Quarter 4 2022 (July 1 - September 30) run on 1/5/2023 reflected the facility triggered for One Star Staffing Rating and Excessively Low Weekend Staffing. The staffing data report is used to identify areas requiring follow-up during the survey. During an interview on 1/20/2023 at 9:18 AM the NHA reported that she was not aware the facility had triggered for exceptionally low weekend staffing. According to the NHA, the facility did a bed reduction plan to decrease staff to resident ratios by 5 beds from July-December 2022. The NHA said the facility is running one CNA short for the first shift and one licensed nurse (RN/LPN) short for second shift. During a telephone interview on 1/24/23 2:25 PM Staff T reported a lot of staff are burned out. Staff T said that 3rd shift CNA's are not mandated like 1st and 2nd shift staff. Staff T said there are only two CNA's typically during days and that is not enough; on weekends there are only 3 staff-2 CNA's and 1 nurse and no management on duty to help take care of patients. Staff T said that they have been told by management over and over again that agency cannot come in to help and when staff do ask management for help with passing trays they don't come out and pass trays. According to Staff T, with two aides and one nurse on floor there is not enough people to look after wandering residents,It's unsafe for them (residents) and unsafe for us.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs, resulting in medication errors, and the potential for residents to receive inadequate care, ongoing medication errors, and to not attain or maintain their highest practicable level of physical, mental, functional and psychosocial well-being. Findings: Review of the facility Certified Nurse Aide (CNA) Position Summary last revised [DATE] revealed, .Required/Desired Qualifications: Education, Training, and Experience: Must possess a current Michigan Certified Nurse Aide Certification or have completed a Michigan approved CNA training program and are eligible to test. Must be certified within 4 months of hire . Review of the facility Initial Competency Checklist-Certified Nurse Aide (no date) revealed, This checklist outlines the information the employee needs to know to perform the responsibilities of the position of Certified Nurse Aide. As each item is completed, both the person providing orientation and the new employee should write their initials and the date in the space provided .This checklist should be signed by the employee and by the instructor and turned into Human Resources before working on the floor alone . Review of the facility Charge Nurse RN (Registered Nurse) Position Summary last revised [DATE] revealed, .Principal Duties and Responsibilities .Administer medications to residents according to the Public Health Code, Nursing Department Policies, and standards and procedures and as prescribed by the physician; notify appropriate clinical and/or nursing personnel of medication contraindications .Required/Desired Qualifications: Education, Training, and Experience .CPR (Cardio Pulmonary Resuscitation) certification required . Review of the facility Initial Competency Checklist-Certified Nurse Aide (no date) revealed, This checklist outlines the information the employee needs to know to perform the responsibilities of the position of Charge Nurse RN. As each item is completed, both the person providing orientation and the new employee should write their initials and the date in the space provided .This checklist should be signed by the employee and by the instructor and turned into Human Resources before working on the floor alone . During an interview on [DATE] at 01:32 PM, Director of Nursing (DON) reported that she was the Staff Educator for the facility. DON reported that during direct care and licensed staff evaluations, areas for improvement are identified and is what drives the yearly education and the education provided during the mandatory monthly meetings. DON reported that beginning January of 2023, licensed nurses were required to attend the monthly meetings. DON reported that mandatory monthly meetings were not yet required for CNAs. During an interview on [DATE] at 10:47 AM, [NAME] President of Human Resources (VPHR) J reported that new hire Initial Competency Checklists were completed by DON. VPHR J reported that because this is a smaller facility the DON was to observe the skills and sign off on each of the items listed in the Initial Competency Checklist for the licensed nurses and direct care staff and submit the completed form to the Human Resources Coordinator. During an interview on [DATE] at 10:34 AM, Human Resources (HR) F reported that she took over as the facility HR Coordinator in [DATE] (hire date [DATE]). HR F reported the previous HR Coordinator had left in July or [DATE] and the Regional/Corporate HR Coordinator was responsible for HR duties prior to HR F's hire. HR F reported she was left with a mess when she hired in (Initial Competency Checklist unavailable, CPR certification expired, missing education). HR F reported that she was working on ensuring all required certifications for licensed nurses were up to date and completed an audit on Friday ([DATE]) ensuring all licensed nurses and CNAs had active licenses/certifications. During an interview on [DATE] at 11:26 AM, HR F reported that DON signs off on all Initial Competency Checklists to ensure the new employees have met the requirements and then turns the completed Initial Competency Checklist to the facility's HR department to keep in the employee file. HR F reported that the Initial Competency Checklist is to be completed within 30 days of hire and reported it did not need to be completed prior to working independently/off orientation. The following employee files were reviewed with HR F at this time: RN E, CNA C, Non-Certified Nurse Aide (NCNA) D, RN U, CNA V, and RN A. Review of CNA C's employee filed revealed a hire date of [DATE]. CNA C did not have an Initial Competency Checklist on file to ensure CNA C had the knowledge and skills required to provide resident care. Review of the Staffing Schedule and Nursing Department Daily Staffing revealed CNA C was not on orientation and worked independently on [DATE], [DATE], [DATE], and [DATE]. Review of NCNA D's employee file revealed a hire date of [DATE]. NCNA D completed Abuse/Neglect training on [DATE] (nearly 5 months after hire). HR F reported no additional Abuse/Neglect education completed prior to [DATE] was available in NCNA D's employee file (indicating it was not completed upon hire). NCNA D did not have an Initial Competency Checklist on file to ensure NCNA D had the knowledge and skills required to provide resident care and did not have an active CNA certification (as of [DATE]). NCNA D was not eligible to work as of [DATE] (per NHA). Review of the Staffing Log and the Nursing Department Daily Staffing revealed NCNA D worked the following shifts in the capacity of a CNA on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of RN U's employee file revealed a hire date of [DATE]. RN U did not have an Initial Competency Checklist on file to ensure RN U had the knowledge and skills required to provide nursing care. Review of the Staffing Schedule and Nursing Department Daily Staffing from [DATE] to present revealed RN U was not on orientation and worked independently as an RN. Review of RN E's employee file revealed a hire date of [DATE]. RN E did not have a current CPR certification and did not have an Initial Competency Checklist on file to ensure RN E had the knowledge and skills required to provide nursing care. The RN Initial Competency Checklist includes an evaluation of Medication Administration and Reporting Systems (physician notification). Review of the Staffing Schedule and Nursing Department Daily Staffing from [DATE] to present revealed RN E was not on orientation and worked independently as an RN. (HR F verified that RN E did not have a current CPR certification). Review of RN A's employee file revealed an Employee Counseling Notice (write-up) dated [DATE] which revealed, Violation Date [DATE] .(RN A) did not follow orders as written for end of life comfort and did not document reason or notify hospice why medications were held .Resident fell later that day, possible root cause end of life restlessness not managed as ordered .(RN A) will follow doctor's orders as written and if have any concerns r/t (related to) orders or holding medications. Document notification of provider medications held .educated nurses on end of life medication s/s (signs and symptoms) of pain in dementia residents-notification of providers if med held .Follow Up Date (blank) .(RN A refused to sign the counseling notice). No documentation that Previous DON or current DON had completed a follow-up evaluation/medication administration competency after the identified medication administration error. Review of Resident #14, #30, #15, #9 and #20's December and January Medication Administration Records (MAR) reflected multiple medication administration errors (administering expired insulin, withholding medications without a physician order, and/or giving medications outside of physician ordered parameters) committed by RN A and RN E. (Refer to noncompliance cited at F658-Services Provided Meet Professional Standards related to medication administration.) Review of the Facility Assessment last revised/reviewed [DATE] revealed, .Staff training/education and competencies 3.4. (Healthcare training company name omitted) online learning system is used to track and provide all annual educations to facility staff at all levels, consistent with their roles. All departments as well as contracted services and volunteers receive abuse training on hire and annually. Licensed nurses receive annual skills check to verify clinical competencies . The Facility Assessment did not include a competency-based approach for Certified Nurse Aides to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. The Facility Assessment did not include or address an evaluation of the facility's training program to ensure training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.

This citation pertains to intake MI000131812 Based on observation, interview, and record review, the facility Governing Body failed to meaningfully engage in operational oversight of the facility to ensure all residents residing in the facility attained/maintained their highest practicable well-being as evidence by: 1.) failed to ensure a sufficient number of competent and qualified licensed nurses, nurse aides, and other nursing personnel to provide quality care and meet the resident's needs, 2.) failed to provide adequate resources to the facility to ensure resident safety when the Fire Monitoring System was disconnected due to non-payment unbeknownst to facility administration, and 3.) failed to ensure corporate policies and the Facility Assessment were reviewed, revised, and implemented to manage operations in the facility. This deficient practice resulted in the mismanagement of the facility, inadequate and incompetent direct care staff, and the potential for serious adverse physical, mental, and psychosocial harm for all residents residing in the facility. Findings: During an interview on 1/20/2023 at approximately 11:00 AM, the Nursing Home Administrator (NHA) reported the facility learned the fire alarm system was not communicating with the security/monitoring company when a routine fire drill was conducted on 10/27/2022. The reason for the system failure was due to non-payment to the fire monitoring/security company and was not known prior to the fire drill. According to the NHA, corporate accounts payable (AP) has been having issues with timely bill payment. When asked, the NHA said the cable television was shut off for approximately 3 days over the holiday season, confidential information/document shredding service was not paid timely in the past, trash removal was an issue in July 2022 and a supply company account was inaccessible until the day prior (1/19/2023) due to non-payment, making purchases of needed equipment and parts impossible. According to the NHA, a transportation company account was not paid timely which put residents who required transportation to outside appointments/dialysis at risk for missing critical access to services. The NHA reported that the AP manager was difficult to communicate with and in order to get financial matters resolved she would call or email COO L who would handle the matter. During an interview on 1/24/2023 at 8:52 AM, Chief Operating Officer (COO) L reported that the corporate body switched Accounts Payable systems 7-8 months ago due to recognition of the former accounting system not working. COO L reported that now all invoices are sent to a system that each facility administrator approves expenses and checks are cut according to terms of the contracts with each vendor. COO L emphasized that individual NHA administrators throughout the corporation have no direct control over AP other than to approve/validate expenses. It was identified during the onsite survey that the Governing Body, required to be involved in the Facility Assessment, did not ensure the Facility Assessment was comprehensive, accurate, complete, and implemented which resulted in the following deficiencies: 1. Based on observation, interview, and record review, the facility failed to ensure a sufficient number of competent staff to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical condition, and plan of care. (Refer to noncompliance cited at F725-Sufficient Nursing Staff) 2. Based on observation and interview the facility failed to keep kitchen equipment in a state of repair that would allow for regular use and operation of the machines. (Refer to noncompliance cited at F908-Essential Equipment in Safe Operating Condition). 3. Based on interview and record review, the facility failed to ensure a fire monitoring system was functional for 15 days (10/25/2022-11/09/2022) without a report to the State Agency and without a Fire Watch implemented. (Refer to noncompliance cited at F689-Free of Accident Hazards/Supervision/Devices). It was identified during the onsite survey that the Governing Body, aware of the staffing concerns at the facility, failed to provide resources to ensure a sufficient number of Administrative/Managerial Nursing staff to 1.) monitor nursing staff for compliance with nursing standards of practice (medication administration, documentation) and complete evaluations, 2.) oversee and supervise development and delivery of in-service education, 3.) ensure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services and 4.) ensure the ICP (Infection Control Preventionist) had the time necessary to properly assess, develop, implement, monitor, and manage the Infection Prevention and Control Program resulting in the following deficiencies: 1. Based on interview and record review, the facility failed to complete a Comprehensive Significant Change Minimum Data Set (MDS) assessment for 1 resident (Resident #7) and failed to accurately complete Minimum Data Set (MDS) assessments for 1 resident (Resident #9). (Refer to noncompliance cited at F637-Comprehensive Assessment After Significant Change and F641-Accuracy of Assessments). 2. Based on interview and record review, the facility to ensure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs, resulting in medication errors for Resident #9, #14, #30, #17, #15, and #20 and incomplete/inaccurate medical records for R15. (Refer to noncompliance cited at F658-Services Provided Meet Professional Standards, F726-Competent Nursing Staff, and F842-Resident Records). 3. Based on interview and record review, the facility to implement an effective and current system of surveillance of resident and staff illnesses to identify possible communicable diseases and infections for all residents and staff to prevent the spread of an illness/outbreak and failed to ensure a complete and accurate outbreak investigation for a COVID-19 outbreak and document follow-up activity in response to the outbreak. (Refer to noncompliance cited at F880-Infection Prevention and Control).

Based on observation, interview and record review, the facility failed to 1.) ensure a complete and comprehensive assessment was completed, 2.) follow facility assessment to ensure sufficient staffing to meet the resident needs, 3.) determine staff training, education, and competencies required to care for residents in the facility, and 4.) ensure the facility assessment was reviewed annually and updated to reflect administrative staff, resulting in unmet care needs, insufficient competent direct care staff, inaccurate information, and the potential for residents to not meet their highest practicable level of wellbeing. Findings: Review of the Facility Assessment revealed it was last revised/reviewed 10/26/22. Prior to the 10/26/22 assessment, the facility had not completed an annual review since 2/24/21 (approximately 20 months). The Facility Assessment did not reflect the current Nursing Home Administrator (NHA) or Director of Nursing (DON). Review of the State Agency Administrator Facility History revealed NHA assumed the role on 3/10/22 and DON assumed the role on 8/9/22. Review of the Facility Assessment revealed, .Staff training/education and competencies 3.4. (Healthcare training company name omitted) online learning system is used to track and provide all annual educations to facility staff at all levels, consistent with their roles. All departments as well as contracted services and volunteers receive abuse training on hire and annually. Licensed nurses receive annual skills check to verify clinical competencies . The Facility Assessment did not include a competency-based approach for Certified Nurse Aides to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. The Facility Assessment did not include or address an evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. During an interview on 1/20/2023 at 9:18 AM, NHA reported the facility did a bed reduction plan to decrease staff to resident ratios by 5 beds from July-December 2022. NHA reported the facility was running 1 CNA short for the 1st shift and 1 licensed nurse (RN/LPN) short for 2nd shift, and to reduce the workload, the facility would not admit residents that required total assist and only residents that required minimum to moderate assist were admitted . The Facility Assessment did not include the bed reduction or workload reduction plan to accurately reflect the type of resident care needs the facility could admit and/or provide care for. During an interview on 01/20/2023 at 9:11 AM, NHA reported that based on the Facility Assessment and the resident acuity level, the Certified Nursing Assistant (CNA) to resident ratio should be 1:10 to 1:12 (1 CNA for 10-12 residents) and a ratio of 1:8 would be ideal. NHA reported that staffing 3 CNAs on 1st shift, 2.5 CNAs on 2nd shift, and 2 CNAs on 3rd shift is the goal. NHA reported that the facility is not consistently staffed based on the Facility Assessment staffing plan. Review of the Facility Assessment Staffing plan revealed: 3.2. Our facility is relatively small in size making the staffing plans unique to ensure appropriate staffing is provided to meet the needs of all patients. The table listed below describes the basic facility staffing needs required to care for patients within our average census patterns. In relation to direct care staffing of nurses and nursing assistants, we staff with consideration of our daily census and flex staff up or down in relation to patient acuity. Our facility uses a basic guideline as below in relation to direct care staffing. Adjustments are made in relation to acuity and census. Licensed Nurses (LN): RN, LPN providing direct care- DON (Director of Nursing): 1 DON RN (Registered Nurse) full-time Days Clinical Care Coordinator/MDS: 1 RN full-time days RN or LPN (Licensed Practical Nurse) Charge Nurse: 2 for each shift am, pm, 1 nurse noc (night) shift 1:x 17 ratio Days and Evenings 1:x 35 ratio Nights An RN is scheduled 8/24 hours daily to meet the RN coverage requirement. Certified Nurse Aide (CNA): providing direct care- 1:8 ratio Days (total licensed or certified) 1:12 ratio Evenings 1:15 ratio Nights These numbers are baselines and are adjusted as needed in relation to patient acuity. During the initial tour of the kitchen, on 01/18/23 at 10:14 AM, it was identified that the facility kitchen equipment was in a state of disrepair: facility ovens, flat top burner, burners for the range top, and three under burner ovens. Review of the Facility Assessment revealed that kitchen equipment was not included in the process to ensure physical equipment was maintained to protect and promote the health and safety of residents related to Physical environment and building/plant needs. During an interview on 1/20/2023, the Nursing Home Administrator (NHA) reported the facility learned the fire alarm system was not communicating with the security/monitoring company when a routine fire drill was conducted on 10/27/2022. The reason for the system failure was due to non-payment to the fire monitoring/security company and was not known prior to the fire drill. Review of the Facility Assessment revealed that fire monitoring/security company was not included in the process to ensure services were maintained to protect and promote the health and safety of residents related to Physical environment and building/plant needs During an interview on 01/24/23 at 10:12 AM, Chief Operating Officer (COO) L confirmed that the Facility Assessment required revision and would be completing an updated assessment with NHA.

Based on interview and record review, the facility failed to identify and implement appropriate plans of action to correct quality deficiencies necessary to assure residents attain and maintain the highest practicable level of well being, resulting in the potential for serious negative physical and psychosocial outcomes for all 35 residents residing at the facility. Findings include: Review of sampled residents revealed concerns with blood sugar monitoring, physician notification, clear monitoring parameters and diabetes control medication administration for R1-5, R1-7, R1-15, R1-18, and R1-102. Review of previous 2567 dated 1/24/23 with a plan of correction date of 2/17/23 revealed concerns with the insulin administration and blood sugar monitoring for R1-15 and R1-30. Plan of Correction (POC) audits completed by the facility revealed the insulin orders for R1-5, R1-7, R1-5, R1-18, and R1-102 we all reviewed. Subsequent audits were completed with the questions was insulin given per physician orders and if insulin was held was it accurate due to parameters? Was physician notified? In a 2/12/23 audit, concerns were indicated and educated staff to put note on board for provider when insulin held. The alleged date of compliance was 2/17/23. Subsequent audits on 2/21/23 and 3/3/23 failed to identify concerns with residents on insulin even though both audits included R1-5, R1-15, R1-18, and R1-102. During an interview completed with the NHA, DON and RDN on 3/7/23 at 2:25 PM monitoring of residents diagnosed with diabetes was discussed. It was shared the orders for residents are very confusing, with blood sugar monitoring being linked to medications, some medications include only a high parameter to contact the physician, some include only a low and inconsistent contact with the physician when residents. The NHA stated they will be working on better charting action plans and will increase the frequency of auditing. The DON stated she planned on ensuring they standardize insulin orders and have talked to the medical director and physician assistant regarding this. Nursing staff will also be educated regarding insulin, and they are starting education with Certified Nursing Assistants to better recognized signs and symptoms of hyper and hypoglycemia. Review of sampled residents revealed concerns with blood pressure monitoring, clear monitoring expectations and blood pressure medication administrations for R1-30 and R1-101. Review of previous 2567 dated 1/24/23 with a plan of correction date of 2/17/23 revealed concerns with blood pressure medication administration with R1-30. The POC audits did not address R1-30 or any other resident on blood pressure administration. When asked why blood pressure monitoring was not included in review of the facility's continued compliance an email was received on 3/7/23 at 2:01 PM in which RCC K responded: Our plan of correction was approved for the material that was submitted, which only included audits of insulin. We have met auditing compliacnce (sic) with the accepted plan of correct but will complete addition education (sic) as needed in regards to docuemntation (sic) of other medication parameters as ordered. They included screenshot of a statement from their consultant pharmacist that the consultant pharmacist reviews blood pressures monthly and irregularities are reported to the physician. During an interview completed with the NHA, DON and RCC K on 3/7/23 at 2:25 PM the lack of focus on blood pressure management and monitoring was discussed and the concern that a previously cited resident (R1-30) was not reviewed by their audits and continuing concerns were found. According to the CMS 2567 form dated 1/24/23 with a plan of correction of 2/17/23, in reference to F686 for pressure ulcers revealed that R1-22 was previously cited for failure to prevent and promote the healing of pressure ulcers. The policies the facility used for training staff were also reviewed. R1-22 was selected for the revisit survey and all aspects of pressure ulcer prevention and management were reviewed. R1-22's Weekly Skin Sweeps were found to be an inaccurate reflection of his skin condition and the weekly wound assessments were missing measurements and individual wound descriptions. Observations made during the onsite survey revealed care planned interventions were not in place for R1-22, resulting in the development of 2 new pressure ulcers after the date of compliance. R1-101's Weekly Skin Sweeps were found to be an inaccurate reflection of her skin condition and there were no weekly wound assessments done for her diabetic ulcer after the compliance date. According to the CMS 2567 form dated 1/24/23 with a plan of correction of 2/17/23, in reference to F908 the plan of correction reflected, The facility oven was inspected by licensed technician and in working order. Also inspected flat top burner and is in working order . According to the Oven/Stove audit completed by DM B (undated), reflected, Was the oven working properly all week, and Y for yes was circled. On 3/1/23 at approximately 3:15 PM, the Surveyor observed the unit not functioning properly upon the start of the onsite survey and was unable to validate the plan of correction as written and accepted by the state agency. The NHA stated that she submitted a request to corporate for a new unit but there was no evidence it was acted on before the start of this survey. The facility did provide a copy of a purchase receipt for a new unit before the exit of the survey. The audit did not reflect the ongoing deficient practice.

Based on interview and record review, the facility failed to implement facility Infection Prevention and Control policies and procedures and ensure the ICP (Infection Control Preventionist) had the time necessary to properly assess, develop, implement, monitor, and manage the Infection Prevention and Control Program for the facility resulting in the following: 1.) failed to review or revise the Infection Prevention and Control Program policies and procedures at least annually, 2.) failed to implement an effective and current system of surveillance of resident and staff illnesses to identify possible communicable diseases and infections for all residents and staff to prevent the spread of an illness/outbreak, and 3.) failed to ensure a complete and accurate outbreak investigation for a COVID-19 outbreak and document follow-up activity in response to the outbreak. This deficient practice placed all residents residing in the facility at risk for the potential of the development and spread of disease and infection and the potential for an outbreak to go undetected. Findings: Infection Control Program Annual Review During an interview on 01/20/23 at 12:54 PM, Director of Nursing (DON) reported that the Infection Control Program policies were to be reviewed and/or revised annually and that was completed at the Corporate level. DON reported the policies provided (dated 12/2020) were the most up to date policies available and utilized by the facility. Surveillance During an interview on 01/20/23 at 12:54 PM, DON reported that if a staff member calls off of work related to an illness, they must report a reason for the call off and include symptoms on the call-in form. DON reported that any facility staff member can take the employee illness report to document on the call-in form and a licensed nurse is not required. DON reported that Health Information Coordinator (HIC) V tracks employee call offs and at the end of each month the Employee Illness Log is reviewed. DON reported that if call-in form is not completed there would be no way to track a potential outbreak. DON reported that if similar symptoms/illness are identified, an outbreak investigation is conducted at the end of the month. DON reported that the system for tracking employee call-ins needed to be improved and confirmed that tracking employee call-ins in real time was necessary to identify outbreaks and prevent the spread of a communicable disease/illnesses to other staff and residents. DON reported that the criteria to return to work after symptoms was to be symptom free for 24 hours. A process to ensure employee symptoms were resolved for 24/48 before returning to work was not provided. Review of the Employee Illness Log revealed, .Employees with diarrhea or vomiting must be excluded from work for at LEAST 24 hours after symptoms are gone. Food Service Workers with diarrhea or vomiting must be excluded from work for at LEAST 48 hours after symptoms are gone. Review of the Infection Control Surveillance Log revealed no September 2022 Employee Illness Log. Review of the October 2022 Employee Illness Log revealed that on 10/8/22 Non-Certified Nurse Aide (NCNA) D called off work for vomiting, fever diarrhea and returned to work on 10/9/22. (Date and time symptoms resolved were not reflected on the form to ensure 24 hours symptom free). Certified Nursing Assistant (CNA) H tested positive for Covid on 10/11/22 was not added to the Employee Illness Log. Review of the November 2022 Employee Illness Log revealed that on 11/7/22 a previous staff member called off work for vomiting and returned to work on 11/8/22. (Date and time symptoms resolved were not reflected on the form to ensure 24 hours symptom free). On 11/8/22 HIC V called off work for no reason given and returned to work on 11/9/22. Review of the December 2022 Employee Illness Log revealed that on 12/7/22 Registered Nurse (RN) A called off work for diarrhea and returned to work 12/8/22. (Date and time symptoms resolved were not reflected on the form to ensure 24 hours symptom free). Review of the Infection Control Surveillance Log revealed no January 2023 Employee Illness Log. Review of the January Staffing Schedule revealed Licensed Practical Nurse (LPN) X was removed from the schedule on 1/2/23 for sick and was removed from the schedule on 1/3/23 for CI (call in) without further documentation. On 01/24/23 at 10:25 AM a copy of the September 2022 and January 2023 Employee Illness Log was requested. During an interview via email at 01/24/23 at 11:39 AM, DON stated, No Ill Call (no employees called in sick) for January 2023 to date. I am working on an AdHOC QAPI (when necessary Quality Assurance meeting) to make sure I am tracking illness in real time going forward. Included in the email communication was a September 2022 Employee Illness Log completed/signed by the DON on 1/23/23. Confirming it had not been completed throughout September 2022. Outbreak Investigation During an interview on 01/20/23 at 12:51 PM, DON and Nursing Home Administrator (NHA) reported the last COVID outbreak was in May of 2022. Review of the Infection Control Surveillance book revealed a Surveillance Line List form (no date) not filed under the September or October surveillance tabs (among other loose documents in the front pouch of the binder). The Surveillance Line List reflected 2 facility staff members and 2 residents with Covid positive results. Review of the Surveillance Line List revealed: 1. Resident 4 was listed as testing positive on 9/30/22 and was asymptomatic 2. Licensed Practical Nurse (LPN) AA was listed as testing positive on 10/18/22 with symptom onset date of 10/18/22. Review of LPN AA's COVID-19 Case Reporting Form revealed LPN AA was asymptomatic. Review of the Health Department notification revealed they were not notified of LPN AA's positive Covid result until 10/24/22. 3. Resident 139 was listed as testing positive on 10/18/22 and was asymptomatic 4. CNA BB was listed as testing positive on 10/3/22 with symptom onset on 10/3/22. Review of CNA BB's COVID-19 Case Reporting Form revealed symptom onset of 9/30/22. MM Z was not reflected on the Surveillance Line List (no documentation of symptoms, onset of symptoms, testing date, resolution of symptoms, or primary floor assignment). Review of the Health Department and facility communication (emails) revealed on 10/17/22 DON reported one staff member tested positive today . No documentation provided identifying the staff member. The unidentified staff member was not reflected on the Surveillance Line List (no documentation of symptoms, onset of symptoms, testing date, resolution of symptoms, or primary floor assignment) Review of the Health Department and facility communication (emails) revealed on 10/20/22 DON reported that CNA H had tested positive for Covid on 10/11/22. CNA H was not reflected on the Surveillance Line List (no documentation of symptoms, onset of symptoms, testing date, resolution of symptoms, or primary floor assignment). The Surveillance Line List did not include 3 positive staff members, was not in chronological order (indicating outbreak tracking/tracing was not concurrent with the testing), and did not reflect accurate symptoms and/or symptom onset dates. During an interview on 01/24/2023 1:33 PM, DON and NHA reported that residents and staff had tested positive for Covid beginning in September 2022 prior to DON assuming the DON role (DON assumed role October 2022) and the outbreak had resolved quickly. DON reported the first Covid positive result was identified on 9/23/22 for a Management Member (MM) Z (title omitted for privacy). DON and NHA reported that following the positive result, facility wide (residents and staff) testing was initiated beginning on 9/23/22 and again on 9/30/22. DON reported that the resident testing and family notification was documented in the Electronic Health Record. DON and NHA reported that they did not have an investigation of the Covid outbreak and were unable to provide documentation of the actions the facility took to prevent the spread of Covid, the date the investigation began, the date the first Covid positive staff was identified, the date that other residents and staff were tested, or the Covid testing results of the facility staff. Review of the State Operations Manual revealed, IP (Infection Preventionist) Hours of Work- Designated IP hours per week can vary based on the facility and its resident population. Therefore, the amount of time required to fulfill the role must be at least part-time and should be determined by the facility assessment, conducted according to §483.70(e), to determine the resources it needs for its IPCP, and ensure that those resources are provided for the IPCP to be effective. Based upon the assessment, facilities should determine if the individual functioning as the IP should be dedicated solely to the IPCP. A facility should consider resident census as well as resident characteristics, types of units such as respiratory care units, memory care, skilled nursing and the complexity of the healthcare services it offers as well as outbreaks and seasonality of infections such as influenza in determining the amount of IP hours needed. The IP must have the time necessary to properly assess, develop, implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees such as QAA. Review of the Centers for Medicare & Medicaid Services Center for Clinical Standards and Quality/Survey & Certification Group memorandum QSO-20-38-NH revised on 9/23/22 revealed, .Facilities must demonstrate compliance with the testing requirements. To do so, facilities should do the following: *For symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results. *Upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested, the dates that staff and residents who tested negative are retested, and the results of all tests (see section Testing of Staff and Residents During an Outbreak Investigation above). *Document the facility's procedures for addressing residents and staff that refuse testing or are unable to be tested, and document any staff or residents who refused or were unable to be tested and how the facility addressed those cases. * .Facilities may document the conducting of tests in a variety of ways, such as a log of community transmission levels, schedules of completed testing, and/or staff and resident records. However, the results of tests must be done in accordance with standards for protected health information. For residents, the facility must document testing results in the medical record. For staff, including individuals providing services under arrangement and volunteers, the facility must document testing results in a secure manner consistent with requirements specified in 483.80(h)(3). Review of the Facility Assessment last reviewed/revised 10/26/22 revealed, .3.11. We have an infection control policy that supports and follows national standards as well as CMS requirements. A Registered Nurse is designated as the Infection Control Nurse. This nurse provides leadership in the process. Infections are initially tracked on an Infection report which uses a McGreer's Criteria format for identification of infection. Infections are also tracked by type of infection, location of patient in facility to evaluate for trends or patterns, and MDRO's. Staff and volunteer symptoms are evaluated for trends or patterns. A proactive approach is taken to Infection Control process with focus on prevention. Staff receives education annually and as needed to remain current with guidelines and recommendations. The Infection Control Nurse remains current on Infection Control practices including Antibiotic Stewardship and it is his/her role to continually build education and improve Infection Control practices within the facility. Infection control practices and documentation are spot checked by a clinical consultant who holds a certificate specializing in Infection Control. This consultant is also referenced as needed if questions arise. Review of the facility policy Infection Prevention and Control Program last reviewed/revised December 2020 revealed, .1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases . 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections, ectoparasites and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's QAPI committee. c. The RNs and LPNs participate in surveillance through assessment of residents and reporting changes in condition to the residents; physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases, ectoparasites and infections . 16. Annual Review: a. The facility will conduct an annual review of the infection prevention and control program . The facility did not provide a policy for the procedure for call-in tracking for employee illness.