**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI100145407. Based on interview and record review, the facility failed to ensure dignified and respectful treatment for three residents (R3, R5, and R69) of 28 residents reviewed for dignity, resulting in residents verbalization of feelings of helplessness, frustration, and discontentment when staff respond rudely when answering the call lights, repeatedly talk on their phones during care while ignoring the residents, and sit in resident's rooms when the resident is not present. Findings include: R3: On 9/10/24 at 9:40 AM, R3 said they felt ignored and disrespected by staff because, The CNAs (certified nursing assistants) sit on that [NAME] (sofa) right there (resident pointed to a sofa in the hallway) and play on their phones. They don't even hide it anymore. They just sit there ignoring us while they are on their phones. I came into my room the other day and a CNA was sitting on my chair on her phone. I was so upset. I told the manager about it, but nothing was done about it. R3 went on to say that this occurs regularly on the PM shift from the same staff members. R3 said this has been brought up in resident council meetings several times and nothing has changed. According to R3's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] and had no cognition impairment. The Minimum Data Set (MDS) dated [DATE] indicated that R3 had bilateral upper extremity impairment and needed assistance with all Activities of Daily Living (ADL). R5: On 9/10/24 at 9:26 AM, R5 said approximately two weeks ago when returning to their room from an activity the resident found two CNAs sitting on the resident's bed looking at their phones. R5 said, I was very upset they were in my room when I wasn't there. They were both sitting on my bed. I asked them why they were in there and they said they had to find their friend and were on facebook trying to figure out where their friend was. R5 said, They sit there and talk to each other in my presence in my room even when they are giving me a bath. I don't want to hear about their personal lives. They don't even include me in the conversation. It's like I'm not even there. It's awful feeling like that. R5 said they did not report this to the manager at this time because they felt helpless because nothing had been done to stop this from earlier complaints. R5 also said that the same two CNAs often sit on the sofa in the hallway and talk to each other or look on their phones instead of checking in on the residents. According to R5's EHR the resident has resided in the facility since 5/20/19 and had no cognition impairment. The MDS dated [DATE] indicated that R5 required assistance for all ADLs. R69: On 9/11/24 at 11:40 AM, R69 said, Some of the CNAs on the afternoon shift are disrespectful and condescending. They either ignore us because they are on the phone the whole time or talk to us like we are two years old. R69 went on to say, When they answer the call lights they say 'What do you want?' or 'I don't have time for that right now, I'll come back.' then they shut the call light off and never come back. We told the manager several times but feel helpless because nothing changed. What can we do? We are at their mercy. R69 said, One time I was napping and woke up because I heard voices. A CNA was in my room, sitting on my chair on the phone while I was asleep. It upset me. It made me feel like I had no privacy. According to R69's EHR the resident had resided in the facility since 9/1/2023 and had no cognition impairment. The MDS indicated that R69 had impairment to one upper extremity and required assistance with all Activities of Daily Living (ADL). On 9/11/24 at 11:02 AM, nurse manager, Registered Nurse (RN) B was asked about use of cell phones during resident care. RN B said, It is in the employee handbook that they (staff) are not supposed to be on their phones during work hours. They can use their phones during their break, but not during care. RN B said she had never heard that CNAs were in resident's rooms sitting on the resident's beds/chairs. RN B said, That's a concern. We will be having an education on that. On 9/11/24 at approximately 12:00 PM the Director of Nursing (DON) was asked about staff's use of cell phones and said, The staff are educated on that. They know they are not supposed to be on their phones during work hours. It is in the employee handbook and I believe there is a policy as well. The DON was unaware that residents had found staff in their rooms sitting on the resident's furniture without an invitation. The DON said that type of behavior would not be considered appropriate. On 9/12/24 at approximately 11:00 AM staff member D who wished to remain anonymous said that she had witnessed staff members looking at their phones while in a resident's room when the resident was not present. Staff member D said that she had notified a unit manager but nothing was really done about it. According to the facility's Telephone, Pager and Electronic Device policy last revised 12/14/2023, reads in part; It is the policy of this facility that, unless specifically designated otherwise, cellular phones . or any other electronic devices are not permitted to be worn or used in any area outside of the designated staff member break room. According to the facility's Resident Rights policy last revised 5/14/2024, reads in part; The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI100145407. Based on interview and record review, the facility failed to act promptly on grievances and concern forms reported in resident council meetings and provide responses and resolutions for two grievances filed in the last four months, as reported during confidential resident council meetings, resulting in unresolved resident concerns, residents expressing feelings of helplessness, and decreased quality of life. Findings include: Review of the Resident Council Meeting (RCM) Minutes, written by Activity Director (AD) C, dated 5/20/24 had the following nursing concerns; Complaints about Certified Nursing Assistant (CNA) E. Complaints about multiple staff in one room at a time. The complaints were not specified. A Resident Assistance Form, completed by AD C from the RCM dated 5/21/24 documented that CNA E was rude and had no bedside etiquette. There were no specific behaviors identified. The Facility Response section indicated that the staff member (CNA E) was educated. There was no specific education identified. Review of the RCM Minutes, written by AD C, dated 6/23/24 had the following nursing concerns; Complaints about multiple CNAs, including CNA E for repeatedly talking about their personal life and being on their cell phones during care, and something else that is whited out and unable to be seen. A Resident Assistance Form written by AD C, from the RCM dated 6/23/24 documented the following concerns; CNA E rude to residents. CNA E stated to a resident We are really busy, Let's get this over with, and What do you need now? The Facility Response section indicated that a manager would talk with staff member (CNA E) and the residents to ensure correct information. There was no additional follow-up documentation. Review of the RCM Minutes written by AD C for both 7/22/24 and 8/26/24 had no Old Business that listed follow-up from the last months minutes. There was no documentation to indicate the previous concerns from the 5/21/24 or 6/23/24 RCM had been resolved. On 9/12/24 at approximately 11:00 AM AD C was asked about the 'whited out' section on the RCM minutes for 6/23/24 and replied, The residents had complained about CNAs being rude and on their phones in May. The residents brought it up again in June, but then retracted it and did not want me to bring it up again, so I whited it out. AD C acknowledged that multiple residents continued to complain about CNA E at both the May and June RCM. AD C said, I did bring the resident's concerns to the manager and the Administrator. Review of the RCM minutes for both 5/21/24 and 6/23/24 included the Nursing Home Administrator's (NHA) signature. AD C could not say if the resident's concerns had been completly addressed to the resident's satisfaction. AD C could not explain why there were no Old Business notes on the July or August RCM minutes. R3: On 9/10/24 at 9:40 AM, R3 said they felt ignored and helpless because they had brought up concerns with certain staff members in resident council meetings several times and nothing has changed. The CNAs sit on that [NAME] (sofa) right there (resident pointed to a sofa in the hallway) and play on their phones. They don't even hide it anymore. They just sit there ignoring us while they are on their phones. I came into my room the other day and a CNA was sitting on my chair on her phone. I was so upset. I told the manager about it, but nothing was done about it. R3 went on to say that this occurs regularly on the PM shift from the same staff members. According to R3's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] and had no cognition impairment. The Minimum Data Set, dated [DATE] indicated that R3 had bilateral upper extremity impairment and needed assistance with all Activities of Daily Living (ADL). R5: On 9/10/24 at 9:26 AM, R5 said approximately two weeks ago when returning to their room from an activity the resident found two CNAs sitting on the resident's bed looking at their phones. R5 they did not report this to the manager at this time because they felt helpless because nothing had been done to stop this from their earlier complaints. According to R5's EHR the resident has resided in the facility since 5/20/19 and had no cognition impairment. The MDS dated [DATE] indicated that R5 required assistance for all ADLs. R69: On 9/11/24 at 11:40 AM, R69 said, We told the manager several times about CNAs being on their phone but feel helpless because nothing changed. What can we do? We are at their mercy. According to R69's EHR the resident had resided in the facility since 9/1/2023 and had no cognition impairment. The MDS indicated that R69 had impairment to one upper extremity and required assistance with all Activities of Daily Living (ADL). On 9/12/24 at 11:40 AM nurse manager, Registered Nurse (RN) B and the Director of Nursing (DON) was asked about the RCM minutes form 5/2024 and 6/2024 and said that the CNAs had received training and had write ups for those incidents. RN B said that she was unaware that the cell phone use in resident care areas had continued or that CNAs were in resident's rooms sitting on the resident's beds/chairs. On 9/12/24 at approximately 12:00 PM the Nursing Home Administrator (NHA) was asked to review the RCM minutes from April - August 2024. The NHA acknowledged there was white-out on the concern section for nursing department for June and then no follow-up on the July or August meetings. The NHA said she was aware there were concerns with CNAs and could not explain why there was no documented follow-up on the RCM minutes. According to the facility's Resident Rights policy last revised 5/14/2024, read in part; The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility These rights include the resident's right to: Voice grievances and have the facility responds to those grievances. According to the facility's Guest/Resident Council last revised 8/25/21 and effective 6/2/22, read in part: The Guest/Resident council provide a formal, organized means of guest/resident input in to facility operations. Procedure: 10. Minutes of the meeting will be recorded and maintained for at least two years. Minutes will not include residents names in regard to issues and complaints. 11. The Guest/Resident Council grievances and recommendations will be documented on the Guest/Resident Assistance Form The completed forms are brought to the attention of the Administrator who will forward the forms to the respective department head for attention and response. 12. Responses regarding resolution are to be documented on the Guest/Resident Assistance Form, reviewed by the Administrator and a copy of the completed forms are sent to [NAME], and kept with the Guest/Resident council minutes. 13. Action taken and/or considerations given to issues will be reported back to the Guest/Resident Council at the following meeting and documented within the minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly date-label food stored in resident refrigerators affecting all the residents who consumed food from the unit refrigerators resulting in unidentifiable resident items and the potential for food-borne illness. Findings include: On 9/11/24 at 8:53 AM unit refrigerators were observed with the Nursing Home Administrator (NHA, the following were noted: Pleasant View Unit -One 16-ounce opened used jar of Betty's dressing expiration date unknown. Evergreen Unit -One box of unlabeled opened [NAME] Dean breakfast sandwiches in freezer. -One box of unlabeled opened ice cream Drumsticks in freezer. -Two 20-ounce bottles of diet mountain dew unlabeled in refrigerator. The NHA agreed all food items should be labeled and dated. Only resident food should be stored in the unit fridges. On 9/12/24 at 9:28 AM the Director of Nursing was interviewed and said that nursing staff are responsible to maintain the unit refrigerators and agreed food items in unit refrigerators should be labeled and dated. Review of the facility policy titled Food from Outside Sources revised 11/12/2021 revealed in part .All food brought in is to be checked by the Nurse, Dietary Manager, or Dietician. It must be placed in a sealed container and labeled for the content, the guest's/resident's name and date the food was received, and an expiration date of 3 days after food was brought in. It is recommended that only enough food be brought in for that visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of employee to resident abuse (per R32) to the State Agency for one resident (R59) out of a sample of one resident reviewed for abuse, resulting in the potential for feelings of not being protected or safe within the facility, and for abuse to continue without being reported. Findings include: On 8/15/23 at 11:44 a.m., R32 said a report was made to the Nursing Home Administrator (NHA) about an incident that was witnessed (by R32) that occurred about 3 weeks ago, on a weekend day. R32 witnessed R59 kicked and yelled at by an aide at the nurse's station of the Meadowview Unit. R32 said the incident was reported to the NHA on Monday. R32 expressed concern about the incident because the aide continued to work at the facility after the incident was reported. On 8/15/23 at 3:05 p.m. the NHA was interviewed. The NHA said they were aware of the allegation made by R32. The NHA was asked was the incident reported to the State Agency. The NHA said the incident was not reported to the State, but an investigation was conducted. The facility concluded the incident did not occur. On 8/15/23 at 4:16 p.m. the NHA submitted a document titled Quality Assurance Interview Summary of Resident Interview. According to the report, the incident occurred on 7/10/23 (no time). R59 was interviewed but was unable to recall the incident. The staff member involved was interviewed on 7/11/23 (no time) and gave their statement of what occurred. On 8/16/23 at 9:49 a.m. review of the clinical record documented R59 was admitted into the facility on 6/15/21 with diagnoses that included Alzheimer's dementia and peripheral vascular disease. According to the quarterly Minimum Data Set assessment dated [DATE], R59 was severely cognitively impaired (brief interview for mental status/BIMS of 6) and required limited one person assist with activities of daily living. On 8/16/23 at 2:05 p.m. the NHA with the Director of Nursing (DON) present was interviewed about not reporting the incident to the State Agency. The NHA stated, I thought because it wasn't abuse that happened and after I investigated and unsubstantiated, I didn't have to report it. I was unaware I had to report allegations. Review of the facility's policy titled Abuse Prohibition dated 9/9/22 documented: The Administrator or designee will notify the guest's/ resident's representative. Also, any State or Federal agencies of allegations per state guidelines .

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure that the facility is free of pests resulting in an increased potential for contamination of food, both food and non-food contact surfaces, and foodborne illness potentially affecting staff, visitors and all 109 residents. Findings include: On 8/16/23 at 9:00 AM, three live flies were observed in the kitchen's dishwashing area. On 8/16/23 at 9:19 AM, two live flies were observed near the kitchen's janitors closet area. Upon observation the surveyor inquired with Dietary Manager staff A on the current state of the insects in this area to which they responded, We've had an issue with gnats and are in the process of starting with a new pest company. They have some new chemical that is supposed to help. At this time the surveyor requested the facility's pest control policy to review. On 8/16/23 at 10:08 AM, one live fly was observed on the kitchen's main food preparation table. On 8/16/23 at 11:13 AM, one live fly was observed in the kitchen's clean equipment storage room. On 8/16/23 at 11:36 AM, two live flies were observed near the kitchen's bread storage rack. On 8/16/23 at 2:43 PM, record review of the facility's most recent Commercial Services Agreement dated, 7/28/23 revealed under the section titled, scope and nature of work that specific targeted pests to be treated in the building were not listed. Instead, the document listed in the other box selected that, Actizyme Drain Cleaning Service (11 Drains), Fill Actizyme Dispenser (1 Gallon). Review of 2017 U.S. Public Health Service Food Code, Chapter 6-501.111 Controlling Pests, directs that: The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (B)Routinely inspecting the PREMISES for evidence of pests; (C)Using methods, if pests are found, such as trapping devices or other means of pest control as specified under §§ 7-202.12,7-206.12, and 7-206.13; Pf

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #76 In an observation on 6/8/22 at 10:56 a.m., Resident #76 (R76) laid in bed with eyes closed and wore a gown. In an observation on 6/8/22 at 1:17 p.m., rolled up linen with a brown spot the size of a basketball laid on R76's bed. R76 sat in a wheelchair and ate lunch. In an interview on 6/8/22 at 1:23 p.m., Certified Nursing Assistant (CNA) D reported she got R76 up at lunch time. CNA D reported she checked and changed R76 around 11:45 am. CNA D then reported she did not change R76 prior to 11:45. Review of an admission Record revealed, R76 admitted to the facility on [DATE] with pertinent diagnosis which included Parkinson's Disease, Functional Quadriplegia (paralysis in all four limbs) and Dementia. Review of a Minimum Data Set (MDS) assessment, with a reference date of 5/25/22 revealed R76 had mild cognitive impairment with a Brief interview for Mental Status (BIMS) score of 12, out of a total possible score of 15. R76 required extensive assistance of two staff with bed mobility and toilet use. Review of a Care Plan with focus (R76) is at risk for complications of altered elimination pattern r/t (related to) admitted with diagnosis of Parkinson's disease . with a initiated dated of 5/18/22. Interventions included . Check q (every) 2 hr and prn (as needed) for incontinence . with a initiated dated of 5/23/22. Based on observation, interview, and record review, the facility failed to ensure incontinence care was provided timely for two Residents (R76, R489) of 7 residents reviewed for activities of daily living (ADLs), resulting in the residents being soiled and uncomfortable for a long period of time, verbalized frustration, and the potential for skin breakdown. Findings include: R489 R489 was observed on 6/8/22 at 1:14 p.m., lying in bed alert and interviewable. An odor of feces-like odor was noted coming from R489's bed. R489's bed sheets were observed with dried feces prior to R489 pulling the covers back himself. After R489 pulled back the sheet and blanket, dried greenish and brownish feces was observed from his chest area to the lower legs. R489 start to point at his colostomy (A plastic bag that collects fecal matter from the digestive tract through an opening in the abdominal wall called a stoma .) bag and said, No, I'm not okay. R489 verified during an interview at this time that no one had been in his room that day to clean him up or assist with any ADL care. R489 said, They (staff) had been in the room only to give him his meal trays. A food tray was observed in a chair and a food tray was observed on R489's bed table. R489 said, Yes, I want to be cleaned up. R489' assigned Registered Nurse (RN) E and Unit Manager/Register Nurse F were summoned to R489's room for observation and interview. RN E agreed the feces appeared dried from chest to lower legs. RN E confirmed he did not see the assigned Certified Nursing Assistance (CNA) enter R489 to provide ADL care. UM/RN E said, No when asked did it appeared R489 had been provided with ADL care while she was preparing to assist R489 with ADL care. Um/RN E said, The last time I been in the room was about 10:00 this morning but did not turn the covers back to assess him. UM/RN said, Someone had to come in the room to bring his breakfast tray. UM/RN E denied after observing R489 that someone provided ADL care within two hours. R489 blue disposable brief was stuck to his upper back with greenish and brownish dried feces after UM/RN E assist R489 to a sitting positing in bed. A louder smell of a feces-like odor noted when R489 was assisted from a lying position to a sitting position. R489 said again while UM/RN F and RN E was assisting him with ADL care, that No one had been in the room to clean me up today (6/8/22). UM/RN F and RN E were then observed to provide a complete bed change due to R489 bed linen was covered in dried feces. During an interview on 6/8/22 at 3:05 P.M., DON 'B' verified that the facility's policy for ADL care is every two hours. On 6/8/22 at 3:10 p.m., the assigned CNA G was interviewed and said, his shift was from 6:45 a.m. through about 3:15: p.m. CNA G said, he is a regular on the unit and familiar with R489. CNA G said, About 7:20 a.m. before breakfast was the last time, I recall going into the resident's room to provide ADL care. Someone told me that the resident needed to clean up. I cannot recall going back into the room after 7:20 a.m. CNA G verified residents are to be check and provide ADL care every two hours. According to R489's electronic medical record, he admitted to the facility on [DATE] with diagnoses that included hypertension, anxiety, A-fibrillation, dementia, and Colostomy status. R19's annual Minimum Data Set (MDS) with a reference date of 4/22/22 indicated R489 was severely cognitively impaired with a BIMS (brief interview for mental status) score of 04. Required limited assistance of one person physically assistant with transfers, personal hygiene, and toileting. Required extensive assistance of one person for dressing and bathing. Review of the ADLs care plan-initiated date 1/16/21 and revision date 6/8/22 documented, R489 has an ADL self-care performance deficit and requires assistance with ADL's and mobility related to resident with recent re-admission from hospital with admission to hospice services for diagnosis of dementia, .Chronic obstruction pulmonary disease, a-fib, colostomy status . Interventions Assist with ADLs . According to the facility's Routine Guest/Resident Care policy revised date 6/16/2021 documented, Guest/Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Guidelines: 8. Incontinent care is provided timely according to each guests/resident's needs.