**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00141226. Based on interview and record review the facility failed to properly secure a resident in a wheelchair before transportation for one resident (R901) out of three residents reviewed for safety, resulting in R901's wheelchair tipping backward and the potential for injury. Findings include: Record review of R901's face sheet revealed admission into the facility on 5/28/21 with a pertinent diagnosis of End Stage Renal Disease. According to the Minimum Data Set (MDS) dated [DATE], R901 had intact cognition and required assistance with Activities of Daily Living (ADLS). During an interview on 12/12/23 at 9:27 AM, R901 reported that on 11/19/23 when leaving the dialysis center and returning to the facility Transportation Aide A turned onto the road and the wheelchair then tipped backwards. During an interview on 12/12/23 at 10:05 AM with Transportation Aide (TA) A it was reported that on 11/19/23 she had picked up R901 at dialysis facility. When turning onto the road, R901 was heard yelling, I am falling. It was further verbalized that the bus was immediately driven into the parking lot of a restaurant. When asked how the resident's wheelchair was able to tip backwards, TA A said, I did not tighten down the hooks causing the wheelchair to fall backwards. At conclusion of the interview, TA A stated, I should have made sure the hooks were tightened down before we left. During an interview with the Nursing Home Administrator (NHA) on 12/12/23 at 12:30 PM, it was reported that it was the responsibility of TA A to make sure the resident was secured before operating the bus. Record review of policy Resident Transport and Escort Services dated 12/30/2019 documented the following: 2. Wheelchair Restraint Systems: Vehicle will have a system in place to secure the wheelchair prior to departure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 79 residents who receive meal services (1 nothing by mouth residents, or NPO) out of the facility's total census of 80 residents. Findings include: 1. On 11/14/23 at 3:04 PM, an accumulation of dust, ice, and food debris was observed on the floor of the walk-in freezer. At this time upon interview with the Dietary Manager, staff A, the surveyor inquired if the facility had any policies in place regarding cleaning related job duties for staff to follow to which they stated, Yes. We do a deep clean in here monthly. At this time the surveyor requested a copy of the walk-in-freezer's cleaning policy to review. On 11/15/23 at 9:14 AM, the exterior of the ovens, stove top, and its surrounding area were observed discolored with heavy staining in sections. At this time the surveyor inquired with staff A on if they thought these areas were being cleaned timely and sufficiently to which they replied, not to my liking. At this time the surveyor requested a copy of the kitchen's cleaning policy to review. On 11/15/23 at 10:19 AM, record review of a document titled, cleaning and sanitizing freezer stated, walk in freezers should be routinely cleaned for sanitization. However, no specific time frame requiring the unit to be cleaned and sanitized was observed on this document. On 11/16/23 at 11:10 AM, record review of a document titled, cleaning procedure for equipment and utensils revealed that facility has systems in place to ensure proper cleaning and sanitizing of equipment occurs. Review of 2017 U.S. Public Health Service Food Code, Chapter 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, directs that: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 2. On 11/14/23 at 2:44 PM, an air gap of at least 1 and twice the diameter of the receiving drain was not observed present on any of the three-compartment sink's drain lines. At this time upon interview with the Dietary Manager, staff A, the surveyor inquired if there had been any recent changes to the plumbing system since the last survey to which they replied, I know about a two months ago after we had the flood they needed to replace a lot of things we could start using our kitchen again. Review of 2017 U.S. Public Health Service Food Code, Chapter 5-203.14 Backflow Prevention Device, When Required directs that: A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under § 5-202.13 P

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to demonstrate that one resident (R39) of five residents and/or their resident representative was made aware of the potential risk(s) or adverse consequences associated with a prescribed psychotropic medication (quetiapine) in a timely manner, resulting in the potential for diminished ability to make informed decisions regarding plan of care. Findings include: The clinical record for Resident #39 (R39) was reviewed and documented an initial admission date of 5/18/2022 and readmission date of 9/16/2022. R39's diagnoses included anxiety disorder, psychotic disturbance, mood disturbance, and Alzheimer's disease. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment and R39 received an antipsychotic medication all seven days of the MDS look back period. The clinical record also revealed an organization responsible for providing case management was granted full guardianship for R39. A review of a progress note dated 11/15/2022 documented in part the following: R39 was prescribed olanzapine as needed that was not effective. Patient was still anxious with increased blood pressure 171/132 and heart rate 102. Physician Y ordered olanzapine discontinued, to start R39 on quetiapine 25 mg nightly, and a psych consult. A review of physician's orders documented that 25 mg quetiapine once daily was initiated on 11/15/2022. During interviews on 1/25/2023 at 12:46 PM and again at 1:21 PM, the Director of Social Services, Social Worker (SW) J was queried about a consent for administering psychotropic medication, quetiapine, to R39. SW J said the nurse practitioner from the company that provided psychiatric services was responsible for calling the resident representative regarding medication changes and recommendations. A review of R39's clinical record, revealed that there was no indication that R39's resident representative was notified of the potential risk(s) or adverse consequences associated with quetiapine and/or gave permission to initiate quetiapine on 11/15/2022. SW J reviewed a progress note dated 12/7/2022 that indicated in part that R39 was evaluated by the psych nurse practitioner and recommendations were made to increase quetiapine 25 mg to twice daily. R39's physician and legal guardian were notified and agreed. During an interview on 1/25/2023 at 1:44 PM, Director of Nursing (DON) said the purpose of receiving consent prior to antipsychotic drug use was so the resident and/or resident representative understood the side effects. The DON was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and no substantially new information was provided. A facility document titled, Behavior Management Guidelines, dated 3/2022, was reviewed and revealed the following: Patients, families/responsible parties are educated regarding the risk/benefits of psychoactive medications prior to the first dose being administered. If required by the specific state, signed consents are obtained and retained in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00128672. R43 Based on observation, interview, and record review, the facility failed to ensure timely incontinence care was provided for one resident (R43) of 11 residents reviewed for activities of daily living (ADLS), resulting in the resident being soiled and uncomfortable for a long period of time, verbalized frustration, and the potential for skin breakdown. Findings include: On 1/22/2023 at 12:50 p.m., during an initial tour of the facility, R43 was observed lying in bed. There was a strong odor of urine around R43's bed. R43 was observed wearing a soiled disposable brief with a urine-like odor and a soiled incontinent pad underneath with brown rings. When interviewed, R43 verified no one had been in the room during the shift to assist with ADL care. R43 stated, They came in the room today, but not to change me. I am wet and need changing. On 1/22/23 at 2:30 p.m., Certified Nursing Assistant (CNA) T was observed in and out of several resident's rooms including R43's. CNA T was not available for an interview. According to the electronic medical record, R43 was admitted into the facility on [DATE] with diagnoses of dementia, and hypertension. R43's admission Minimum Data Set (MDS) with a reference date of 12/30/22 indicated R43 was cognitively intact with a BIMS (brief interview for mental status) score of 13. Required extensive assistance of one person physically assistant with dressing and toileting. Required extensive assistance of two person for transfers, bed mobility, hygiene and bathing. MDS assessment indicated R43 was frequently Incontinent of bowel and bladder. Review of the ADLs care plan with a revision date of 1/13/2023 revealed, ADL self-care deficit as evidenced by physical limitations, decreased mobility, incontinence, spinal stenosis, Alzheimer's disease, dementia, chronic pain, anxiety, major depressive disorder. Goal as following: -Will receive assistance necessary to meet ADL needs daily. Interventions as following: -ADL assist of 1. -assist with daily hygiene, grooming, dressing as needed. On 1/25/23 at 11:32 a.m., the Director of Nursing (DON) was interviewed regarding the time frame incontinent residents are to be checked and changed. The DON said, Residents should be checked and changed every two hours. If a resident has a brown ring on the incontinent pad and soiled, that's a bit excessive. I wouldn't think that resident had been checked and changed. On 1/25/23 at 12:13 p.m., Licensed Practical Nurse (LPN) U stated during an interview, I did not see the CNA (CNA P) go into room [ROOM NUMBER] Sunday (#43) at all. My shift starts at 7:00 a.m., but I did see CNA T go into his room (#43) and change him when he got here. She (CNA P) is here from 7:00 a.m. to 11:00 a.m. then CNA T came in at 1100 a.m. We are struggling with not having enough CNAs. On 1/25/23 at 12:53 a.m., CNA P, R43's assigned CNA for 1/22/23 day shift was asked during an interview, was R43 changed during the shift? CNA P stated, I was here four hours on Sunday. CNA P was then asked, how often does she check and change the residents? CNA P stated, I try to do it every four hours, two times is the goal. Sunday, I went into room [ROOM NUMBER] around 8:30 a.m. when we were passing trays for breakfast. He was trying to get out of bed, so I fixed his legs by moving them over. I just covered him up, not change him then. Honestly, I didn't go back in his room to check and change him. But I told CNA T the rooms I didn't get to. I get here at 6:45 a.m. and I left Sunday around 11:00ish (11:00 a.m.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to intake #MI00128412. Based on interview and record review, the facility failed to ensure one resident (R235) at risk for falls was assisted off the toilet out of four residents reviewed for accidents, resulting in the potential for a fall with injury(ies). Findings include: According to the facility reported incident (FRI) dated 4/24/22, R235 alleges that a nurse aide on afternoon shift on 4/24/22 was rough when providing care. Statement was taken from patient R235. Patient R235 stated, There was this Jamaican nurse aide on the afternoon shift who treated me like a ragdoll when I needed to go to the bathroom. She took me to the restroom and just set me next to the toilet and left me there and said she would be back. She did this twice .Statement was taken from nurse aide V who was identified to be the nurse aide working at the time of the alleged incident. Nurses' aide V stated she did not touch the patient. Nurses' aide V stated she brought in her dinner tray but when she came back in the patient hadn't touched it . Nurses' aide V stated when she came back in after that the patient had taken herself to the restroom and there was no call light on. Nurses' aide Then told the patient to notify her when she was done but she did not and when the nurse aide came in, R235 was lying in bed. She was at the edge of the bed but would not let the nurse aide move her to the middle . Nurses' aide V statement dated 4/24/22 revealed, .I gave her a dinner tray and she was sitting in the bed. I put the tray table in front of her and I asked if she wanted a sandwich instead and she said, 'maybe something'. When I came back in, she was lying in the bed like she was sleeping. I said mam are you going to eat the food and she said that is lunch and I said no, that's dinner. I just brought it in, and she said oh, that Is dinner and said it looks good, and she started eating it. I went back in the room, and she was no sitting in the bed, but she was in the bathroom. I checked on her and she was sitting on the toilet. I said, are you okay and I said please, please, just call when you are done. She did not say anything else, and she never called. When I came back in again, she was lying in bed. I never touched her. On 1/25/23 at 11:25 a.m., an unsuccessful attempt was made to contact Nurses 's aide V via telephone. Human Resource X confirmed Nurse's aide V was not a staff employee but was through the agency. According to the electronic medical record, R235 was admitted into the facility on 3/22/2019 with diagnoses of multiple fractures of ribs, left side injuries of the head, anxiety disorder, epilepsy, major depressive disorder, panic disorder, psychotic disturbance, dementia, difficulties in walking, and hypertension. R235's admission Minimum data Set (MDS) with a reference date of 4/29/2022 indicated, R235 had moderate cognition impairment with a BIMS (brief interview for mental status) score of 10, required extensive assistance of one-person physical assistance with bed mobility, transfers, dressing, toileting, and hygiene. R235 required limited assistance of one person with ambulation. Section G0300 of the admission assessment documented, 'Balancing during transitions and walking as following: -A. Moving from seated to standing position; not steady, only stabilize with staff assistance. -C. Moving on and off toilet: not steady, only able to stabilize with staff assistance. -D. Surface to surface transfer (transfer between bed and chair or wheelchair); not steady, only able to stabilize with staff assistance. Section H0300: Urinary Continent (always continent). Section H0400: Bowel Continent (always continent). - Review of R235's care plans revision date 5/13/22 documented as following: - Activity daily living (ADL): ADL self-care deficit as evidenced by other lack of coordination related to multiple fractures of ribs left side with routine healing. Interventions: Use gait belt with one assist and two wheeled walker to facilitate safe transfers. -Falls: At risk for falls due to impaired balance/poor coordination, poor safety awareness, self-transfers, at times does not use call light. Interventions: provide assist to transfer and ambulate as needed. -discharge: Resident is at risk for hospital readmission, most probable cause for readmission is safety. Review of the 'Falls' assessment dated [DATE] revealed, History of falls with a fall score of 13 indicative of a fall risk. During an interview with the Director of Nursing (DON) on 1/25/23 at 11:29 a.m., The DON was asked, should a resident that was a fall risk be left on the toilet alone? The DON stated, if they (CNAs) put them (risk for falls residents) there (On the toilet), they should be staying there. If the resident self-transfer themselves without assistance from the staff and the staff see the resident on the toilet, they should stand there with them, not leave them alone. According to the facility policy titled, Fall practice Guide issue date 12/2011, documented the following: -Purpose: The purpose of the falls practice guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Fall management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the patient's quality of life. The center utilizes the APIE framework as a systematic method to identify risk, select interventions to reduce the risk and monitor the effect on risk reduction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a timely nutrition assessment for one resident (R29) of one reviewed for weight loss with a PEG tube (Percutaneous Endoscopic Gastrostomy, enteral feeding through a tube placed in the stomach) resulting in the potential for unmet nutritional needs. Findings include. On 1/23/23 at approximately 9:30 AM, Nurse AA was observed to perform care. Nurse AA was observed to discontinue R29's tube feeding and flush R29's gastrostomy tube (PEG). Nurse AA explained that R29 recently had to have the PEG tube replaced because R29 is known to pull and tug on the tube. Record review revealed R29 was readmitted to the facility on [DATE] with diagnoses that included Aphasia, Stroke, and at Risk for Malnutrition. According to the MDS dated [DATE] R29 had severely impaired cognition and had a PEG intact. Review of facility records revealed R29 had lost weight while receiving tube feeding. Review of the R29's clinical record revealed a Quarterly/Enteral Nutrition Review dated 8/8/22 that documented, Resident remains under hospice care. Current weight is 128.4# with a BMI of 22. Stable weight at 30x, 90x and 180x days. Resident is NPO with EN via PEG tube. Current orders for continuous feedings of Jevity 1.5 at 40 ml/hr until 600 mls have infused; flush with 120 ml q4 hours. Provides: 900 kcal / 38 gms protein / 456 ml free fluid / 720 ml flushes / 1176 ml total fluids. Tolerating current enteral feeding. Skin remains intact. No change in nutrition plan of care at this time, patient is nutritionally stable. However, further clinical record review revealed no monthly nutrional assessments for R29 during the months of September 2022, October 2022, November 2022, or December 2022. On 1/25/23 at approximately 10:15 AM, the Registered Dietician explained that resident (R29) is high risk and should have a monthly assessement to determine nutritional needs.

Based on observation, interview and record review, the facility failed to implement an effective in-service training program for nurse aides that supported and ensured consistency in procedure for perineal care with 2 out of 3 Certified Nurse's Aides (CNA), (D, E, F), resulting in the potential for unmet resident care needs. On 1/23/2023 at 1:20 PM, during observations, CNA D approached surveyor and said, recently the certified nurse assistants were trained to perform perineal care by turning and repositioning residents away from self (rolling away). CNA D said, in the past, training for perineal care was to turn and reposition residents towards self (rolling towards). CNA D said, changes in the procedure for perineal care was not explained and that no additional education was provided. CNA D said, she had concerns as to which procedure is correct for resident care. On 1/24/2024 at 4:30 PM during interview, UM B, with 25 years at facility, was queried on explaining the procedure for perineal care, she said, I would need to read the policy. On 01/25 at 8:45 AM, during interview and observation, CNA E, an agency staff, with one year at facility was queried on the procedure with positioning residents while providing perineal care. CNA E demonstrated, to roll from side to side and roll away to clean resident. Then CNA E changed her answer and stated, no, I mean to roll resident towards self (gestured .with arms raising inward towards self) then clean for perineal care, is that right? On 01/25 at 9:00 AM, during interview and observation, CNA/Scheduler F, with one to 5 years at facility, was also queried on positioning and turning while performing perineal care. CNA F said, the procedure for perineal care was to roll resident away from self. On 01/25/2023 at 9:15 AM, during interview, Infection Control, Staff Development (ICSD), RN C with start date in September 2022, was queried of the training provided to CNAs on perineal care. ICSD, RN C stated I have not done this in years, I need to review the policy. When asked to describe procedures she had used in the past, she stated, rolled away, place clean pad, wipe to front to back, then roll back and remove the dirty brief. Facility Policy titled, Perineal care on Female, date revised, May 20, 2022 .Turn the patient onto the side to the Sims (left side) position . to expose the anal area. Facility Policy titled, Perineal care on Male, date revised, May 20, 2022 . Help the patient into a supine position (lying on back; face up) . Turn the patient onto the side, if possible, to expose the anal area. Neither policy explained the procedure for positioning while performing perineal care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI000128672. Based on observation, interview, and record review, the facility failed to consistently follow the facility-wide planned menu, resulting in resident dissatisfaction for five residents (#44, #58, #38, #57, and #59) of eight residents reviewed for meal acceptance and missed opportunities to serve expected meals to all residents consuming food from the kitchen. Findings include: A concern was reported to the State Agency regarding the lack of variety in the meals served to the residents. During a kitchen observation on 1/22/2023 at 11:43 AM, hot items included on the tray line for lunch meal service included fried chicken, mashed potatoes, mixed vegetables, green peas, green beans, and hot dogs. During an observation on 1/22/2023 at 1:57 PM, a menu posted in a resident's room documented the following hot foods were to be offered at lunch: fried chicken, mashed potatoes, and sliced carrots. The alternate meal offerings included: Italian sausage sandwich and green peas. During an interview on 1/24/2023 at 2:15 PM, a substitution log for lunch on 1/22/2023 was requested. Dietary Manager (DM) G stated, We haven't been doing a substitution log. DM G said the kitchen did not have carrots at lunch but served French [NAME] vegetables (a vegetable mix of green beans and carrots) instead. Italian sausage was not available, so they substituted hot dogs. DM G stated they are having to do a lot of substitutions. Sometimes it's (the food) not on the truck. A review of menus provided to residents was compared to food service documents titled, Daily Temperature Log. The daily temperature logs documented the food actually served to residents. This comparison revealed the following: On 1/9/2023 residents were to receive: Baked chicken breast with gravy, garlic mashed potatoes, Italian blend vegetables, chocolate brownie. Alternate entree was Italian Sausage with onions and peppers. Actual food served: Cheeseburger, tater tots, and brownie. On 1/10/2023 residents were to receive glazed ham, mashed sweet potatoes, green peas, and peach cobbler. Alternate choices included tuna salad sandwich and green beans. The actual food served included pork loin, stuffing, broccoli, tuna salad sandwich with chips, and cherry tart. On 1/11/2023 residents were to receive cream of broccoli soup with crackers, cheeseburger with lettuce, tomato & pickles, three bean salad, mandarin oranges. Alternate choices included Quiche [NAME] and carrots. The actual food served included chicken thighs, garlic mashed potatoes, peas & carrots, peas, mandarin oranges/peaches, and the alternate entree was supreme pizza. On 1/13/2023 residents were to receive devil's food cake for dessert but received chocolate chip cookies instead. On 1/14/2023 residents were to receive a veggie burger as an alternate entree. The actual alternate entree served was a cheeseburger on a bun. On 1/16/2023 residents were to receive a tuna melt as an alternate entree. The actual alternate entree served was a tuna salad sandwich. On 1/25/2023 at 10:11 AM during an interview, Registered Dietitian (RD) L stated the facility should follow the menu as posted so that patients can gauge what's coming and have something to look forward too, or if something is being served that they don't like, they can ask for a substitution. It's nice to have menus as a reminder of what's going to happen. RD L added that the kitchen notifies nursing about menu substitution and nursing notifies the residents. On 1/25/2023 beginning at 12:43 PM, three cognitively intact residents, Resident 23# (R23), Resident #44 (R44), and Resident #58 (R58), were individually and separately interviewed about menu substitutions. These interviews yielded the following comments: - R23 said they are not notified when the kitchen makes menu substitutions. - R44, stated, I wish they would serve what they are saying. They don't (tell us about menu substitutions). - R58 stated, (Expletive) no when queried if they were informed about menu substitutions. During an interview on 1/25/2023 at 12:35 PM, Registered Nurse W said they have not been notified of any menu changes this month. R38 On 1/22/23 at approximately 2:45 PM, R38 was observed in bed and was queried regarding any food concerns. R38 expressed dissatisfaction with the food served and stated, Flat out (a matter of fact) the menus are not being followed. Record review revealed R38 was admitted in to the facility on 6/24/21 with diagnoses that included Hypertension, Lymphedema, Respiratory Failure, Cataract (Blind in right eye). According to the MDS dated [DATE], R56 had intact cognition and was able to make her needs known. R57 On 1/22/23 at approximately 10:20 AM, R57 was observed up in a wheelchair at the bedside. R57 was queried regarding any food concerns and reported there is not enough salad and limited choices for the alternative meal. R57 explained that the facility lists the alternative, but when the alternative is ordered that is not what comes on the tray. R57 stated, The facility does follow the menu. Resident #57 was readmitted to the facility on [DATE] with diagnoses that included Osteoarthritis of hip, COPD, and Morbid Obesity. Per the MDS dated [DATE], R57 only required set-up for eating, had intact cognition, and was able to make his needs known. R59 On 1/24/23 at approximately 1:45 PM R59 was observed up in the wheelchair at bedside. R59 was asked about any food concerns and explained that she can not eat foods that cause a lot of gas because of her colostomy. Resident #59 reviewed the menu with the surveyor and identified brussel sprouts as the vegetable for dinner and carrots as the alternate vegetable for the night before and stated, I can not eat brussels sprouts. I asked for the alternate which was carrots. I received no alternate. They never send the alternate. They (CNA CC who called the kitchen ) told me they (the kitchen) just did not have it. I said, are they really gonna do this (not send any alternate) when the state is here?? Record review revealed R59 was readmitted in to the facility on 7/28/21 with Chrohn's disease and Depression. R59 explained that she had a colostomy. Per the MDS dated [DATE], R59 had intact cognition and was able to make her needs known.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00128672. Based on observation, interview, and record review the facility failed to staff the third floor to meet the needs of 12 residents (R68, R27, R64, R56, R38, R67, R59, R8, R29, R41, R5, and R66) of 20 residents reviewed for staffing concerns resulting in untimely/incomplete incontinence care, no set-up assistance for personal care, limited assistance with activities of choice, inconsistent supervision, and concerns with safety with subsequent refusal of care. Findings include: On 1/22/23 during the initial tour at approximately 10:30 AM, of the 20 residents on the third floor, two residents (R67 and R68) were observed in the dining/day room area with the television on and unsupervised. R67 and R68 were not within view of where Nurse BB stood to pass medication at the nurses station. Three residents were observed awake, dressed, and up at the bedside in their room (R42, R57, and R25). The remaining 15 residents were observed in bed. There was no additional staff assisting residents on the floor at the time of observation. R68 Record review revealed R68 was readmitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus and Depression. According to the Minimum Data Set (MDS) dated [DATE], R68 had moderate cognitive impairment. On 01/22/23 at 10:58 AM Nurse BB was queried regarding the nursing staff available for patient care for the 20 residents on the 3rd floor. Nurse BB reported there was one nurse and one Certified Nursing Assistant (CNA) present on the floor. Nurse BB explained that one nurse and one CNA is how the 3rd floor is usually staffed and that sometimes a CNA is scheduled to work the floor around noon. R27 On 1/22/23 at 11:27 AM, R27 was observed in bed and was queried regarding nursing staff. R27 explained that most of the time there are not enough staff to assist the residents. When asked what would he do if there were more staff available he stated, I would like to have been up about an hour ago so I could be working on my puzzle in the day room. I keep asking for someone but they keep telling me they are going to come back (to assist). Record review revealed R27 was readmitted into the facility on [DATE] with diagnoses that included Congestive Heart Failure, Stroke, Hemiplegia (weakness to one side/part of the body), and End-Stage Renal Dialysis. Per the Minimum Data Set (MDS) dated [DATE], R27 had intact cognition. R64 On 1/22/23 at 2:00 PM R64 was observed in bed with a full beard. R64 was queried regarding any staffing concerns and explained that he requires some set-up help in order to complete his routine of self-care. R64 stated, I can get up. I would like to clean my beard up. I would shave it all off if I had someone to assist me. I have some weakness from my strokes. I laid here for months and got weak. During the interview, R64 repeatedly touched his facial hair while explaining that he wanted a clean shaven face again. Record review revealed R64 was admitted to the facility on [DATE] with diagnoses that included CVA/Stroke, Hemiparesis, and Hemiplegia. Per the MDS dated [DATE], R64 had intact cognition. R56 On 1/22/23 at approximately 2:30 PM, R56 was observed in bed and was queried regarding staffing. R56 explained that most of the time 'up here' (3rd floor) residents have to wait on a shower. R56 said that earlier on this shift she had to wait to be changed but R56 is alright now. R56 stated, They need more help. It is difficult for one person to care for the entire third floor. It is not fair to the CNAs. Record review revealed R56 was readmitted to the facility on [DATE] with diagnoses that included Stroke and paraplegia. Per the MDS dated [DATE], R56 had intact cognition. R38 On 1/22/23 at approximately 2:45 PM, R38 was observed in bed and was asked about any concerns with staffing. R38 stated, There is not enough staff. If they had enough staff, I would be getting up in the morning, I would recieve set up help to wash (self) and comb my hair. R38 explained there was a problem with having a dry brief and a wet pad on yesterday (Saturday, 1/21/23). R38 stated, I tried to keep my feet and legs out of the pad. I told the nurse and the nurse told the aid to assist the resident. R38 explained how she had to lay on a wet pad from roughly 6:10 PM to 9:30 PM and that R38 telephoned her family member regarding how she felt having to wait so long for assistance. R38 stated, There are not enough aids to take care of the residents. One aid (CNA) is not enough. I do not think two aids are enough. Record review revealed R38 was admitted in to the facility on 6/24/21 with diagnoses that included Hypertension, Lymphedema, Respiratory Failure, Cataract (Blind in right eye). According to the MDS dated [DATE], R56 had intact cognition. On 1/23/23 at approximately 9:30 AM Nurse AA and CNA Z were queried regarding staffing on the 3rd floor when there are 9 identified residents who require a hoyer lift for transfer. CNA Z regular 3rd floor staff explained that staff get R67 up first thing because, we have a midnight shift nurse and CNA available to assist with the hoyer transfer until 7 AM. Staff were then queried how a check and change is performed throughout the shift for the 3rd floor residents. CNA Z and Nurse AA explained that they plan to lay R67 back down after lunch. The plan of care for R67 was planned. However, the explaination for one resident (R67) did not explain how the care and needs of the remaining 19 residents were addressed when one nurse and one aid are providing care to R67. LPN AA and CNA Z acknowledged that it can be difficult to provide resident care at times. R67 Record review revealed R67 was admitted in to the facility on [DATE] with diagnoses that included Facial Fractures, Post Traumatic Stress Disorder (PTSD), and at Risk for Malnutrition. According to the MDS dated [DATE], R67 was severely cognitively impaired. R59 On 1/24/23 at approximately 1:45 PM R59 was observed up in the wheelchair at bedside. When queried regarding any staffing concerns, R59 explained that one CNA on the 3rd floor is not enough. R59 stated, I give up my showers because I don't feel safe when the staff come in and have to rush. I do not know how they do it with one person. They come on at 7 AM and have to change everyone and get people up for breakfast, then assist for breakfast. Record review revealed R59 was readmitted in to the facility on 7/28/21 with Chrohn's disease and Depression. R59 explained that she was a left above the knee amputee. Per the MDS dated [DATE], R59 had intact cognition. Review of the facility-provided list titled, 3rd Floor Hoyer Lift Transfer dated 1/24/23, included a total of 9 residents that required 2 staff to assist with the mechanical transfer of a Hoyer lift. The list included the following residents: R8 - According to the MDS dated [DATE], R8 required extensive 2-person assistance with all Activities of Daily Living (ADLs) and transfers. ADLs include getting dressed, toileting, hygiene, and bathing/showering. R29 - According to the MDS dated [DATE], R29 required 2- person, total assistance with ADLs and transfers. R41 - According to the MDS dated [DATE], R41 required the total assistance of 2 staff for ADL care and transfers. R56 - Accordidng to the MDS dated [DATE], R56 required 2 person assistance with transfers. R38 - According to the MDS dated [DATE], R38 required extensive to total 2-person assistance with transfers. R5 - According to the MDS dated [DATE], R5 required extensive to total 2-person assistance with transfers. R59 - According to the MDS dated [DATE], R59 required extensive to 2-person assistance with transfers. R67 - According to the Significant Change MDS dated [DATE], R-67 was an extensive to total 2-person assistance with ADL care and transfers. R66 According to the quarterly MDS dated [DATE], R66 required the extensive assistance of 2 persons with ADL care and transfers. Of note transfers did not occur during the assessment period of the most recent MDS. On 1/25/23 at approximately 2:00 PM, the Director of Nursing (DON) and the Administrator (NHA) were interviewed regarding 3rd floor staffing concerns. The DON and NHA acknowledged there were 9 residents who required two staff for transfers and that the 3rd floor was often staffed with one Nurse and one CNA. When queried regarding the acuity of care on the 3rd floor, the DON and NHA acknowledged the high acuity of care. When asked the expectation of care, the DON explained that there is an effort to get half-a-staff (staff to work part of shift) but there are many call-offs (staff not reporting to work.) The DON stated, I have lost a lot of staff. When asked what is the purpose for the half-a-staff the DON responded, I know it's hard. Just to get people up, you need two people. It is hard to staff three separate floors. I understand that we are short of staff.

This citation pertains to intake MI00128788. Based on interview and record review, the facility failed to consistently ensure no more than 14 hours occurred between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, resulting in the potential for resident dissatisfaction and unmet care needs for all residents consuming food from the kitchen. Findings include: A concern was reported to the State Agency regarding timely meal service. On 1/22/2023 at approximately 11:07 AM, during a meeting with the Nursing Home Administrator (NHA), a CMS (Centers for Medicare & Medicaid Services) document titled, Entrance Conference Worksheet was reviewed which listed information requested from the facility. Item number 18 indicated a schedule of meal times for residents of the facility was needed. A document titled, Meal times, undated, was submitted during the survey by the NHA. A review of this document revealed the beginning breakfast and dinner mealtimes occurred at 7:45 AM and 4:45 PM respectively. During an interview on 1/24/2023 at 1:03 PM, Licensed Practical Nurse (LPN) H said a snack box comes up to the nursing unit from the kitchen after dinner. LPN H stated, Residents get one snack. If there are more left, they can have more. During an interview on 1/24/2023 at 1:49 PM Certified Nurse Aide (CNA) I said the kitchen provided a container of snacks and the CNAs take the snacks from room to room and offers them to the residents. CNA I stated unlabeled snacks (general snacks not specified for a particular resident) included cookies, peanut butter crackers, string cheese, (gelatin dessert), pudding, (fish-shaped crackers), apples, and fruit cups. During an interview and record review on 1/24/2023 at approximately 2:15 PM, Dietary Manager (DM) G provided a copy of a document titled, Meal and Dining room service, dated 1/22/2023. A review of this document revealed the beginning breakfast and dinner mealtimes occurred at 7:45 AM and 4:45 PM respectively. After this review, DM G agreed there was a 15-hour time span between dinner and breakfast the next day. DM G said the kitchen had no specific snack rotation. General evening snacks provided to residents in the facility included a variety of potato chips, pretzels, cheese puffs, pudding cups, applesauce, (gelatin dessert), and a variety of cookies. During an interview on 1/25/2023 at 10:11 AM, Registered Dietitian (RD) L stated the purpose of an evening snack was to give the resident some type of nourishment before they go to bed (and a substantial snack) was something that included a carbohydrate and a protein. RD L said that cookies, potato chips, pudding, and gelatin dessert would not be considered a substantial evening snack. During an interview on 1/25/2023 at 1:44 PM, the NHA said she knows about the mealtime span between dinner and breakfast the following day, and she now understands what a substantial snack is. The NHA was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and no substantially new information was provided.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the use of hair restraints of staff working in the kitchen; 2. Properly date-label opened food; 3. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, baked penne, mashed potatoes, and meat cutlets; 4. Ensure ladles were stored properly to prevent contamination; 5. Consistently log the temperature of the high-temperature sanitizing dish washing machine; and 6. Removed expired, undated, unlabeled food from a resident refrigerator. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On 1/22/2023 beginning at 8:56 AM, the initial tour of the kitchen was conducted with Dietary Aide Q. Upon entering the kitchen, DA Q was observed near the tray serving line and steam tables and had not donned a hair net. During the tour, the following items observed in various refrigerators and were opened and undated: - 46 ounce container of thicken water - 46 ounce container of thicken apple juice - approximately 1 pound of sliced salami - five pound tub of sour cream - 16 ounce tube of whipped cream The following previously cooked and cooled food items were observed in the walk-in cooler: - 1/2 size pan of baked penne, dated 1/19/23 - 1/4 size pan of mashed potatoes, dated 1/20/23 - six to seven cutlets of Country Fried Steaks, undated When asked if there were cooling logs for the previously cooked food, DA Q stated, No. Four ladles of varying sizes were observed hanging from a metal bar, bowl side up. On 1/22/2023 at approximately 9:30 AM, the morning cook, [NAME] S, was observed running meal trays through the high temperature dish machine. During interviews on 1/22/2023 at 11:43 AM and 1/24/2023 at 2:15 PM, Dietary Manager (DM) G was unable to provide a dish machine temperature log for January 2023. DM G stated, We don't know if the machine was sanitizing correctly. In reference to the way the ladles were stored, DM G said particles of debris can fall in them. DM G said the shelf life of an opened container of thicken liquids was seven days. The opened containers of thicken liquids should have had an opened and expiration date. DM G stated, A cooling log was available, but it wasn't used (by the cooks). DM G said cooks are to use the cooling log to avoid the danger zone and to know how long you have to cool food properly. Finally, DM G stated, Food service is responsible for removing outdated foods and ensuring food is properly labeled in the kitchen and for refrigerators on the resident units. During an observation and interview on 1/24/2023 at 1:22 PM with Licensed Practical Nurse (LPN) H, the following was noted in the resident refrigerator on the second floor. The top freezer section contained an opened and undated 20-ounce bag of pepperoni pizza snacks. All other items listed were observed in the lower refrigerator section: - a ham and cheese sandwich with two dates: 1/12/23 and 1/14/23. LPN H stated, These should have been discarded 1/14/23. - a slice of garlic toast in a clear plastic bag, undated. - a glass of apple juice, of pudding thickened consistency, with an undecipherable date. - an undated chicken or tuna salad sandwich, not labeled with a resident's name. - an undated container of spaghetti, not labeled with a resident's name. - pot pie, dated 1/12 - not labeled with a resident's name, LPN H said the kitchen staff was responsible for cleaning the refrigerator. A review of a facility document titled, Cleaning and Sanitizing Dishes, Utensils, Pots and Pans using Ware Washing Machines, undated but provided during the survey, revealed the following: Before running dishes through the dishwasher, warm up the dishwasher by running through an entire wash-rinse cycle and record the appropriate temperature. Record the wash and rinse temperature on the temperature log before washing dishes at each meal. According to the 2013 FDA Food Code: - Section 2-402, Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. - Section 3-101.11, Safe, Unadulterated, and Honestly Presented: Food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented. - Section 3-501.14, Cooling: Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135ºF to 70°F; and (2) Within a total of 6 hours from 135ºF to 41°F or less. - Section 4-903.11, Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.