**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) accurately reflected the estimated cost of items and services for which the resident may be charged for two (Resident #13 and #14) of three reviewed for Beneficiary Notification. Findings include: Resident #13 (R13): Review of the medical record reflected R13 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included heart failure, chronic kidney disease and diabetes. Facility documentation reflected R13 exhausted their Medicare Part A benefit days, with a last covered day of 8/26/24, and remained in the facility. The ABN form included the cost per 15 minutes of Occupational Therapy (OT) and Physical Therapy (PT) services. The ABN did not include other potential financial liability or services that may no longer be covered by Medicare, such as room and board. Resident #14 (R14): Review of the medical record reflected R14 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included diabetes and dementia. Facility documentation reflected R14 exhausted their Medicare Part A benefit days, and beginning 10/7/24, they may have had to pay out of pocket for OT, PT and daily skilled nursing care. The ABN form reflected the cost per 15 minutes of services. The ABN did not include other potential financial liability or services that may no longer be covered by Medicare, such as room and board. In an interview on 01/08/25 at 4:18 PM, Business Office Manager (BOM) J indicated it made sense that room and board charges would be included on an ABN, however, that was not how they had been taught.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide necessary care to two of five residents (R22 and R31) reviewed for activities of daily living (ADLs), resulting in these residents not receiving the care needed to maintain their highest practicable well-being. Findings include: Resident #31 (R31) Review of the medical record reflected R31 was an initial admission to the facility on [DATE]. Diagnoses of Anoxic Brain Damage (brain injury happens when your brain loses oxygen supply), Dry Mouth, Major depression, Contracture of right hand (when one or more fingers bend toward the palm of the hand), Neuromuscular Dysfunctionof Bladder (when neurological (nervous system) conditions affect the way your bladder works), Dysphagia (difficulty in swallowing), Gastrostomy Tube (surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) and Post-Traumatic Hydrocephalus (is a frequent and serious complication that follows a traumatic brain injury (TBI). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2024, revealed R31 had a Brief Interview of Mental Status (BIMS) of 11 (moderately intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 was dependent on all care. During an interview on 01/06/25 at 12:45 PM, R31's family R stated R31 had built up around his teeth and what appears to be hanging substance from his back teeth and his tongue covered with a white buildup. R31's family member R also stated she did not feel the staff were brushing his teeth like they should be. R31's family R also stated staff are supposed to be putting a rolled washcloth rolled up in his right hand to keep the fingers from digging into his palm. Record review revealed R31' s care plan included wash and dry right hand every shift and place palm protector or rolled wash cloth between the palm and his fingers. During an observation on 01/06/25 at12:50 PM, R31 had a buildup that appeared to be plaque around teeth and what appears to be stringy substance hanging from his back teeth. R31's tongue was covered with a white, dry buildup. R31's gums were swollen and inflamed. Observation of R31 laying in his bed with the head of his bed elevated approximately 45 degrees to accommodate tube feeding. R31's feet were not floating on a pillow and his feet were rubbing against the foot board. R31's right hand was contracted, and his fingers were bend tightly against his palm. No observation of a rolled washcloth or device to keep his fingers from digging into his palm or to absorb moisture. During an observation on 01/06/25 at 4:30PM, R31 was laying in the same position as 12:45 PM today, in his bed with the head of his bed elevated approximately 45 degrees to accommodate tube feeding. R31's feet were not floating up off the mattress and his feet rubbing up against the foot board. R31's right hand was contracted, and his fingers were bend tightly against his palm. No observation of a rolled washcloth or device to keep his fingers from digging into his palm or to absorb moisture. During an observation on 01/07/25 at 9:00 AM, R31 was laying in his bed with the head of his bed elevated approximately 45 degrees. R31's feet were not floating off the mattress and his feet were pushed up against the foot board. R31's right hand was contracted, and his fingers were bend tightly against his palm. No observation of a rolled washcloth or device to keep his fingers from digging into his palm or to absorb moisture. During an observation on 01/07/25 at 1:00PM, R31 was laying in his bed with the head of bed elevated approximately 45 degrees to accommodate tube feeding. R31's feet were not floating on a pillow or up off the mattress. R31's feet were pressed up against the foot board. R31 had been in the same position for the last four hours with no changes in his position in the bed. During an observation on 01/07/25 at 4:00PM, R31 was laying in the same position in his bed, feet were not floating, feet firm against the foot board. During an interview and observation on 01/07/25 at 12:33 PM, Licensed Practical Nurse (LPN) B, stated she came in do oral care for R31, looked around for supplies, didn't have any in the room, she had to go out of the room to gather supplies. This writer could observed build up on his teeth, gum line puffy, same condition as yesterday, with stringy stuff hanging off his back teeth. LPN B returned to his room with oral care supplies. LPN B used a sponge on a stick, dipped in mouth wash to do oral care. LPN B stated he had a hard thing in the roof of his mouth, and she finally got it out. During this same observation, LPN B was touching and moving his gastrostomy tube and clamp without PPE for enhanced barrier precaution. The sign on this resident's door stated he was on enhanced barriers precautions and required gown and gloves for staff providing any care. LPN B covered him back up and told him she had to go get supplies. During an interview and observation on 01/07/25 at 12:50 PM, LPN B hung his tube feeding, did not start the infusion pump, wearing gloves but no gown. LPN B removed gloves and exited the room, no hand hygiene observed after removal of her gloves. LPN B came back into R31's room, put new gloves on and checked the gastric residual (amount of enteral feeding left in the stomach from the last feeding) again with gloves but no gown. LPN B stated R31 did not have any gastric residual left in his stomach. However, this writer was unable to see over the side of his bed due to LPN B being so close to the resident's side performing that task. LPN B took her gloves off and put new gloves on to clean off the over the bed table. During an interview on 01/07/25 at 3:27 PM, Social Worker (SW) D stated she does follow up after appts such as dental, if more appointments are needed. Writer asked her if there were any follow up appointments made on R31's teeth as the dentist documented he had heavy plaque and cavities. SW D stated she would have to investigate it and wound let writer know. Record review revealed R31 got a shower on Tues and Fri nights. Does not reflect that he had a shower last night (Tuesday night, 01/07/25). R31 does have hospice services so the hospice CNA would be providing care through the week as well. Record review of care plan revealed R31 is care planned for Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily. Turn/reposition every 2 hours and prn. Observe/document/report to physician PRN s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. During an interview on 01/07/25 at 4:27 PM, writer asked LPN B what the medication left at the bedside of R31 was used for, as there was no name on it, no date on it, nor an order for it in the electronic medical record (EMR). LPN B stated there had to be an order for it since they have been using it. LPN B stated she would direct this concern to the RN/Unit Manager M. During an interview on 01/07/25 at 4:35 PM, RN/Unit Manager M was observed looking in her computer for an order for Bio-[NAME] medication. RN/Unit Manager M stated there was not an order, it must have dropped off. RN/Unit Manager asked writer if she should put an order in for the Bio-[NAME] medication? Writer stated I cannot tell you what to do, but it would make sense to have an order for any medications that were given or being used. Record review of physician orders on 01/08/25 at 8:04 AM, revealed a new order put in on 01/07/25 at 6:00 PM for (Bio-[NAME] Dry Mouth Moisturizing Mouth/Throat Solution. Give 1 application by mouth every 4 hours for xerostomia may have at bedside) During an observation on 01/08/25 at 8:24 AM, the bottle of the medication Bio-[NAME] was still setting on R31's dresser without any name, date opened or instructions for this medication on it. During an interview on 01/08/25 at 8:26 AM, SW D stated R31 saw the dentist in 03/24 and 10/24. SW D stated the dentist recommendation was for staff to assist with oral care and use a toothbrush. Writer asked if R31 had any additional follow up appointments with the dentist, and SW D stated she didn't know, but she would check. Record review of the dental visit notes dated 10/09/24 recommendation was for staff to brush his teeth and do oral care due to the buildup of plaque. During an observation on 01/08/25 at 8:34 AM, R31's wash basin with hygiene products, did not have a toothbrush in it, only a small tube of toothpaste was present. During an interview on 01/08/25 at 8:50 AM, Certified Nursing Assistant (CNA) N stated she uses a sponge on a stick to do oral care on R31. During an interview on 01/08/25 at 8:52 AM, CNA O stated she cleans R31's teeth with a sponge on a stick, dipped in mouthwash. During an interview on 01/08/25 at 8:51 AM, CNA P, stated she usually cleans R31's mouth with a sponge on a stick and tries to clean his teeth off with that. During an interview on 01/08/25 at 8:58 AM, Registered Nurse (RN) C stated she used a sponge on a stick to get the plaque buildup off, and sometimes she uses a toothbrush. RN C added R31 is a tough one due to the plaque buildup on his teeth. RN C also stated she uses the Bio-[NAME] to keep his mouth moist. Record review revealed R31' s care plan included wash and dry right hand every shift and place palm protector or rolled wash cloth between the palm and his fingers. Resident #22 (R22) Review of the medical record reflected that R22 was initially admitted to the facility on [DATE] with diagnoses that included: major depressive disorder, anxiety disorder, intermittent explosive disorder, muscle weakness and difficulty in walking. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/24, revealed R22 had a Brief Interview of Mental Status (BIMS) of 15 out of 15, which indicated intact cognition. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R22 required substantial/maximal assistance for showering, partial/moderate assistance with upper body dressing and substantial/maximal assistance with lower body dressing. During an observation on 1/6/25 at 1:01 PM, R22 was observed to have greasy, uncombed hair and reported that he had only received 3 showers since he had been here. R22 reported that the staff does not offer him a shower twice weekly. It should be noted that resident was in isolation requiring an N-95 mask to be worn, unable to determine if odor was present. During an observation on 1/8/25 at approximately 2pm, R22 was observed in the hallway, hair remained greasy and uncombed. A review of R22's shower task revealed only one shower documented in a 30-day time span (12/16/24 through 1/6/25), one refusal documented and Not Applicable documented 5 times. Record review revealed R22's shower days should be Monday and Thursday each week. During an interview with Unit Manager (UM) M on 1/8/25 at 2:21PM, she reviewed R22's shower task log for the past 30 days and stated it looked bad. UM M was asked when it would be appropriate to document Not Applicable on the shower task, she reported it would never be appropriate, and that staff should be offering and documenting showers or refusals twice weekly. When asked if the unit managers audit shower and shower related tasks she reported she is new to the role (2 months) and they are working hard on getting everything to match (paper shower sheets that indicate which residents are due for showers each day and task information in the electronic medical record). She further stated that they have not gotten to audits yet but they have done education on charting and 1:1's. Review of the facilities policy titled Activities of Daily Living (ADL) Program updated 4/24, documented in part A resident requiring skill practice and/or training in activities of daily living (ADL) is evaluated for restorative nursing. ADL may include, but are not limited to, bathing, grooming, and dressing. Restorative ADL program may be provided by nursing assistants and other staff trained in provision of ADL care under the supervision of the licensed nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pressure ulcer treatments as ordered for one (Resident 54) of three reviewed, resulting in the potential of a worsened pressure ulcer. Findings include: Review of the medical record reflected that R54 was initially admitted to the facility on [DATE] with diagnoses that included: Periprosthetic (relating to an artificial joint) fracture around internal prosthetic (artificial) right knee joint, morbid obesity, Parkinson's disease, heart failure and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/24, revealed R54 had a Brief Interview of Mental Status (BIMS) of 12 out of 15, which indicated moderate cognitive impairment. On 1/6/25 at 10:37 AM R54 was observed sitting up at the edge of her bed. A soiled pillow/pillowcase was observed at the foot of R54's bed with brown/yellow colored stain. When asked what the substance was on the pillowcase she reported that she believed it was drainage from the dressing on her right heel and added that the staff isn't good about changing her dressing every day and she was told it was supposed to be changed each day. On 1/6/25 at 10:46 AM, CNA A applied gloves and removed R54's sock to reveal 2 dressings to R54's lateral foot and heel on her right foot. Dressings were dated 1/4/25. CNA A confirmed the date on the dressing was 1/4/25. A review of R54's physician orders revealed the following wound care orders: Wound care to right lateral outer ankle: cleanse with wound wash, pat dry, apply skin prep to reddened skin, cover with a gently border foam gauze daily and as needed, with a start date of 12/27/2224. Wound care to right posterior ankle: Cleanse wound with wound wash, pat dry, apply Medihoney to wound, apply skin prep peri wound, cover with gentle border foam gauze daily and as needed with a start date of 12/20/24. A review of R54's Treatment administration record revealed wound care was documented as completed by LPN B. An attempt was made to contact LPN B on 1/8/25 via phone at 12:22 PM. No return call was received prior to survey exit. On 1/8/25 at 12:38 PM an interview was conducted with Director of Nursing (DON) and Nursing Home Administrator (NHA). When notified of dressing change not completed for R54 on 1/5/25 but documented as completed on the TAR, they reported that they were aware and had spoken with LPN B and provided 1:1 education. LPN B was educated on not documenting a task that hasn't been completed. DON stated that LPN B stated that she passed on to the oncoming nurse that the dressing change had not been done. DON stated that the expectation for documenting is that it should be completed immediately after the task had been completed. Review of the facilities policy titled Documentation Expectations updated 6/23, documented in part Chart events as they occur and maintain chronological order .If a medication or treatment is not administered as ordered, the nurse circles the appropriate box and enters the reason for omission per facility policy .Entries in the medical record should be completed in a timely manner. Entries should be made at the time of the occurrence .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure for one out of 15 residents (Resident #31) medications were properly and safely stored, labeled with resident's name, date opened, and physician's order for administration. Findings include: Resident #31 (R31) Review of the medical record reflected R31 was an initial admission to the facility on [DATE]. Diagnoses of Anoxic Brain Damage (brain injury happens when your brain loses oxygen supply), Dry Mouth, Major depression, Contracture of right hand (when one or more fingers bend toward the palm of the hand), Neuromuscular Dysfunctionof Bladder (when neurological (nervous system) conditions affect the way your bladder works), Dysphagia (difficulty in swallowing), Gastrostomy Tube (surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) and Post-Traumatic Hydrocephalus (is a frequent and serious complication that follows a traumatic brain injury (TBI). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2024, revealed R31 had a Brief Interview of Mental Status (BIMS) of 11 (moderately intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 was dependent on all care. Concern r/t no physician order for medication for R31, and potential to affect all residents (1 of 60) During an interview on 01/07/25 at 4:27 PM, writer asked LPN B what the medication left at the bedside of R31 was used for, as there was no name on it, no date on it, nor an order for it in the electronic medical record (EMR). LPN B stated there had to be an order for it since they have been using it. LPN B stated she would direct this concern to the RN/Unit Manager M. During an interview on 01/07/25 at 4:35 PM, RN/Unit Manager M was observed looking in her computer for an order for Bio-[NAME] medication. RN/Unit Manager M stated there was not an order, it must have dropped off. RN/Unit Manager asked writer if she should put an order in for the Bio-[NAME] medication? Writer stated I cannot tell you what to do, but it would make sense to have an order for any medications that were given or being used. Record review of physician orders on 01/08/25 at 8:04 AM, revealed a new order put in on 01/07/25 at 6:00 PM for (Bio-[NAME] Dry Mouth Moisturizing Mouth/Throat Solution. Give 1 application by mouth every 4 hours for xerostomia may have at bedside) During an observation on 01/08/25 at 8:24 AM, the bottle of the medication Bio-[NAME] was still setting on R31's dresser without any name, date opened or instructions for this medication on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure for one out of 15 residents (Resident #31) medications were properly and safely stored, labeled with resident's name, date opened, and physician's order for administration. Findings: Resident #31 (R31) Review of the medical record reflected R31 was an initial admission to the facility on [DATE]. Diagnoses of Anoxic Brain Damage (brain injury happens when your brain loses oxygen supply), Dry Mouth, Major depression, Contracture of right hand (when one or more fingers bend toward the palm of the hand), Neuromuscular Dysfunctionof Bladder (when neurological (nervous system) conditions affect the way your bladder works), Dysphagia (difficulty in swallowing), Gastrostomy Tube (surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) and Post-Traumatic Hydrocephalus (is a frequent and serious complication that follows a traumatic brain injury (TBI). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2024, revealed R31 had a Brief Interview of Mental Status (BIMS) of 11 (moderately intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 was dependent on all care. During an interview on 01/07/25 at 4:27 PM, writer asked LPN B what the medication left at the bedside of R31 was used for, as there was no name on it, no date on it, nor an order for it in the electronic medical record (EMR). LPN B stated there had to be an order for it since they have been using it. LPN B stated she would direct this concern to the RN/Unit Manager M. During an interview on 01/07/25 at 4:35 PM, RN/Unit Manager M was observed looking in her computer for an order for Bio-[NAME] medication. RN/Unit Manager M stated there was not an order, it must have dropped off. RN/Unit Manager asked writer if she should put an order in for the Bio-[NAME] medication? Writer stated I cannot tell you what to do, but it would make sense to have an order for any medications that were given or being used. Record review of physician orders on 01/08/25 at 8:04 AM, revealed a new order put in on 01/07/25 at 6:00 PM for (Bio-[NAME] Dry Mouth Moisturizing Mouth/Throat Solution. Give 1 application by mouth every 4 hours for xerostomia may have at bedside) During an observation on 01/08/25 at 8:24 AM, the bottle of the medication Bio-[NAME] was still setting on R31's dresser without any name, date opened or instructions for this medication on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 1) implement Enhanced Barrier Precautions for one (Resident #31); and 2) implement measures to mitigate the spread of COVID-19 infection to facility staff and residents. During an interview on 01/08/25 at 8:50 AM, with the Director of Nursing (DON) and Infection Preventionist (IP) I (in attendance via phone), it was reported that the facility's COVID-19 outbreak was believed to have started after Registered Nurse (RN) K tested positive for COVID-19 (on 12/30/24). It was reported that facility-wide COVID-19 testing was initiated for all residents and staff, as RN K had worked all over the facility, and they were unable to determine close contacts. It was reported the first residents tested positive for COVID-19 on 12/31/24. Review of a facility surveillance log reflected RN K had symptoms of stuffy nose, dry cough and body aches, which began on 12/28/24. RN K had a positive result on a COVID-19 test on 12/30/24. A time card report for RN K reflected they worked from 5:56 PM on 12/28/24 to 6:47 AM on 12/29/24, for a total of 12.25 hours. RN K worked from 5:56 PM on 12/29/24 to 7:38 AM on 12/30/24, for a total of 13.25 hours. According to Centers for Disease Control and Prevention (CDC), .Symptoms of COVID-19 .People with COVID-19 have a wide range of symptoms ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Symptoms may start as mild, and some people will progress to more severe symptoms .Possible symptoms include: .Cough .Sore throat .Muscle or body aches . (https://www.cdc.gov/covid/signs-symptoms/index.html In an interview with the Nursing Home Administrator (NHA) and DON on 01/08/25 at 3:48 PM, it was reported that RN K worked while experiencing symptoms that could have been consistent with COVID-19 but did not notify the facility. The facility became aware of RN K's symptoms after they tested for COVID-19 (on 12/30/24). According to the facility's COVID-19 infection surveillance logs, 31 residents had tested positive for COVID-19 between 12/31/24 and 1/8/25, and 23 staff had tested positive for COVID-19 between 12/30/24 and 1/7/25. During an interview with the DON and IP I (who attended via phone) on 1/08/25 at 1:43 PM, it was reported if staff were experiencing symptoms consistent with COVID-19, they were to notify the facility, which included the DON and IP I. It was reported that staff were to come to the facility for COVID-19 testing, outdoors. Staff were not to report to work if they were symptomatic. Resident #31 (R31) Review of the medical record reflected R31 was an initial admission to the facility on [DATE]. Diagnoses of Anoxic Brain Damage (brain injury happens when your brain loses oxygen supply), Dry Mouth, Major depression, Contracture of right hand (when one or more fingers bend toward the palm of the hand), Neuromuscular Dysfunctionof Bladder (when neurological (nervous system) conditions affect the way your bladder works), Dysphagia (difficulty in swallowing), Gastrostomy Tube (surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) and Post-Traumatic Hydrocephalus (is a frequent and serious complication that follows a traumatic brain injury (TBI). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2024, revealed R31 had a Brief Interview of Mental Status (BIMS) of 11 (moderately intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 was dependent on all care. During an interview and observation on 01/07/25 at 12:33 PM, Licensed Practical Nurse (LPN) B, stated she came in do oral care for R31, looked around for supplies, didn't have any in the room, she had to go out of the room to gather supplies. This writer could observed build up on his teeth, gum line puffy, same condition as yesterday, with stringy stuff hanging off his back teeth. LPN B returned to his room with oral care supplies. LPN B used a sponge on a stick, dipped in mouth wash to do oral care. LPN B stated he had a hard thing in the roof of his mouth, and she finally got it out. During this same observation, LPN B was touching and moving his gastrostomy tube and clamp without PPE for enhanced barrier precaution. The sign on this resident's door stated he was on enhanced barriers precautions and required gown and gloves for staff providing any care. LPN B covered him back up and told him she had to go get supplies. During an interview and observation on 01/07/25 at 12:50 PM, LPN B hung his tube feeding, did not start the infusion pump, wearing gloves but no gown. LPN B removed gloves and exited the room, no hand hygiene observed after removal of her gloves. LPN B came back into R31's room, put new gloves on and checked the gastric residual (amount of enteral feeding left in the stomach from the last feeding) again with gloves but no gown. LPN B stated R31 did not have any gastric residual left in his stomach. However, this writer was unable to see over the side of his bed due to LPN B being so close to the resident's side performing that task. LPN B took her gloves off and put new gloves on to clean off the over the bed table. LPN B removed the gloves and exited the room without washing her hands.

Based on observation and intrview the facility failed to maintain safe food temperatures affecting all 61 residents with the potential for causing food-related illnesses. Findings include: On 1/6/25 at 12:45 PM during second tour of the facility kitchen the plating of food was observed. Following the plating of food done by the cook S the remaining food still on the steam table was immediately tested for temperature. The cook S utilized the kitchen thermometer. The food temperatures in degrees farenheight were as follows: Cream of Potato Casserole: 128 Peas: 90 Fish: 120 Green Beans 140 Mashed Potatoes 130 Gravy 135 Garlic Bread: 80 The cook S acknowledged the low readings and said the temperature readings would be addressed with administration. On 01/07/25 12:55 PM during interview the Consultant Dietician U said the low temperatures had been communicated (and the Dietary Manager (DM) T and CD U were communicating via email during the iterview) and CD U said DM T would address the problem of food being . not up to temperature. On 01/08/25 02:02 PM during observation of the pantry DM T was interviewed. DM T explained the refrigerator in the pantry is a main pantry used by all residents in the facility. The refrigerator temperature gauge was checked and showed a reading of 44 degrees. DM T was asked about the acceptable range which DM T stated as 32 to 41 degrees. DM T said that the temperature is monitored daily. A form secured to the refrigerator showed temperatures for the month of January consistently documented as 40 degrees. DM T was asked about actions to be taken when there is an out of range reading and responded by saying that there could be reasons the temperature was not at the required level. DM T said she would typically confirm the door was sealing shut and would return in an hour to check the temperature. If the temperature was found to be out of range the next step would be to transfer food to the backup refrigerator in therapy department. On 1/8/25 at 2:48 PM during second observation the pantry refrigerator temperature registered at 60 degrees. A dietary employee had just exited the room after having washed the inside of the refrigerator. On 1/8/25 at 2:55 PM the DM T and a dietary employee pulled a large plastic container of turkey sandwiches out of the refrigerator. DM T instructed the dietary employee that each layer of sandwiches would be checked for temperature and all products in the refrigerator would be checked and anything not within an acceptable level of temperature would be discarded and all food that was within range would be transferred to the backup refrigerator. The turkey sandwiches were testing at around 50 degrees F. Following that another container of cheese sandwiches was tested which tested at around 46 degrees F. DM T said these would all need to be discarded. The NHA A was present in the room. The testing continued. There were many products in the refrigerator. According to a facility policy titled Food Temperatures with a date of revision of 12/12/21 states in part, The temperature of holding hot foods at point of service will be > 130 degrees F. The temperature of holding cold foods at point of service will be < 41 degrees F. The cook is responsible for ensuring all food is at the proper serving temperature. Food temperatures will be taken and recorded for all TCS foods at all meals. According to an article on USDA.gov (United States Department of Agriculture) website the temperature of food at safe levels prevents foodborne illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00145732. Based on interview and record review, the facility failed to prevent involuntary seclusion in one of 10 residents reviewed for abuse (Resident #6), resulting in verbal behaviors and frustration. Findings include: Resident #6 (R6) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R6 was found in the dining room participating in sexual behaviors. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R6's care plan dated 3/21/23 revealed he had neurodevelopmental disorder and history of temporary stroke. R6's Behavior Monitoring task indicated he had behaviors of entering others personal space, sexually touching other consenting resident, reaching out toward others, masturbating with the door open and curtain not pulled. Interventions included to guide R6 away from the area while redirecting to other activity of interest such as watching game shows. Progress Note dated 6/27/24 at 4:39 PM revealed R6 was sexually inappropriate 3 times during the shift with another resident. The last occurrence was noted at 4:15 PM. The same note indicated when R6 was told touching other residents below the waist in the dining room was not to continue, R6 yelled and refused to leave the dining room. R6 attempted to stop staff from backing him up in his wheelchair to take him to his room. R6 was informed by the nurse that he was to stay in his room for his meal because of his inability to follow directions and for the inappropriate sexual behavior that had taken place 2 times prior. R6 started to get loud and stated he was coming out. R6 was informed that he was to stay in his room to eat because he was unable to keep his hands to himself and follow instructions. There was no mention R6's guardian was contacted or agreeable to R6 being confined to his room. Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R6's chart documentation and progress notes were reviewed. The same report indicated additional interviews were not performed and was not necessary or feasible. The same report under conclusion indicated R6's guardian did not consent for residents to participate in sexual behaviors with other residents. The report instructed to provide a brief description of the plan to avoid this situation in the future; the response was education provided to residents and staff on redirection when sexual behaviors were exhibited. The same Incident and Investigation Report dated 6/27/24 at 2:39 PM instructed to describe any action taken by the facility to protect the resident during the investigation and in response to the question was education provided to Licensed Practical Nurse (LPN) J on abuse and safety policies. The same form questioned if the incident was reported to State Agency, and the facility staff checked no, it was not reported. The same report was signed by Interim Director of Nursing (DON) B and Nursing Home Administrator (NHA) A. LPN J was interviewed on 7/23/24 at 12:29 PM and stated on 6/27/24 following the incident with another resident in the dining room, an activity aide took R6 to his room. LPN J stated she went to R6's doorway and told him he needed to keep his hands to himself and that he should eat his dinner in his room. R6 wanted to go back to the dining room, and LPN J stated she told R6 to go back to his room. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated had been interim DON since May of 2024. DON B stated LPN J attempted to barricade R6 in his room on 6/27/24. DON B stated R6 was forced to eat dinner in his room on 6/27/24 and stay in his room for approximately 2 hours. DON B stated LPN J was terminated on 7/18/24, LPN J was not removed from the schedule pending investigation. DON B confirmed she did not interview other staff regarding the incidents that occurred on 6/27/24. DON B stated she did not know why incident with R6 and LPN J was not reported to State Agency. NHA A was interviewed on 7/19/24 at 2:45 PM, and stated she could see why she should have reported the incident with R6 and LPN J to State Agency. Abuse Prohibition Policy revised 9/09/22 defined Involuntary Seclusion as separation of a resident from other residents or from his/her room or confinement to her/his room against the resident's will or the will of the resident's legal representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received appropriate assessment and treatment for a change of condition in one of 10 residents reviewed for abuse (Resident #8), resulting in delayed treatment and a medication error. Findings include: Resident #8 (R8) During an interview with Interim Director of Nursing (DON) B on 7/19/24 at 1:30 PM, DON B stated on 7/14/24, Licensed Practical Nurse (LPN) J administered Narcan/naloxone (medication that rapidly reversed an opioid [heroin, fentanyl, oxycodone, Vicodin, codeine, morphine] overdose, medication attaches to opioid receptors and reversed/blocked effects of other opioids; Narcan could restore normal breathing to a person if breathing had slowed or stopped due to an opioid overdose). DON B stated there was no indication to administer Narcan, R8's vital signs were stable, Narcan was not prescribed, opioids were not prescribed, and R8 did not have a history of opioid abuse. DON B stated LPN J administered another residents Narcan to R8 without a physician's order. DON B stated LPN J called emergency services after the Narcan failed to wake R8. Physicians Progress Note dated 7/12/24 at 12:00 AM, revealed R8 was [AGE] years old, had a history of bladder cancer, multiple urinary tract infections (UTI); and was in need of medical clearance for further bladder due to a tumor and possible urethral stent placement. Nurses note dated 7/14/24 at 8:48 PM revealed at 12:00 PM, she overheard Physical Therapy reporting to the Certified Nurse Assistant that they had attempted to wake R8 and he did not arouse when they attempted to set him up on the edge of the bed. The same note indicated nurse was unable to arouse R8, and his breathing was shallow, respirations were 10 (normal respiration rate was 12-18 breaths per minute), his blood pressure was 187/89 (normal blood pressure 120/80), pulse was 73 (normal 60 to 100 beats per minute). There was no temperature included in the note. The same note indicated at 12:12 PM Narcan 4 milligrams (mg) was administered. R8 showed no changes in response to the medication. Emergency Medical Services were notified and R8 was transferred to the hospital. In review of R8's July 2024's Medication Administration Record (MAR), R8 was admitted to the facility on [DATE], and there was no documentation Narcan was ordered to administer. Medication and Treatment Incident Report dated 7/14/24 indicated R8 received Narcan without a physician order and the Narcan used was ordered for a different resident. The same report indicated R8's physician was notified on 7/14/24 at 1:05 PM. LPN J was interviewed on 7/23/24 at 12:29 PM and stated she administered another residents Narcan to R8 on 7/14/24, because he took Gabapentin (anticonvulsant) medication and there was not any Narcan in the back-up box. LPN J stated Gabapentin had the ability to be abused, and she used her own judgement when she administered Narcan to R8. LPN J stated she understood Gabapentin was not an opioid. R8's Progress Note dated 7/17/24 at 4:40 PM revealed he was re-admitted to the facility and was diagnosed with a UTI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00145732. Based on observation, interview and record review, the facility failed to implement their abuse policy and procedures in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and Resident #7), resulting in continued allegations of abuse. Findings include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). Progress Note dated 6/27/24 at 5:02 PM indicated R2 had been sexually inappropriate 3 times during the shift with another resident. The last occurrence was at 4:15 PM, R2 was seen behind the warming station in the dining room, with another male resident, being inappropriate below the waist, same as 2 times prior. R2 was told behavior was not to happen and R2 began yelling and wouldn't leave the dining room. The same note indicated the progress note would be included in the shift report, 24 hour report and a communications report. R2's Behavior Monitoring and interventions task, in the electronic medical record, included history of yelling, cursing, making rude comments, throwing things, and verbal threats. Interventions included reapproach at later time or alternate staff, redirect with conversation, snacks, or activity and to guide R2 away from others. The same report revealed on 6/22/24 at 4:44 PM R2 displayed public sexual acts. Activities note dated 6/22/24 at 4:24 PM revealed R2 was asked 3 times to get away from another resident and asked to leave Bingo for being rude to other residents. R2's care plan dated 7/02/24 indicated he had episodes of hypersexuality (sexual addiction, excessive sexual thoughts, desires, urges or behaviors) and R2's guardian did not consent to sexual contact with R6. R6's care plan dated 3/21/23 revealed he had neurodevelopmental disorder and history of temporary stroke.R6's Behavior Monitoring task indicated he had behaviors of entering others personal space, sexually touching other consenting resident, reaching out toward others, masturbating with the door open and curtain not pulled. Interventions included to guide R6 away from the area while redirecting to other activity of interest such as watching game shows. The same task indicated to redirect R6 away from R2, do not seat the two next to each other or allow them to be in areas by themselves. The same task report revealed R6 was sexually inappropriate on 6/27/24 at 8:55 PM, 7/04/24 at 12:10 PM and 7/21/24 at 5:36 AM. Progress Note dated 6/27/24 at 4:39 PM revealed R6 was sexually inappropriate 3 times during the shift with another resident. The last occurrence was noted at 4:15 PM. The same note indicated when R6 was told touching other residents below the waist in the dining room was not to continue, R6 yelled and refused to leave the dining room. R6 attempted to stop staff from backing him up in his wheelchair to take him to his room. R6 was informed by the nurse that he was to stay in his room for his meal because of his inability to follow directions and for the inappropriate sexual behavior that had taken place 2 times prior. R6 started to get loud and stated he was coming out. R6 was informed that he was to stay in his room to eat because he was unable to keep his hands to himself and follow instructions. There was only one incident report generated on 6/27/24 regarding R2 and R6. Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6's chart documentation and progress notes were reviewed. The same report indicated additional interviews were not performed and was not necessary or feasible. Under conclusion it was documented guardians of both residents did not consent for residents to participate in sexual behavior. The report instructed to provide a brief description of the plan to avoid this situation in the future; the response was education provided to residents and staff on redirection when sexual behaviors were exhibited. The same Incident and Investigation Report dated 6/27/24 at 2:39 PM instructed to describe any action taken by the facility to protect the resident during the investigation and in response to the question was education provided to Licensed Practical Nurse (LPN) J on abuse and safety policies. The same form questioned if the incident was reported to State Agency, and the facility staff checked no, it was not reported. The same report was signed by Interim Director of Nursing (DON) B and Nursing Home Administrator (NHA) A. The same investigation included an audit, a list of 21 residents, identified by room number only, dated 6/28/24. The list included 20 residents that were located on the 100 wing, and 1 resident on the 200 wing; there were no residents from the 300 or 400 units. Residents were asked two yes or no questions: had they ever been sexually abused (touched or verbal) and have they seen another resident be sexually abused. Psychiatric Note dated 7/09/24 and signed by physician's assistant on 7/19/24, revealed R2 was seen due to increased inappropriate sexual behavior. Since last visit changes to R2's medications included Paxil (antidepressant) was discontinued on 7/05/24, Lexapro (antidepressant) was started on 7/12/24 by the primary care physician; and Estradiol (estrogen, female sex hormone) was started by the primary care physician on 7/06/24. The same note indicated R2 was recently noted by staff with his hands down another residents' pants. It was recommended to monitor R2, as several medication changes had been implemented by his primary care physician. Certified Nurse Assistant (CNA) M was interviewed on 7/23/24 at 2:30 PM and stated on 6/27/24, she observed R2 and R6, sitting side by side next to each other at a table in the middle of the main dining room; and was not behind the warming station. CNA M stated R2 was slouched in his wheelchair and R6 had his hand on R2's pants, over his perineal area. CNA M stated R2 and R6 were separated around 7 times on 6/27/24. LPN J was interviewed on 7/23/24 at 12:29 PM and stated the incident on 6/27/24 with R2 and R6 occurred more than once. LPN J stated she wrote occurrences in residents progress notes and other nurses did not because it occurred frequently. LPN J stated she was directed to chart using the term sexual behavior versus sexually inappropriate. LPN J stated on 6/27/24 following the incident with R2, an activity aide took R6 to his room. LPN J stated she went to R6 doorway and told him he needed to keep his hands to himself and that he should eat his dinner in his room. R6 wanted to go back to the dining room, and LPN J stated she told R6 to go back to his room. LPN J stated R6 was drawn to R2, and it was absolutely ridiculous. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated had been interim DON since May of 2024. DON B did not know why incident with R2 and R6 were not reported to State Agency. DON B stated LPN J attempted to barricade R6 in his room on 6/27/24. DON B stated R6 was forced to eat dinner in his room on 6/27/24 and stay in his room for approximately 2 hours. DON B stated LPN J was terminated on 7/18/24, LPN J was not removed from the schedule pending investigation. DON B confirmed she did not interview other staff regarding the incidents that occurred on 6/27/24. DON B stated she did not know why incident with R6 and LPN J was not reported to State Agency. Resident #5 (R5) and Resident #4 (R4) R5 filed a grievance on 7/02/24 alleging R4 kept harassing her and kissing her hand. The same grievance indicated R5 did not like it, it was an ongoing problem and she wanted it to stop. R5's MDS dated [DATE] revealed she was admitted to the facility on [DATE] and had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment indicated she had not had any physical, verbal or other behaviors during the look-back period. R5's progress note dated 6/19/24 indicated she had increased anxiety. Progress note dated 7/02/24 at 1:32 PM indicated they had spoke with R5 regarding the grievance filed about an altercation with a male resident. The male resident was provided with a sitter to ensure resident was safe. R5 was agreeable to the plan. R4's MDS dated [DATE] revealed he had a BIMS score of 03 (00-07 Severe Cognitive Impairment). R4's Behavior Monitoring and interventions task report included history of making verbal threats of physical violence, sexual comments and sexual gestures. The same report instructed to redirect R4 from the area or triggering event, make R4 aware his comments feel uncomfortable, guide R4 way from others if he starts making sexual or other inappropriate comments, provide one to one staff supervision as necessary. The same report ran on 7/19/24 did not indicate R4 had any behaviors, including sexually inappropriate or grabbing, noted during the last 30 days. Progress Note dated 6/19/24 at 12:10 PM indicated R4 was being followed by resident at risk and his physician had increased his estrogen medication. The same note revealed R4 had an increase in sexually inappropriate comments, entering others personal space and attention seeking. Action taken included staff to redirect R4 away from others, redirect him with activities, and conversation. Progress Note dated 6/30/24 at 5:21 AM revealed R4 had inappropriate behavior the first 5 hours of the shift. R4 had followed and made inappropriate comments to another female resident who told him no multiple times, when redirected resident would laugh and then hit on the nurse. R4 was continually redirected and removed twice from common areas for harassing female residents. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the incident between R4 and R5 wasn't documented on an incident report or reported to State Agency. Resident #1 (R1), Resident #3 (R3), Resident #6 (R6) On 7/19/24 at 10:04 AM R1 was observed sitting in her wheelchair in the hallway near the small dining room. MDS dated [DATE] revealed R1 was admitted to the facility on [DATE], had severely impaired cognition, and had diagnoses including depression and Dementia. Receptionist I was interviewed on 7/24/24 at 12:43 PM, and confirmed she was working on 7/04/24, and witnessed R3 standing in the hall by the front dining room, with his penis exposed. Receptionist I stated R1 was in her wheelchair next to him. R3 was reaching for R1's arm, like he wanted her to touch him. Receptionist I stated she separated R3 and R1 and asked activities staff to keep a close eye on R1. Receptionist I stated she reported the incident to NHA A via phone. Activities Aide (AA) O was interviewed on 7/23/24 at 3:40 PM and stated on 7/04/24, around 3:30 PM, she was in the dining room for Bingo with a group of residents, and saw R2 looking down R1 shirt and R6 hand was on top of R2's pants, over his perineal area. AA O stated she wrote a statement and put in under NHA A's door. AA O stated she had witnessed R6 chase after R2. AA O stated she had also witnessed R2 and R6 with their hands down each others pants, behind the steam table, but did not remember the date. Social Services (SS) C was interviewed on 7/19/24 at 2:00 PM and stated she was not aware of any additional details related to documentation of R3 checked for sexually inappropriateness, in behavior tracking task on 7/04/24 at 12:11 PM, 7/06/24 at 10:22 AM and 3:09 PM; and on 7/07/24 at 12:27 PM. SS C stated R3 had the potential to masturbate in the hallway. SS C stated when behaviors were documented in behavior tracking, she reviewed the care plan, discussed the behavior in the morning meetings and revised the care plan. SS C was unable to provide details of R2's behaviors of public sexual acts documented on 6/22/24 at 4:44 PM or on 7/04/24 at 11:32 AM; in which included cursing. SS C stated R2 and R3 had medication adjustments due to increase masturbation in inappropriate places. SS C stated she had no knowledge of allegations of abuse that involved R1. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the facility had an increase in resident sexual behaviors recently. NHA A stated she did not have any knowledge of any incidents that occurred with R1, R3 or R6 on 7/04/24. NHA A stated the facility did not have cameras, but cameras could be useful because of the layout of the building. During an interview on 7/23/24 at 12:29 PM, LPN J stated on 7/04/24 at 11:09 AM, a CNA reported to her R2 was following R1 around and touched R1 breasts with his hands. LPN J stated she did not see R2 touch R1's breasts, but did observe R2 following R1 around that morning. LPN J stated R2 stalked people and acted like he was crazy, but R2 knew what he was doing. LPN J stated she reported the incident to DON B via text message. Resident #7 (R7) R7's significant change MDS assessment dated [DATE] revealed R7 had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment revealed R7 had the diagnoses of endometrial cancer, schizoaffective-bipolar type disorder, and obesity. An electronic mail (email) from hospice staff was sent to facility staff on 7/15/24 at 12:17 PM and indicated a concern regarding LPN J. The hospice staff stated they had spoken to LPN J many times; LPN J refused to give R7 additional food as requested or has removed food from R7's room. The email indicated LPN J had stated that she forced the nurse assistants to clean R7 up after R7 had refused. Hospice staff stated in the same email they had observed LPN J being very gruff and even rude toward residents, including residents that were not under hospice care. The same email indicated if R7 wished to eat chocolate pudding for every meal, then so be it. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated it was reported LPN J was rude and gruff to R7. DON B stated LPN J told R7 she did not need any more pudding because she weighed 500 pounds. DON B stated the incident with LPN J and R7 was first verbally reported on 7/12/24, and LPN J was terminated on 7/18/24. LPN J was not removed from the schedule pending investigation. There was no incident report and no other residents or other staff, with the exception of LPN J that were interviewed. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated behaviors were reviewed in the morning meetings by reviewing the dashboard and notes. DON B stated she was not aware behaviors were documented in the tasks section of the medical record and had never run that report. DON B stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation. DON B stated the first time she heard about the incidents that occurred on 7/04/24 with R1, R3, and R6 was on 7/23/24 during the survey. Abuse Prohibition Policy revised 9/09/22, revealed each resident would be free from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience that were not required to treat the resident's medical symptoms. The same policy defined sexual abuse as non-consensual sexual contact of any type with a resident and included but not limited to: unwanted intimate touching of any kind especially of breasts or perineal area; all types of sexual assault or batter, such as rape, sodomy, fondling and/or intercourse or coerced nudity; forced observation of masturbation and/or pornography. If at anytime the facility had reason to suspect the resident did not have the capacity to consent to sexual activity the facility should evaluate whether the resident had the capacity to consent. Verbal abuse was use of verbal or nonverbal conduct, gestured communication or sounds to residents within hearing distance, regardless of age, ability to comprehend, or disability; which caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. The same policy defined Involuntary Seclusion as separation of a resident from other residents or from his/her room or confinement to her/his room against the resident's will or the will of the resident's legal representative. The Director of Nursing or designee would complete an assessment of the resident(s) and document findings in the medical record. The same policy indicated if the accused was an employee of the facility, he/she would be suspended until the investigation was completed. The facility Quality Assurance Performance Improvement Committee would investigate occurrences, patterns, and trends that may indicate presence of abuse, neglect or misappropriation of resident property to determine the direction of the investigation/intervention, through analysis of systems, audits, and reports. Identification through the safety program begins with the Incident Report. The Administrator or designee would notify any State or Federal agencies of allegations per state guideline (2 hours if abuse allegation or serious injury; all other not later than 24 hours). Substantiated complaints against nurses would be reported to the State Board of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00145732. Based on observation, interview and record review, the facility failed to immediately report allegations of abuse in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and Resident #7), resulting in likelihood of continued abuse. Findings include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). Progress Note dated 6/27/24 at 5:02 PM indicated R2 had been sexually inappropriate 3 times during the shift with another resident. The last occurrence was at 4:15 PM, R2 was seen behind the warming station in the dining room, with another male resident, being inappropriate below the waist, same as 2 times prior. R2 was told behavior was not to happen and R2 began yelling and wouldn't leave the dining room. The same note indicated the progress note would be included in the shift report, 24 hour report and a communications report. R2's Behavior Monitoring and interventions task revealed on 6/22/24 at 4:44 PM R2 displayed public sexual acts. Activities note dated 6/22/24 at 4:24 PM revealed R2 was asked 3 times to get away from another resident and asked to leave Bingo for being rude to other residents. R2's care plan dated 7/02/24 indicated he had episodes of hypersexuality (sexual addiction, excessive sexual thoughts, desires, urges or behaviors) and R2's guardian did not consent to sexual contact with R6. R6's care plan dated 3/21/23 revealed he had neurodevelopmental disorder and history of temporary stroke. R6's Behavior Monitoring task indicated he was sexually inappropriate on 6/27/24 at 8:55 PM, 7/04/24 at 12:10 PM and 7/21/24 at 5:36 AM. Progress Note dated 6/27/24 at 4:39 PM revealed R6 was sexually inappropriate 3 times during the shift with another resident. The last occurrence was noted at 4:15 PM. The same note indicated when R6 was told touching other residents below the waist in the dining room was not to continue, R6 yelled and refused to leave the dining room. R6 attempted to stop staff from backing him up in his wheelchair to take him to his room. R6 was informed by the nurse that he was to stay in his room for his meal because of his inability to follow directions and for the inappropriate sexual behavior that had taken place 2 times prior. R6 started to get loud and stated he was coming out. R6 was informed that he was to stay in his room to eat because he was unable to keep his hands to himself and follow instructions. There was only one incident report generated on 6/27/24 regarding R2 and R6. Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6's chart documentation and progress notes were reviewed. The same report indicated additional interviews were not performed and was not necessary or feasible. The same report under conclusion indicated guardians of both residents did not consent for residents to participate in sexual behavior. The report instructed to provide a brief description of the plan to avoid this situation in the future; the response was education provided to residents and staff on redirection when sexual behaviors were exhibited. The same form questioned if the incident was reported to State Agency, and the facility staff checked no, it was not reported. The same report was signed by Interim Director of Nursing (DON) B and Nursing Home Administrator (NHA) A. Psychiatric Note dated 7/09/24 and signed by physician's assistant on 7/19/24, revealed R2 was seen due to increased inappropriate sexual behavior. The same note indicated R2 was recently noted by staff with his hands down another residents' pants. Certified Nurse Assistant (CNA) M was interviewed on 7/23/24 at 2:30 PM and stated on 6/27/24, she observed R2 and R6, sitting side by side next to each other at a table in the middle of the main dining room; and was not behind the warming station. CNA M stated R2 was slouched in his wheelchair and R6 had his hand on R2's pants, over his perineal area. CNA M stated R2 and R6 were separated around 7 times on 6/27/24. LPN J was interviewed on 7/23/24 at 12:29 PM and stated the incident on 6/27/24 with R2 and R6 occurred more than once. LPN J stated she wrote occurrences in residents progress notes and other nurses did not because it occurred frequently. LPN J stated she was directed to chart using the term sexual behavior versus sexually inappropriate. LPN J stated on 6/27/24 following the incident with R2, an activity aide took R6 to his room. LPN J stated she went to R6 doorway and told him he needed to keep his hands to himself and that he should eat his dinner in his room. R6 wanted to go back to the dining room, and LPN J stated she told R6 to go back to his room. LPN J stated R6 was drawn to R2, and it was absolutely ridiculous. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated had been interim DON since May of 2024. DON B did not know why incident with R2 and R6 were not reported to State Agency. DON B stated LPN J attempted to barricade R6 in his room on 6/27/24. DON B stated R6 was forced to eat dinner in his room on 6/27/24 and stay in his room for approximately 2 hours. DON B stated LPN J was terminated on 7/18/24, LPN J was not removed from the schedule pending investigation. DON B stated she did not know why incident with R6 and LPN J was not reported to State Agency. Resident #5 (R5) and Resident #4 (R4) R5 filed a grievance on 7/02/24 alleging R4 kept harassing her and kissing her hand. The same grievance indicated R5 did not like it, it was an ongoing problem and she wanted it to stop. R5's MDS dated [DATE] revealed she was admitted to the facility on [DATE] and had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment indicated she had not had any physical, verbal or other behaviors during the look-back period. Progress note dated 7/02/24 at 1:32 PM indicated they had spoke with R5 regarding the grievance filed about an altercation with a male resident. The male resident was provided with a sitter to ensure resident was safe. R5 was agreeable to the plan. R4's MDS dated [DATE] revealed he had a BIMS score of 03 (00-07 Severe Cognitive Impairment). R4's Behavior Monitoring and interventions task report included history of making verbal threats of physical violence, sexual comments and sexual gestures. Progress Note dated 6/19/24 at 12:10 PM indicated R4 was being followed by resident at risk and his physician had increased his estrogen medication. The same note revealed R4 had an increase in sexually inappropriate comments, entering others personal space and attention seeking. Progress Note dated 6/30/24 at 5:21 AM revealed R4 had inappropriate behavior the first 5 hours of the shift. R4 had followed and made inappropriate comments to another female resident who told him no multiple times, when redirected resident would laugh and then hit on the nurse. R4 was continually redirected and removed twice from common areas for harassing female residents. Progress Note dated 6/30/24 at 9:01 PM revealed R4 .just came out of room in wheelchair and was witnessed fondeling [sic] the same female resident he has been harassing tonight and last night while this nurse taking care of him. Resident was rubbing up her arm and placing hand on her lower back, while holding her hand with his other hand. Resident reminded that hands are to be kept to himself and that it is not ok to touch other residents, especially females. Resident started laughing and said well, what can I do then, touch you? and winked and laughed and started propelling himself towards this nurse. Resident politely asked to return to his room or another area of facility away from this female resident if he could not follow rules and keep his hands to himself. Resident then returned to his room and is now resting in bed . Registered Nurse H was interviewed on 7/23/24 at 9:25 AM regarding R4's progress note dated 6/30/24 at 9:01 PM and stated fondling was a poor choice of words. R4 was holding another resident's hand and rubbing her wrist and forearm. RN H stated R4 was not re-directable at times and there was two weeks where he was really ramped up. RN H stated the female resident R4 was touching on 6/30/24 was not R5, it was with another female resident. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the incident between R4 and R5 wasn't documented on an incident report or reported to State Agency. Resident #1 (R1), Resident #3 (R3), Resident #6 (R6) 7/19/24 at 10:04 AM R1 was observed sitting in her wheelchair in the hallway near the small dining room. MDS dated [DATE] revealed R1 was admitted to the facility on [DATE], had severely impaired cognition, and had diagnoses including depression and Dementia. Receptionist I was interviewed on 7/24/24 at 12:43 PM, and confirmed she was working on 7/04/24, and witnessed R3 standing in the hall by the front dining room, with his penis exposed. Receptionist I stated R1 was in her wheelchair next to him. R3 was reaching for R1's arm, like he wanted her to touch him. Receptionist I stated she separated R3 and R1 and asked activities staff to keep a close eye on R1. Receptionist I stated she reported the incident to NHA A via phone. Activities Aide (AA) O was interviewed on 7/23/24 at 3:40 PM and stated on 7/04/24, around 3:30 PM, she was in the dining room for Bingo with a group of residents, and saw R2 looking down R1 shirt and R6 hand was on top of R2's pants, over his perineal area. AA O stated she wrote a statement and put in under NHA A's door. AA O stated she had witnessed R6 chase after R2. AA O stated she had also witnessed R2 and R6 with their hands down each others pants, behind the steam table, but did not remember the date. Social Services (SS) C was interviewed on 7/19/24 at 2:00 PM and stated she was not aware of any additional details related to documentation of R3 checked for sexually inappropriateness, in behavior tracking task on 7/04/24 at 12:11 PM, 7/06/24 at 10:22 AM and 3:09 PM; and on 7/07/24 at 12:27 PM. SS C stated R3 had the potential to masturbate in the hallway. SS C stated when behaviors were documented in behavior tracking, she reviewed the care plan, discussed the behavior in the morning meetings and revised the care plan. SS C was unable to provide details of R2's behaviors of public sexual acts documented on 6/22/24 at 4:44 PM or on 7/04/24 at 11:32 AM; in which included cursing. SS C stated R2 and R3 had medication adjustments due to increase masturbation in inappropriate places. SS C stated she had no knowledge of any abuse allegations that involved R1. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the facility had an increase in resident sexual behaviors recently. NHA A stated she did not have any knowledge of any incidents that occurred with R1, R3 or R6 on 7/04/24. During an interview on 7/23/24 at 12:29 PM, LPN J stated on 7/04/24 at 11:09 AM, a CNA reported to her R2 was following R1 around and touched R1 breasts with his hands. LPN J stated she did not see R2 touch R1's breasts, but did observe R2 following R1 around that morning. LPN J stated R2 stalked people and acted like he was crazy, but R2 knew what he was doing. LPN J stated she reported the incident to DON B via text message. Resident #7 (R7) R7's significant change MDS assessment dated [DATE] revealed R7 had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment revealed R7 had the diagnoses of endometrial cancer, schizoaffective-bipolar type disorder, and obesity. An electronic mail (email) from hospice staff was sent to facility staff on 7/15/24 at 12:17 PM and indicated a concern regarding LPN J. The hospice staff stated they had spoken to LPN J many times; LPN J refused to give R7 additional food as requested or has removed food from R7's room. The email indicated LPN J had stated that she forced the nurse assistants to clean R7 up after R7 had refused. Hospice staff stated in the same email they had observed LPN J being very gruff and even rude toward residents, including residents that were not under hospice care. The same email indicated if R7 wished to eat chocolate pudding for every meal, then so be it. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated it was reported LPN J was rude and gruff to R7. DON B stated LPN J told R7 she did not need any more pudding because she weighed 500 pounds. DON B stated the incident with LPN J and R7 was first verbally reported on 7/12/24, and LPN J was terminated on 7/18/24. LPN J was not removed from the schedule pending investigation. There was no incident report and no other residents or other staff, with the exception of LPN J that were interviewed. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated behaviors were reviewed in the morning meetings by reviewing the dashboard and notes. DON B stated she was not aware behaviors were documented in the tasks section of the medical record and had never run that report. DON B stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation. DON B stated the first time she heard about the incidents that occurred on 7/04/24 with R1, R3, and R6 was on 7/23/24 during the survey. NHA A was interviewed on 7/24/24 at 12:09 PM and stated she did not investigate the allegation of abuse reported by hospice staff because she did not receive the email. NHA A stated she has had 6 DON's since December 2023, and the DON B did not know everything she was supposed to be doing. Abuse Prohibition Policy revised 9/09/22, revealed the Administrator or designee would notify any State or Federal agencies of allegations per state guideline (2 hours if abuse allegation or serious injury; all others not later than 24 hours) and substantiated complaints against nurses would be reported to the State Board of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00145732. Based on observation, interview and record review, the facility failed to thoroughly investigate allegations of abuse, in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and #7), resulting in the likelihood of continued abuse. Findings include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). Progress Note dated 6/27/24 at 5:02 PM indicated R2 had been sexually inappropriate 3 times during the shift with another resident. The last occurrence was at 4:15 PM, R2 was seen behind the warming station in the dining room, with another male resident, being inappropriate below the waist, same as 2 times prior. R2 was told behavior was not to happen and R2 began yelling and wouldn't leave the dining room. R2's Behavior Monitoring and interventions task, in the electronic medical record, included history of yelling, cursing, making rude comments, throwing things, and verbal threats. The same report revealed on 6/22/24 at 4:44 PM R2 displayed public sexual acts. Activities note dated 6/22/24 at 4:24 PM revealed R2 was asked 3 times to get away from another resident and asked to leave Bingo for being rude to other residents. R2's care plan dated 7/02/24 indicated he had episodes of hypersexuality (sexual addiction, excessive sexual thoughts, desires, urges or behaviors) and R2's guardian did not consent to sexual contact with R6. R6's care plan dated 3/21/23 revealed he had neurodevelopmental disorder and history of temporary stroke. R6's Behavior Monitoring task indicated he had behaviors of entering others personal space, sexually touching other consenting resident, reaching out toward others, masturbating with the door open and curtain not pulled. The same Behavior Monitoring task indicated to redirect R6 away from R2, do not seat the two next to each other or allow them to be in areas by themselves. The same report revealed R6 was sexually inappropriate on 6/27/24 at 8:55 PM, 7/04/24 at 12:10 PM and 7/21/24 at 5:36 AM. Progress Note dated 6/27/24 at 4:39 PM revealed R6 was sexually inappropriate 3 times during the shift with another resident. The last occurrence was noted at 4:15 PM. The same note indicated when R6 was told touching other residents below the waist in the dining room was not to continue, R6 yelled and refused to leave the dining room. R6 attempted to stop staff from backing him up in his wheelchair to take him to his room. R6 was informed by the nurse that he was to stay in his room for his meal because of his inability to follow directions and for the inappropriate sexual behavior that had taken place 2 times prior. R6 started to get loud and stated he was coming out. R6 was informed that he was to stay in his room to eat because he was unable to keep his hands to himself and follow instructions. There was only one incident report generated on 6/27/24 regarding R2 and R6. Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6's chart documentation and progress notes were reviewed. The same report indicated additional interviews were not performed and was not necessary or feasible. The same report under conclusion indicated guardians of both residents did not consent for residents to participate in sexual behavior. The report instructed to provide a brief description of the plan to avoid this situation in the future; the response was education provided to residents and staff on redirection when sexual behaviors were exhibited. The same report instructed to describe any action taken by the facility to protect the resident during the investigation, and in response to the question, education was provided to Licensed Practical Nurse (LPN) J on abuse and safety policies. The same form questioned if the incident was reported to State Agency, and the facility staff checked no, it was not reported. The same investigation included an audit, a list of 21 residents, identified by room number only, dated 6/28/24. The list included 20 residents that were located on the 100 wing, and 1 resident on the 200 wing; there were no residents from the 300 or 400 units. Residents were asked two yes or no questions: had they ever been sexually abused (touched or verbal) and have they seen another resident be sexually abused. The same report was signed by Interim Director of Nursing (DON) B and Nursing Home Administrator (NHA) A. Psychiatric Note dated 7/09/24 and signed by physician's assistant on 7/19/24, revealed R2 was seen due to increased inappropriate sexual behavior. Since last visit changes to R2's medications included Paxil (antidepressant) was discontinued on 7/05/24, Lexapro (antidepressant) was started on 7/12/24 by the primary care physician; and Estradiol (estrogen, female sex hormone) was started by the primary care physician on 7/06/24. The same note indicated R2 was recently noted by staff with his hands down another residents' pants. It was recommended to monitor R2, as several medication changes had been implemented by his primary care physician. Certified Nurse Assistant (CNA) M was interviewed on 7/23/24 at 2:30 PM and stated on 6/27/24, she observed R2 and R6, sitting side by side next to each other at a table in the middle of the main dining room; and was not behind the warming station. CNA M stated R2 was slouched in his wheelchair and R6 had his hand on R2's pants, over his perineal area. CNA M stated R2 and R6 were separated around 7 times on 6/27/24. LPN J was interviewed on 7/23/24 at 12:29 PM and stated the incident on 6/27/24 with R2 and R6 occurred more than once. LPN J stated she wrote occurrences in residents progress notes and other nurses did not because it occurred frequently. LPN J stated she was directed to chart using the term sexual behavior versus sexually inappropriate. LPN J stated on 6/27/24 following the incident with R2, an activity aide took R6 to his room. LPN J stated she went to R6 doorway and told him he needed to keep his hands to himself and that he should eat his dinner in his room. R6 wanted to go back to the dining room, and LPN J stated she told R6 to go back to his room. LPN J stated R6 was drawn to R2, and it was absolutely ridiculous. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated had been interim DON since May of 2024. DON B did not know why incident with R2 and R6 were not reported to State Agency. DON B stated LPN J attempted to barricade R6 in his room on 6/27/24. DON B stated R6 was forced to eat dinner in his room on 6/27/24 and stay in his room for approximately 2 hours. DON B stated LPN J was terminated on 7/18/24, LPN J was not removed from the schedule pending investigation. DON B confirmed she did not interview other staff regarding the incidents that occurred on 6/27/24. DON B stated she did not know why incident with R6 and LPN J was not reported to State Agency. Resident #5 (R5) and Resident #4 (R4) R5 filed a grievance on 7/02/24 alleging R4 kept harassing her and kissing her hand. The same grievance indicated R5 did not like it, it was an ongoing problem and she wanted it to stop. R5's MDS dated [DATE] revealed she was admitted to the facility on [DATE] and had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment indicated she had not had any physical, verbal or other behaviors during the look-back period. R5's progress note dated 6/19/24 indicated she had increased anxiety. Progress note dated 7/02/24 at 1:32 PM indicated they had spoke with R5 regarding the grievance filed about an altercation with a male resident. The male resident was provided with a sitter to ensure resident was safe. R5 was agreeable to the plan. R4's MDS dated [DATE] revealed he had a BIMS score of 03 (00-07 Severe Cognitive Impairment). R4's Behavior Monitoring and interventions task report included history of making verbal threats of physical violence, sexual comments and sexual gestures. The same report instructed to redirect R4 from the area or triggering event, make R4 aware his comments feel uncomfortable, guide R4 way from others if he starts making sexual or other inappropriate comments, provide one to one staff supervision as necessary. Progress Note dated 4/21/24 at 10:00 PM revealed R4 had to be redirected with his sexually charged language, and had been approaching residents being sexually inappropriate. Progress Note dated 4/21/24 at 10:55 PM revealed R4, over the last month, had become increasingly sexually inappropriate to staff and female residents. Progress Note dated 6/19/24 at 12:10 PM indicated R4 was being followed by resident at risk and his physician had increased his estrogen medication. The same note revealed R4 had an increase in sexually inappropriate comments, entering others personal space and attention seeking. Action taken included staff to redirect R4 away from others, redirect him with activities, and conversation. Progress Note dated 6/30/24 at 5:21 AM revealed R4 had inappropriate behavior the first 5 hours of the shift. R4 had followed and made inappropriate comments to another female resident who told him no multiple times, when redirected resident would laugh and then hit on the nurse. R4 was continually redirected and removed twice from common areas for harassing female residents. Progress Note dated 6/30/24 at 9:01 PM revealed R4 .just came out of room in wheelchair and was witnessed fondeling [sic] the same female resident he has been harassing tonight and last night while this nurse taking care of him. Resident was rubbing up her arm and placing hand on her lower back, while holding her hand with his other hand. Resident reminded that hands are to be kept to himself and that it is not ok to touch other residents, especially females. Resident started laughing and said well, what can I do then, touch you? and winked and laughed and started propelling himself towards this nurse. Resident politely asked to return to his room or another area of facility away from this female resident if he could not follow rules and keep his hands to himself. Resident then returned to his room and is now resting in bed . Registered Nurse H was interviewed on 7/23/24 at 9:25 AM regarding R4's progress note dated 6/30/24 at 9:01 PM and stated fondling was a poor choice of words. R4 was holding another resident's hand and rubbing her wrist and forearm. RN H stated R4 was not re-directable at times and there was two weeks where he was really ramped up. RN H stated the female resident R4 was touching on 6/30/24 was not R5, it was with another female resident. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the incident between R4 and R5 wasn't reported to State Agency and that she asked R5 questions and took care of it right away, the day the grievance was filed. Resident #1 (R1), Resident #3 (R3), Resident #6 (R6) 7/19/24 at 10:04 AM R1 was observed sitting in her wheelchair in the hallway near the small dining room. MDS dated [DATE] revealed R1 was admitted to the facility on [DATE], had severely impaired cognition, and had diagnoses including depression and Dementia. Receptionist I was interviewed on 7/24/24 at 12:43 PM, and confirmed she was working on 7/04/24, and witnessed R3 standing in the hall by the front dining room, with his penis exposed. Receptionist I stated R1 was in her wheelchair next to him. R3 was reaching for R1's arm, like he wanted her to touch him. Receptionist I stated she separated R3 and R1 and asked activities staff to keep a close eye on R1. Receptionist I stated she reported the incident to NHA A via phone. Activities Aide (AA) O was interviewed on 7/23/24 at 3:40 PM and stated on 7/04/24, around 3:30 PM, she was in the dining room for Bingo with a group of residents, and saw R2 looking down R1 shirt and R6 hand was on top of R2's pants, over his perineal area. AA O stated she wrote a statement and put in under NHA A's door. AA O stated she had witnessed R6 chase after R2. AA O stated she had also witnessed R2 and R6 with their hands down each others pants, behind the steam table, but did not remember the date. Social Services (SS) C was interviewed on 7/19/24 at 2:00 PM and stated she was not aware of any additional details related to documentation of R3 checked for sexually inappropriateness, in behavior tracking task on 7/04/24 at 12:11 PM, 7/06/24 at 10:22 AM and 3:09 PM; and on 7/07/24 at 12:27 PM. SS C stated R3 had the potential to masturbate in the hallway. SS C stated when behaviors were documented in behavior tracking, she reviewed the care plan, discussed the behavior in the morning meetings and revised the care plan. SS C was unable to provide details of R2's behaviors of public sexual acts documented on 6/22/24 at 4:44 PM or on 7/04/24 at 11:32 AM; in which included cursing. SS C stated R2 and R3 had medication adjustments due to increase masturbation in inappropriate places. SS C stated she had no knowledge of any abuse allegations regarding R1. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the facility had an increase in resident sexual behaviors recently. NHA A stated she did not have any knowledge of any incidents that occurred with R1, R3 or R6 on 7/04/24. NHA A stated the facility did not have cameras and recently received a quote, but cameras could be useful due to the layout of the building. During an interview on 7/23/24 at 12:29 PM, LPN J stated on 7/04/24 at 11:09 AM, a CNA reported to her R2 was following R1 around and touched R1 breasts with his hands. LPN J stated she did not see R2 touch R1's breasts, but did observe R2 following R1 around that morning. LPN J stated R2 stalked people and acted like he was crazy, but R2 knew what he was doing. LPN J stated she reported the incident to DON B via text message. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated behaviors were reviewed in the morning meetings by reviewing the dashboard and notes. DON B stated she was not aware behaviors were documented in the tasks section of the medical record and had never run that report. DON B stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation. DON B stated the first time she heard about the incidents that occurred on 7/04/24 with R1, R3, and R6 was on 7/23/24, during the survey. A reasonable person (one expect a reasonable person in a similar situation to suffer as a result of the noncompliance), in R1's position would likely suffer recurrent debilitating fear/anxiety that may be manifested as panic, immobilization, screaming, and/or extremely aggressive or agitated behavior(s) (e.g., trembling, cowering) in response to an identifiable situation (e.g., approach of specific residents) Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation, that persisted regardless of whether the precipitating event(s) had ceased. Resident #7 (R7) R7's significant change MDS assessment dated [DATE] revealed R7 had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment revealed R7 had the diagnoses of endometrial cancer, schizoaffective-bipolar type disorder, and obesity. An electronic mail (email) from hospice staff was sent to facility staff on 7/15/24 at 12:17 PM and indicated a concern regarding LPN J. The hospice staff stated they had spoken to LPN J many times; LPN J refused to give R7 additional food as requested or has removed food from R7's room. The email indicated LPN J had stated that she forced the nurse assistants to clean R7 up after R7 had refused. Hospice staff stated in the same email they had observed LPN J being very gruff and even rude toward residents, including residents that were not under hospice care. The same email indicated if R7 wished to eat chocolate pudding for every meal, then so be it. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated it was reported LPN J was rude and gruff to R7. DON B stated LPN J told R7 she did not need any more pudding because she weighed 500 pounds. DON B stated the incident with LPN J and R7 was first verbally reported on 7/12/24, and LPN J was terminated on 7/18/24. R7 was observed lying in bed 7/24/24 at 1:25 PM and stated staff were still denying her food. R7 stated she had requested a second serving at lunch and she did not receive any more food. R7 began crying during the interview and stated when denied food it made her feel less than a human. R7 stated the facility staff thinks she should be on a diet. Certified Nurse Assistant (CNA) K was interviewed on 7/24/24 at 1:30 PM and stated she had requested R7 receive more food and a kitchen staff member stated R7 already received double portions with her lunch meal. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated she did not investigate allegations of abuse regarding R7. NHA A was interviewed on 7/24/24 at 12:09 PM and stated she did not investigate the allegation of abuse reported by hospice staff because she did not receive the email. NHA A stated she has had 6 DON's since December 2023, and the DON B did not know everything she was supposed to be doing. NHA A stated staff should not deny R7's requests for food. Dietary Manager (DM) N was interviewed on 7/24/24 at 1:45 PM and stated the kitchen had run out of bratwurst's during lunch, and stated she did not know if R7 was offered a different item; but would go ask her if she would like something else to eat. Abuse Prohibition Policy revised 9/09/22, revealed the Administrator or designee would notify any State or Federal agencies of allegations per state guideline (2 hours if abuse allegation or serious injury; all others not later than 24 hours).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00145732. Based on interview and record review, the facility failed to ensure adequate staff were scheduled to supervise and report residents with sexual behaviors and protect vulnerable residents in a census of 61 residents, resulting in the likelihood of allegations of abuse not identified, reported or documented. Findings include: Facility assessment dated [DATE] indicated the facility was approximately 3200 square feet and the average daily census over the past 12 months was 62 residents. 26 residents had a diagnosis of dementia. 54 out of 62 residents were dependent or required staff assistance for dressing. 59 out of 62 residents were dependent or required staff assist for bathing. 49 out of 62 residents were dependent or required staff assist for transfers. 36 residents were dependent or required staff assist for eating. 52 out of 62 residents were dependent or required staff assist in toileting. Staff Schedule dated 6/27/24 indicated a census of 59 residents. 5 Certified Nurse Assistants (CNA's) were scheduled during the 6:00 AM to 6:00 PM shift. One CNA was scheduled to work from 6:00 AM to 10:00 AM and then go home. The same schedule indicated one restorative CNA was scheduled from 7:00 AM to 3:30 PM. There were multiple resident to resident sexual occurrences documented on 6/27/24, that indicated additional staff to supervise resident behavior may have prevented abuse. Staff Schedule dated 7/04/24 revealed a census of 59 residents. There were 5 Certified Nurse Assistants (CNA's) and 2 Nurses on the schedule to work day shift (6:00 AM to 6:00 PM). One CNA was assigned to be one to one with a resident that resided on 100 hall for the entire shift. There was one other CNA assigned to 100 hall. One CNA was noted as no call no show; and was scheduled to work from 8:00 AM through 6:00 PM on 200 hall. There were no CNA's assigned to 200 hall residents from 8:00 AM to 4:00 PM. 2 CNA's were on 300 hall. One CNA was scheduled on 400 hall from 6:00 AM to 3:30 PM. There were no CNA's scheduled on 400 hall from 3:30 PM to 6:00 PM. From 8:00 AM to 4:00 PM, there were 4 CNA's to care for 58 residents, 14 to 15 residents each. There was no restorative CNA scheduled on 7/04/24. During the survey from 7/19/24 through 7/23/24, Staff IP was interviewed and stated they recalled they had a call off on 7/04/24 and they had complained to management about the lack of enough staff. Staff D was interviewed during the survey from 7/19/24 through 7/23/24 and stated staffing on 7/04/24 was not adequate. During the survey from 7/19/24 through 7/23/24, Staff Q stated they was not enough staff on 7/04/24 and the Director of Nursing was notified. Staff Q stated they did not witness any abuse on 7/04/24, and stated they were too busy taking care of their residents to notice anything. During the survey from 7/19/24 through 7/23/24 staff E stated staffing was really difficult on 7/04/24. One resident followed the ladies around with his hand down his pants and was hard to re-direct. During the survey from 7/19/24 through 7/23/24, staff F stated on 7/04/24, there was not enough staff to meet residents needs and they did not get a break or take a lunch. During the survey from 7/19/24 through 7/23/24, staff G stated staffing on 7/04/24 was rough. One CNA was pulled to work on another hall; but the nurse kept pulling them back to work on the hall they were pulled from. There was a fall, on 7/04/24; staff G stated they had just finished assisting another resident, when he heard another resident scream. The resident bumped his head when he fell, and was attempting to use the bathroom. Staff G stated they ended their employment at the facility due to low staffing and poor resident care. Scheduler/CNA R was interviewed on 7/23/24 at 3:36 PM and stated they have budgeted hours and divide by census to determine staffing. Scheduler/CNA stated when the census drops they send staff home. Scheduler/CNA R stated 6 CNA's run a lot smoother during the day. Scheduler/CNA R stated on 7/04/24, had a craziness going on, and did not like to see that. On 6/27/24 they had 5 CNA's that day due to the census. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00145732. Based on interview and record review, the facility administration failed to operationalize its policy and procedures to manintain effective use its resources and ensure identification, investigation, and protection of residents from mental abuse, verbal abuse, sexual abuse and deprivation of goods and services in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and Resident #7), and failed to ensure sufficient nursing staff to meet residents needs and the likelihood for continued abuse and unmet resident needs in a current facility census of 61 residents. Findings include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). Progress Note dated 6/27/24 at 5:02 PM indicated R2 had been sexually inappropriate 3 times during the shift with another resident. The last occurrence was at 4:15 PM, R2 was seen behind the warming station in the dining room, with another male resident, being inappropriate below the waist, same as 2 times prior. Activities note dated 6/22/24 at 4:24 PM revealed R2 was asked 3 times to get away from another resident. R2's Behavior Monitoring and interventions task, in the electronic medical record, revealed on 6/22/24 at 4:44 PM R2 displayed public sexual acts. There were no resident at risk notes or other notes indicating the circumstances of R2's behavior on 6/22/24 at 4:44 PM was investigated or that no other residents were affected. R2's care plan dated 7/02/24 indicated he had episodes of hypersexuality (sexual addiction, excessive sexual thoughts, desires, urges or behaviors) and R2's guardian did not consent to sexual contact with R6. R6's Behavior Monitoring task indicated he had behaviors of entering others personal space, sexually touching other consenting resident, reaching out toward others, masturbating with the door open and curtain not pulled. The same report revealed R6 was sexually inappropriate on 6/27/24 at 8:55 PM, 7/04/24 at 12:10 PM and 7/21/24 at 5:36 AM. There were no investigations of documented behaviors on 7/04/24 or 7/21/24. Progress Note dated 6/27/24 at 4:39 PM revealed R6 was sexually inappropriate 3 times during the shift with another resident. The last occurrence was noted at 4:15 PM. The same note indicated when R6 was told touching other residents below the waist in the dining room was not to continue, R6 yelled and refused to leave the dining room. R6 attempted to stop staff from backing him up in his wheelchair to take him to his room. R6 was informed by the nurse that he was to stay in his room for his meal because of his inability to follow directions and for the inappropriate sexual behavior that had taken place 2 times prior. R6 started to get loud and stated he was coming out. R6 was informed that he was to stay in his room to eat because he was unable to keep his hands to himself and follow instructions. There was only one incident report generated on 6/27/24 regarding R2 and R6. Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6's chart documentation and progress notes were reviewed. The same report indicated additional interviews were not performed and was not necessary or feasible. The same report under conclusion indicated guardians of both residents did not consent for residents to participate in sexual behavior. The report instructed to provide a brief description of the plan to avoid this situation in the future; the response was education provided to residents and staff on redirection when sexual behaviors were exhibited. The same report was signed by Interim Director of Nursing (DON) B and Nursing Home Administrator (NHA) A. The same Incident and Investigation Report dated 6/27/24 at 2:39 PM instructed to describe any action taken by the facility to protect the resident during the investigation and in response to the question was education provided to Licensed Practical Nurse (LPN) J on abuse and safety policies. The same form questioned if the incident was reported to State Agency, and the facility staff checked no, it was not reported. The same investigation included an audit, a list of 21 residents, identified by room number only, dated 6/28/24. The list included 20 residents that were located on the 100 wing, and 1 resident on the 200 wing; there were no residents from the 300 or 400 units. Residents were asked two yes or no questions: had they ever been sexually abused (touched or verbal) and have they seen another resident be sexually abused. There were not any yes answers documented from the facility. Psychiatric Note dated 7/09/24 and signed by physician's assistant on 7/19/24, revealed R2 was seen due to increased inappropriate sexual behavior. Since last visit changes to R2's medications included Paxil (antidepressant) was discontinued on 7/05/24, Lexapro (antidepressant) was started on 7/12/24 by the primary care physician; and Estradiol (estrogen, female sex hormone) was started by the primary care physician on 7/06/24. The same note indicated R2 was recently noted by staff with his hands down another residents' pants. It was recommended to monitor R2, as several medication changes had been implemented by his primary care physician. Certified Nurse Assistant (CNA) M was interviewed on 7/23/24 at 2:30 PM and stated on 6/27/24, she observed R2 and R6, sitting side by side next to each other at a table in the middle of the main dining room, not behind the warming station. CNA M stated R2 was slouched in his wheelchair and R6 had his hand on R2's pants, over his perineal area. CNA M stated R2 and R6 were separated around 7 times on 6/27/24. LPN J was interviewed on 7/23/24 at 12:29 PM and stated the incident on 6/27/24 with R2 and R6 occurred more than once. LPN J stated she wrote occurrences in residents progress notes and other nurses did not because it occurred frequently. LPN J stated she was directed to chart using the term sexual behavior versus sexually inappropriate. LPN J stated on 6/27/24 following the incident with R2, an activity aide took R6 to his room. LPN J stated she went to R6 doorway and told him he needed to keep his hands to himself and that he should eat his dinner in his room. R6 wanted to go back to the dining room, and LPN J stated she told R6 to go back to his room. LPN J stated R6 was drawn to R2, and it was absolutely ridiculous. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated had been interim DON since May of 2024. DON B did not know why incident with R2 and R6 were not reported to State Agency. DON B stated LPN J attempted to barricade R6 in his room on 6/27/24. DON B stated R6 was forced to eat dinner in his room on 6/27/24 and stay in his room for approximately 2 hours. DON B stated LPN J was terminated on 7/18/24, LPN J was not removed from the schedule pending investigation. DON B confirmed she did not interview other staff regarding the incidents that occurred on 6/27/24. DON B stated she did not know why incident with R6 and LPN J was not reported to State Agency. Resident #5 (R5) and Resident #4 (R4) R5 filed a grievance on 7/02/24 alleging R4 kept harassing her and kissing her hand. The same grievance indicated R5 did not like it, it was an ongoing problem and she wanted it to stop. R5's MDS dated [DATE] revealed she was admitted to the facility on [DATE] and had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment indicated she had not had any physical, verbal or other behaviors during the look-back period. R5's progress note dated 6/19/24 indicated she had increased anxiety. Progress note dated 7/02/24 at 1:32 PM indicated they had spoke with R5 regarding the grievance filed about an altercation with a male resident. The male resident was provided with sitter to ensure resident was safe. R5 was agreeable to the plan. R4's MDS dated [DATE] revealed he had a BIMS score of 03 (00-07 Severe Cognitive Impairment). R4's Behavior Monitoring and interventions task report included history of making verbal threats of physical violence, sexual comments and sexual gestures. Progress Note dated 4/21/24 at 10:00 PM revealed R4 had to be redirected with his sexually charged language, and had been approaching residents being sexually inappropriate. Progress Note dated 4/21/24 at 10:55 PM revealed R4, over the last month, had become increasingly sexually inappropriate to staff and female residents. Progress Note dated 6/19/24 at 12:10 PM indicated R4 was being followed by resident at risk and his physician had increased his estrogen medication. The same note revealed R4 had an increase in sexually inappropriate comments, entering others personal space and attention seeking. Progress Note dated 6/30/24 at 5:21 AM revealed R4 had inappropriate behavior the first 5 hours of the shift. R4 had followed and made inappropriate comments to another female resident who told him no multiple times, when redirected resident would laugh and then hit on the nurse. R4 was continually redirected and removed twice from common areas for harassing female residents. There were no incident reports generated. Progress Note dated 6/30/24 at 9:01 PM revealed R4 .just came out of room in wheelchair and was witnessed fondeling [sic] the same female resident he has been harassing tonight and last night while this nurse [sic] taking care of him. Resident was rubbing up her arm and placing hand on her lower back, while holding her hand with his other hand. Resident reminded that hands are to be kept to himself and that it is not ok to touch other residents, especially females. Resident started laughing and said well, what can I do then, touch you? and winked and laughed and started propelling himself towards this nurse. Resident politely asked to return to his room or another area of facility away from this female resident if he could not follow rules and keep his hands to himself. Resident then returned to his room and is now resting in bed . NHA A was interviewed on 7/19/24 at 2:45 PM and stated the incident between R4 and R5 wasn't reported to State Agency; and stated that she took care of the grievance right away, the day the grievance was filed. It was not clear how many times R5 felt she was harassed or received unwanted touching by R4 or if there was a pattern regarding the time of day. Resident #1 (R1), Resident #3 (R3), Resident #6 (R6) MDS dated [DATE] revealed R1 was admitted to the facility on [DATE], had severely impaired cognition, and had diagnoses including depression and Dementia. Receptionist I was interviewed on 7/24/24 at 12:43 PM, and confirmed she was working on 7/04/24, and witnessed R3 standing in the hall by the front dining room, with his penis exposed. Receptionist I stated R1 was in her wheelchair next to him. R3 was reaching for R1's arm, like he wanted her to touch him. Receptionist I stated she separated R3 and R1 and asked activities staff to keep a close eye on R1. Receptionist I stated she reported the incident to NHA A via phone. Activities Aide (AA) O was interviewed on 7/23/24 at 3:40 PM and stated on 7/04/24, around 3:30 PM, she was in the dining room for Bingo with a group of residents, and saw R2 looking down R1 shirt and R6 hand was on top of R2's pants, over his perineal area. AA O stated she wrote a statement and put it under NHA A's door. AA O stated she had witnessed R6 chase after R2. AA O stated she had also witnessed R2 and R6 with their hands down each others pants, behind the steam table, but did not remember the date. Social Services (SS) C was interviewed on 7/19/24 at 2:00 PM and stated she was not aware of any additional details related to documentation of R3 checked for sexually inappropriateness, in behavior tracking task on 7/04/24 at 12:11 PM, 7/06/24 at 10:22 AM and 3:09 PM; and on 7/07/24 at 12:27 PM. SS C stated R3 had the potential to masturbate in the hallway. SS C stated when behaviors were documented in behavior tracking, she reviewed the care plan, discussed the behavior in the morning meetings and revised the care plan. SS C was unable to provide details of R2's behaviors of public sexual acts documented on 6/22/24 at 4:44 PM or on 7/04/24 at 11:32 AM; in which included cursing. SS C stated R2 and R3 had medication adjustments due to increase masturbation in inappropriate places. SS C stated she had no knowledge of an abuse allegation that involved R1 and other residents. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the facility had an increase in resident sexual behaviors recently. NHA A stated she did not have any knowledge of any incidents that occurred with R1, R3 or R6 on 7/04/24. NHA A stated the facility did not have cameras, but cameras could be useful because of the layout of the building, and had recently received a quote. During an interview on 7/23/24 at 12:29 PM, LPN J stated on 7/04/24 at 11:09 AM, a CNA reported to her R2 was following R1 around and touched R1 breasts with his hands. LPN J stated she did not see R2 touch R1's breasts, but did observe R2 following R1 around that morning. LPN J stated R2 stalked people and acted like he was crazy, but R2 knew what he was doing. LPN J stated she reported the incident to DON B via text message on 7/04/24. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated behaviors were reviewed in the morning meetings by reviewing the dashboard and notes. DON B stated she was not aware behaviors were documented in the tasks section of the medical record and had never run that report. DON B stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation. DON B stated the first time she heard about the incidents that occurred on 7/04/24 with R1, R3, and R6 was on 7/23/24, during the survey. Resident #7 (R7) R7's significant change MDS assessment dated [DATE] revealed R7 had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment revealed R7 had the diagnoses of endometrial cancer, schizoaffective-bipolar type disorder, and obesity. An electronic mail (email) from hospice staff was sent to facility staff on 7/15/24 at 12:17 PM and indicated a concern regarding LPN J. The hospice staff stated they had spoken to LPN J many times; LPN J refused to give R7 additional food as requested or has removed food from R7's room. The email indicated LPN J had stated that she forced the nurse assistants to clean R7 up after R7 had refused. Hospice staff stated in the same email they had observed LPN J being very gruff and even rude toward residents, including residents that were not under hospice care. The same email indicated if R7 wished to eat chocolate pudding for every meal, then so be it. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated it was reported LPN J was rude and gruff to R7. DON B stated LPN J told R7 she did not need any more pudding because she weighed 500 pounds. DON B stated the incident with LPN J and R7 was first verbally reported on 7/12/24, and LPN J was terminated on 7/18/24. DON B was interviewed on 7/24/24 at 11:21 AM and stated she did not investigate allegations of abuse regarding R7. NHA A was interviewed on 7/24/24 at 12:09 PM and stated she did not investigate the allegation of abuse reported by hospice staff because she did not receive the email. NHA A stated she has had 6 DON's since December 2023, and the DON B did not know everything she was supposed to be doing. Abuse Prohibition Policy revised 9/09/22, revealed the Administrator or designee would notify any State or Federal agencies of allegations per state guideline (2 hours if abuse allegation or serious injury; all others not later than 24 hours). Facility assessment dated [DATE] indicated the facility was approximately 3200 square feet and the average daily census over the past 12 months was 62 residents. 26 residents had a diagnosis of dementia. 54 out of 62 residents were dependent or required staff assistance for dressing. 59 out of 62 residents were dependent or required staff assist for bathing. 49 out of 62 residents were dependent or required staff assist for transfers. 36 residents were dependent or required staff assist for eating. 52 out of 62 residents were dependent or required staff assist in toileting. Staff Schedule dated 6/27/24 indicated a census of 59 residents. 5 Certified Nurse Assistants (CNA's) were scheduled during the 6:00 AM to 6:00 PM shift. One CNA was scheduled to work from 6:00 AM to 10:00 AM and then go home. The same schedule indicated one restorative CNA was scheduled from 7:00 AM to 3:30 PM. There were multiple resident to resident sexual occurrences documented on 6/27/24, that indicated additional staff to supervise resident behavior may have prevented abuse. Staff Schedule dated 7/04/24 revealed a census of 59 residents. There were 5 Certified Nurse Assistants (CNA's) and 2 Nurses on the schedule to work day shift (6:00 AM to 6:00 PM). One CNA was assigned to be one to one with a resident that resided on 100 hall for the entire shift. There was one other CNA assigned to 100 hall. One CNA was noted as no call no show; and was scheduled to work from 8:00 AM through 6:00 PM on 200 hall. There were no CNA's assigned to 200 hall residents from 8:00 AM to 4:00 PM. 2 CNA's were on 300 hall. One CNA was scheduled on 400 hall from 6:00 AM to 3:30 PM. There were no CNA's scheduled on 400 hall from 3:30 PM to 6:00 PM. From 8:00 AM to 4:00 PM, there were 4 CNA's to care for 58 residents, 14 to 15 residents each. There was no restorative CNA scheduled on 7/04/24. During the survey from 7/19/24 through 7/23/24, Staff IP was interviewed and stated they recalled they had a call off on 7/04/24 and they had complained to management about the lack of enough staff. Staff D was interviewed during the survey from 7/19/24 through 7/23/24 and stated staffing on 7/04/24 was not adequate. During the survey from 7/19/24 through 7/23/24, Staff Q stated they was not enough staff on 7/04/24 and the Director of Nursing was notified. Staff Q stated they did not witness any abuse on 7/04/24, and stated they were too busy taking care of their residents to notice anything. During the survey from 7/19/24 through 7/23/24 staff E stated staffing was really difficult on 7/04/24. One resident followed the ladies around with his hand down his pants and was hard to re-direct. During the survey from 7/19/24 through 7/23/24, staff F stated on 7/04/24, there was not enough staff to meet residents needs and they did not get a break or take a lunch. During the survey from 7/19/24 through 7/23/24, staff G stated staffing on 7/04/24 was rough. One CNA was pulled to work on another hall; but the nurse kept pulling them back to work on the hall they were pulled from. There was a fall, on 7/04/24; staff G stated they had just finished assisting another resident, when he heard another resident scream. The resident bumped his head when he fell, and was attempting to use the bathroom. Staff G stated they ended their employment at the facility due to low staffing and poor resident care. Scheduler/CNA R was interviewed on 7/23/24 at 3:36 PM and stated they have budgeted hours and divide by census to determine staffing. Scheduler/CNA stated when the census drops they send staff home. Scheduler/CNA R stated 6 CNA's run a lot smoother during the day. Scheduler/CNA R stated on 7/04/24, had a craziness going on, and did not like to see that. On 6/27/24 they had 5 CNA's that day due to the census. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess the use of a full lap tray as a potential chair restraint for one (Resident #60) of one reviewed for restraints, resulting in the potential for residents not having the least restrictive devices. Findings include: Review of the medical record reflected Resident #60 (R60) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included autistic disorder, repeated falls and Lennox-Gastaut syndrome with status epilepticus (seizure disorder). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/20/23, reflected R60 had short-term and long-term memory problems, used a wheelchair for mobility and was dependent for many aspects of care. R60 was not coded for the use of restraints. On 11/13/23 at 07:52 AM, R60 was observed in the dining room, receiving total feeding assistance by a staff member that was seated beside him. A full lap tray was observed on his wheelchair. A seatbelt was observed on the back of the chair, which was buckled on itself and not around the resident. On 11/13/23 at 08:48 AM, R60 was observed in bed, hollering repetitive sounds. R60's bed was in a low position, and an extra mattress was observed on the floor, at the right bedside. The left side of the bed was against the wall, with a mattress between the bed and the wall. On 11/13/23 at 02:08 PM, R60 was observed seated in a wheelchair near the nurse's station. A full lap tray was in place on the wheelchair. On 11/14/23 at 07:39 AM, R60 was observed in the dining room, receiving total assistance with breakfast. A full lap tray was noted on R60's wheelchair. A seatbelt was observed hanging from the back of the wheelchair, buckled on itself and not around R60. R60 was observed leaned over to the left side, with their head down. Certified Nurse Aide (CNA) G assisted to position R60 upright to accept a bite of food. During a phone interview on 11/14/23 at 09:18 AM, CNA M reported the lap tray was used for positioning and to keep R60 from falling out of their wheelchair. The lap tray had been on R60's wheelchair for about three to four months, according to CNA M. Review of R60's medical record did not reflect a Physician's Order for a lap tray. There was no assessment or evaluation for the use of the lap tray. The lap tray was not documented on the Care Plan or [NAME] (CNA care guide). During an interview on 11/14/23 at 01:34 PM, CNA G reported they knew of resident care needs by looking at the [NAME] but had never personally reviewed R60's [NAME]. If they did not know the resident, then they reviewed the [NAME]. CNA G reported coming to work one day, and the lap tray was on R60's wheelchair, with permission from R60's family member. CNA G reported R60 needed the lap tray, otherwise they would be toppled over. During an interview that began on 11/14/23 at 01:08 PM, Director of Nursing (DON) B reported R60's family member ordered their wheelchair, which had a lap tray, per the family member's request. DON B reported she did not see an assessment or order for the lap tray in R60's medical record. DON B acknowledged that the lap tray was not noted on R60's Care Plan or [NAME] but should have been. DON B stated they would have to complete a restraint assessment to make sure the device was safe, and it would have to be ordered and care planned. A Physical Device Evaluation was the initial assessment, then a Physical Restraint Reduction Assessment was to be completed quarterly, according to DON B. She reported those should have been completed for R60. The facility's Restraint Management policy, with a revision date of 9/9/22 reflected, .Restraints are not used unless the guest/resident has medical symptoms that warrant the use of the restraint .Physical Restraints are defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the guest's/resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Physical Restraints include, but are not limited to .lap trays the guest cannot easily remove. Also included as a restraint are facility practices that meet the definition of a restraint, such as .Using devices in conjunction with a chair, such as trays, tables .that the guest/resident cannot remove and prevents the guest/resident from rising . The Restraint Management policy further reflected, .When a guest's/resident's condition necessitates consideration for a restraint, alternative interventions must be attempted and documented on the Physical Device Evaluation and in the care plan .A Physical Device Evaluation will be completed prior to initiating a device by a licensed nurse or the interdisciplinary team .Guests/residents using physical restraints will have a Physical Restraint Reduction Evaluation completed quarterly, annually, and with any significant change of condition for the use and appropriateness of physical restraints .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident and/or resident's representative a written reason of transfer to the hospital for one (Resident #68) of three reviewed for transfer/discharge, resulting in the potential for residents and/or family being uninformed of the reason for transfer. Findings include: Review of the medical record reflected Resident #68 (R68) admitted to the facility on [DATE], with diagnoses that included encephalopathy (a change in brain function that may cause altered mental state and confusion), disorientation, vascular dementia and urinary tract infection. R68 did not reside in the facility at the time of the survey. A Progress Note for 9/27/23 at 2:15 PM reflected R68 had an unobserved fall and was observed on the floor, with blood coming from their right ear and mouth. R68 was sent to the emergency room for evaluation. There was no documentation of a written transfer notice in R68's medical record. On 11/15/23 at 12:31 PM, an email was sent to Nursing Home Administrator (NHA) A to request items that included the transfer/discharge notice. During an interview on 11/15/23 at 01:31 PM, NHA A reported the transfer notice with appeal rights and Ombudsman contact information would be given to residents when they left the facility. The facility did not retain a copy. A completed transfer/discharge notice was not provided prior to the exit of the survey on 11/15/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12 (R12): Review of the medical record reflected R12 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), delusional disorders, major depressive disorder and anxiety disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/19/23, reflected R12 was coded for routine antipsychotic use. The MDS reflected a gradual dose reduction (GDR) had not been attempted and was not documented by a physician as clinically contraindicated. A Physician's Order, with a start date of 6/21/23, reflected Zyprexa (antipsychotic medication) 15 milligrams (mg) was to be given daily, at bedtime. R12's Zyprexa order history reflected a prior dose of 20 mg daily with a start date of 5/12/23 and a stop date of 6/20/23. During an interview on 11/15/23 at 08:47 AM, Social Worker (SW) C reported R12 had a GDR of Zyprexa on 6/21/23. Psychiatric Services Notes for 7/11/23, 9/12/23 and 10/11/23 documented GDRs as clinically contraindicated. However, the 7/11/23 note reflected R12's Zyprexa GDR appeared successful. During an interview on 11/15/23 at 09:50 AM, MDS Coordinator D reported R12's quarterly MDS with an ARD of 8/19/23 was inaccurately coded and should have reflected that a GDR had been initiated on 6/21/23. Based on observation, interview and record review the facility failed to ensure accurate Minimum Data Set (MDS) assessments for three (Resident #6, #12, #31 ) of 16 reviewed, resulting in inaccurate MDS assessments and the potential for unmet care needs. Findings include: Resident #6 (R6) Review of the medical record revealed R6 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease. The MDS with an Assessment Reference Date (ARD) of 8/9/23 revealed R6 had a significant weight loss of 5% or more in the last month or 10% or more in last 6 months. On 11/13/23 at 12:26 PM, R6 was observed feeding herself in the dining room. Review of R6's weight history revealed the following weights: 1/5/23 221.8 pounds (#) 3/8/23 223.6# 4/6/23 219.4# 5/1/23 221.7# 6/6/23 214.2# 7/7/23 215.8# 8/7/23 211.6# R6 did not have a significant weight loss of 5% or more in one month or 10% or more in the last 6 months. In an interview on 11/13/23 at 2:08 PM, MDS Coordinator D reported R6 did not have a significant weight loss during the look back period and agreed the MDS was incorrectly coded. Resident #31 (R31) Review of the medical record revealed R31 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included Alzheimer's Disease, anxiety, schizophrenia, insomnia, major depressive disorder, and bipolar disorder. The MDS with an ARD of 9/15/23 revealed R31 received antipsychotic medications on a routine basis and that a physician had not documented a Gradual Dose Reduction (GDR) as clinically contraindicated. Review of the psychiatric group's progress note dated 6/17/23 revealed documentation that a GDR was clinically contraindicated for R31. In an interview on 11/15/23 at 9:49 AM, MDS Coordinator D reported R31's MDS with an ARD of 9/15/23 was inaccurate and should have reflected that R31's GDR was documented as clinically contraindicated on 6/17/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a baseline care plan summary was provided for one (Resident #68) of 12 reviewed for care plans, resulting in the potential for care preferences not being honored and unmet care needs. Findings include: Review of the medical record reflected Resident #68 (R68) admitted to the facility on [DATE], with diagnoses that included encephalopathy (a change in brain function that may cause altered mental state and confusion), disorientation, vascular dementia and urinary tract infection. R68's medical record reflected they transferred to the hospital on 9/27/23 and did not reside in the facility at the time of the survey. According to the medical record, R68 was his own responsible party. The medical record did not reflect documentation that a care conference had been provided to R68 or that they had been provided with a summary of the baseline care plan. During an interview on 11/15/23 at 12:53 PM, Nursing Home Administrator (NHA) A reported R68 was his own responsible party, and the facility went over the baseline care plan at the 72 hour care conference. On 11/15/23 at 01:31 PM, NHA A confirmed that R68's care conference was not held. She stated a baseline care plan summary would have been reviewed and offered during the care conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide range of motion/restorative services for one (Resident #61) of two reviewed, resulting in the potential for a decrease in range of motion and worsening contractures. Findings include: Review of the medical record revealed Resident #61 (R61) was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included cerebral infarction and bipolar disorder. the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/23 revealed R61 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had functional limitation in range of motion impairments on both sides of upper and lower extremities. On 11/13/23 at 8:45 AM, R61 was observed with contractures in both hands. R61 did not have a brace or splint on either hand. There was a brace observed on R61's roommate's side of the room. R61's roommate reported the brace did not belong to her. On 11/13/23 at 9:04 AM, R61 was observed using her communication board. R61 did not have a brace in place to either hand. R61 used her right pinky finger to point to the letters on the communication board. On 11/13/23 at 10:47 AM, R61 was observed in the hall propelling her wheelchair with her feet. R61 did not have a brace or splint to either hand. R61 used the communication board to spell out answers to questions. R61 reported she did not have a hand brace, but she had asked for one. R61 demonstrated she was not able to extend her fingers on her left hand and could partially extend her fingers on her right hand. On 11/13/23 at 12:31 PM, R61 was observed self-propelling her wheelchair with her feet. R61 did not have a brace on either hand. Resident # 61 went on a leave of absence with her family on 11/13/23 and did not return until the evening of 11/14/23. Review of R61's Physical Therapy and Occupational Therapy notes revealed on 8/14/23 a WHFO (brace/splint) was trialed for R61's right upper extremity. The notes dated 8/22/23 revealed the WHFO (brace/splint) to the left hand to reduce risk of contractures was adjusted for comfort. R61 was instructed to wear the brace for a couple hours at a time. The notes dated 8/24/23 revealed object placement/release techniques were done with R61's right upper extremity to increased movements. R61 reported she did not like the WHFO brace and would not use it. Review of R61's Activities of Daily Living (ADL) Self Care Performance Deficit care plan revealed the intervention of Please apply right hand brace this should be placed everyday it is to keep her index finger from becoming contracted was initiated on 10/11/23. Review of the restorative documentation provided by Nursing Home Administrator (NHA) A for R61's entire stay at the facility revealed the documentation was not included in the electronic medical record. The Resident Daily Progress Notes dated 10/11/23 revealed Has hand brace for her right hand that needs to be placed everyday. There was no further mention of the brace in restorative documentation. In an interview on 11/13/23 at 2:38 PM, Certified Nursing Assistant (CNA) G reported she was the facility's restorative program CNA. CNA G reported she recently found out that R61 was supposed to have a brace for her left hand. CNA G reported she cannot perform range of motion to R61's fingers because R61's fingers were contracted. CNA G reported it has become more difficult for R61 to grip the walker due to worsening contractures. In an interview on 11/14/23 at 8:21 AM, Occupational Therapist (OT) F reported she was the therapy director. OT F reported R61's current restorative program consisted of balance activities, ambulating, lower extremity exercises, and toilet transfer. OT F reported she was not familiar with a hand brace for R61. OT F referenced the therapy notes and reported a brace was trialed to R61's right hand, but R61 did not want to use the brace. OT F reported there were other options that could be trialed such as a different brace, palm protector, or wash cloth, but the documentation did not reflect anything else had been trialed to help prevent contractures and worsening of contractures. In an interview on 11/14/23 at 1:08 PM, Director of Nursing (DON) B reported R61's restorative program included toilet transfers and standing on parallel bars. When asked about range of motion to her upper extremities, DON B reported R61 wore a splint. When asked about the documentation of the splint use and or refusals of the splint, DON B reported when R61 readmitted to the facility on [DATE], her restorative program did not get entered in the medical record and therefore it was not documented as it should have been. DON B reported she was not aware of R61 refusing the use of a splint. In an interview on 11/15/23 at 8:16 AM, OT F and Certified Occupational Therapy Assistant (COTA) H reported the therapy documentation was incorrect and that R61's brace was for her left hand. OT F reported the brace in R61's room did not belong to R61 or her roommate. OT F reported they were unable to locate R61's splint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician ordered parameters upon administration of blood pressure medications for one (Resident #31) of 5 reviewed for unnecessary medications, resulting in the potential for adverse drug consequences. Findings include: Review of the medical record revealed Resident #31 (R31) admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included hypertension (high blood pressure). On 11/14/23 at 8:57 AM, R31 was observed awake in bed. Review of the Physician's Order with a start date of 6/8/23 revealed an order for Bumex 1 milligram (mg) two times a day, hold if blood pressure is not above 120/80. The Physician's Order with a start date of 6/9/23 revealed an order for Amlodipine 10 mg daily, hold if blood pressure is not above 120/80. Review of the Medication Administration Record (MAR) revealed Amlodipine and Bumex were given when R31's blood pressure was not above 120/80 on 7/13/23, 7/16/23, 7/22/23, 7/28/23, 8/3/23, 8/5/23, 8/6/23, 8/9/23, 8/10/23, 8/11/23, 9/4/23, 9/25/23, 9/30/23, 10/2/23, 10/5/23, and 11/2/23. In an interview on 11/15/23 at 10:30 AM, Director of Nursing (DON) B reported R31's blood pressure parameters were not clear and that the order needed to be clarified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain radiology services for one (Resident #11) of one reviewed, resulting in the potential for misdiagnosed medical conditions and ineffective treatment. Findings include: Review of the medical record revealed Resident #11 (R11) admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included end stage renal disease. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/11/23 revealed R11 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 11/14/23 at 8:12 AM, R11 was observed awake in bed. R11 reported she recently had a respiratory infection with chest congestion and yellow and brown sputum. Review of the telehealth note dated 11/6/23 revealed R11's dialysis center order an antibiotic for chest congestion. The note revealed Ordered CXR [chest x-ray] and CBC with diff [lab work] as well. There was no documentation or results of a chest x-ray in R11's medical record. In an interview on 11/14/23 at 1:08 PM, Director of Nursing (DON) B reported a physician's order for the chest x-ray was not written. DON B was unable to locate evidence that R11's chest x-ray was performed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure appropriate transmission-based precautions (TBP) and disposal of personal protective equipment (PPE) for one (Resident #12) of one reviewed for TBP, resulting in the potential for the spread of infection to other facility residents. Findings include: Review of the medical record reflected R12 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), delusional disorders, major depressive disorder and anxiety disorder. R12's medical record reflected a bronchial wash laboratory result that was collected on 11/2/23, with detection of rhinovirus (virus), pseudomonas aeruginosa (bacteria), proteus (bacteria), staphylococcus aureus (bacteria) and strep agalactiae (bacteria). A Physician's Order, with a revision date of 11/10/23, reflected R12 was to be on droplet precautions (precautions intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions) and contact precautions (precautions intended to prevent transmission of infectious agents that are spread by direct or indirect contact with a patient or their environment). On 11/13/23 at 06:51 AM, Certified Nurse Aide (CNA) J was observed entering R12's room with a gown, surgical mask, face shield and gloves on. Upon exiting the room, CNA J removed the PPE and discarded the items in a trash receptacle in the hallway. The lid of the trash was left displaced. CNA J reported R12 had a contagious respiratory virus, which she believed to be rhinovirus, so staff had to wear PPE for R12's room. A sign on R12's room door was reflective of droplet and contact precautions. There was an additional stop sign to see the nurse before entering. During an observation that began on 11/13/23 at 07:55 AM, CNA J was observed providing a breakfast tray to R12, without the use of PPE. On 11/13/23 at 08:07 AM, CNA J stated it was a mistake to deliver R12's breakfast tray without wearing PPE. She reported staff were supposed to have PPE on with each interaction with the resident. During an interview on 11/13/23 at 09:41 AM, Licensed Practical Nurse (LPN) I reported R12 was on an antibiotic for several respiratory bacterial lung infections and rhinovirus. When queried on PPE use for contact with R12, LPN I stated she wore a mask, gown and gloves. She stated she did not wear a face shield because she had a mask on. On 11/14/23 at 07:46 AM, R12 was observed from the hallway, to be lying in bed. A PPE cart and trash receptacle were observed outside the room door. The trash receptacle, which had a lid that flipped/turned, was observed open, with a used gown hanging out of it. During an interview on 11/15/23 at 10:30 AM, Director of Nursing (DON) B reported a gown, gloves, mask and face shield or goggles were to be worn during contact with R12 and when in their room.

Based on interview and record review the facility failed to address and resolve grievances brought forth by the Resident Council resulting in unmet needs, missing items, and not getting their basic needs met. Findings include: During a record review of the past year's grievance forms, several of the forms were not filled out completely. The last option on the form was the follow up section to be completed by the facility person addressing the complaint. Resident Council President had signed off on many of these grievances agreeing to the action that was documented to take place, not knowing the follow up findings from the facility. During an interview on 11/14/23 at 2:45PM, Resident Council President stated Next time she would not be signing any forms until she knows for sure that the grievance was resolved. During a resident council meeting on 11/14/23 at 02:00 PM, there were concerns voiced from the group of 18 residents that had not been resolved. 1) Call light response time was an ongoing problem, it was resolved for one month, and then not the next month. Resident Council President stated The facility filled out the grievance form with the actions that were going to take place and asked her to sign it. Then it came back up as a problem the next meeting. 2) Showers and bathes were brought up. 6 out of 18 residents voiced that they were not getting the bathes and showers they want. The residents shared that they ask for another shower and are told that was not their shower day or staff do not have time. There were 9 grievances filled out on this during the last year. 4) CENA's are turning off the call lights without providing care, telling the resident they will be back, and never return. Resident council group voiced concerns with the CENAs on night shift. Resident shared if you turn the call light on at 0400, they won't answer the call light telling them they are making rounds and cannot help them. There were 6 grievances filled out this during the last year. 5) Missing clothing items did not get any better. There were 19 grievances filled out on this during the last year. 6) Staff being respectful and showing dignity. Resident council group voiced concerns with the CENAs on night shift. There were 7 grievances filled out on this during the last year. 7) Don't know what the medications are that they are taking, asked the nurse and they don't know or won't tell them. Group discussion on the right to know what the medications are for. 8) The group voiced concern on not getting fresh water delivered to their rooms more than once daily. They would like it two or three times a day. 9) The group voiced concerns about their rooms and bathrooms not being cleaned. There were 5 grievances filled out on this during the last year. During an interview on 11/15/23 at 11:30AM, Administrator A stated that there were so many sections to the grievance forms that she questioned if they needed to use all of them. Then stated she wasn't aware that some of the concerns were still a problem and going to look at the current process. Record review of the grievance policy titled Care Policy. The CARE process listed out the steps. 1) Concern .staff should encourage and assist the resident in completing a grievance form . 2) Action .all concerns will be discussed with department managers during the morning interdisciplinary team following the day of receipt. The department manager or designee will have 5-7 days to complete the investigation and document their conclusions. 3) Response .The administrator or department manager will contact the resident within 72 hours of receipt of the concern to inform them of the status of the concern 4) Evaluation .The administrator or designee will follow up with the concern within 7 days after the initial follow-up to assure that the concerns are addressed to their satisfaction. The facility representative will continue to complete quality rounds as scheduled to continue to ensure concerns are resolved .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #48 (R48) Review of the medical record revealed Resident #48 (R48) was admitted to the facility on [DATE] with diagnoses that included Dementia, Major Depression, Anxiety, Muscle Weakness, Difficulty in Walking. According to Resident #48 (R48)'s Minimum Data Set (MDS) dated [DATE], revealed R48 scored 03 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R48 was independent with ambulation, completing her own activities of daily living. During a record review of R48's care plan and nursing progress notes revealed R48 had 2 falls on 10/26/23 and went to the emergency department for new symptoms of dizziness and a large hematoma from hitting the back of her head. 10/27/23 R48 was released from the emergency department and returned to facility. R48 did not have any new interventions for the new falls. During a record review of 48's care plan and nursing progress notes revealed R48 had a third fall on 10/31/23 at 10:30PM in her bedroom, face down on stomach, small laceration on bridge of her nose. R48 went to the emergency room for evaluation. R48 did not have any new interventions for the new fall. During a record review R48's care plan and nursing progress notes revealed R48 was started on oxygen at 1 lpm per nasal canula on 10/29/23 and this was not on her care plan. No focus, goal or interventions were found. Resident #60 (R60): Review of the medical record reflected R60 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included autistic disorder, repeated falls and Lennox-Gastaut syndrome with status epilepticus (seizure disorder). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/20/23, reflected R60 had short-term and long-term memory problems, used a wheelchair for mobility and was dependent for many aspects of care. R60 was not coded for the use of restraints. On 11/13/23 at 07:52 AM, R60 was observed in the dining room, receiving total feeding assistance by a staff member that was seated beside him. A full lap tray was observed on his wheelchair. A seatbelt was observed on the back of the chair, which was buckled on itself and not around the resident. On 11/13/23 at 08:48 AM, R60 was observed in bed, hollering repetitive sounds. R60's bed was in a low position, and an extra mattress was observed on the floor, at the right bedside. The left side of the bed was against the wall, with a mattress between the bed and the wall. On 11/13/23 at 02:08 PM, R60 was observed seated in a wheelchair near the nurse's station. A full lap tray was in place on the wheelchair. On 11/14/23 at 07:39 AM, R60 was observed in the dining room, receiving total assistance with breakfast. A full lap tray was noted on R60's wheelchair. A seatbelt was observed hanging from the back of the wheelchair, buckled on itself and not around R60. R60 was observed leaned over to the left side, with their head down. Certified Nurse Aide (CNA) G assisted to position R60 upright to accept a bite of food. During a phone interview on 11/14/23 at 09:18 AM, CNA M reported the lap tray was used for positioning and to keep R60 from falling out of their wheelchair. The lap tray had been on R60's wheelchair for about three to four months, according to CNA M. Review of R60's medical record did not reflect a Physician's Order for a lap tray. There was no assessment or evaluation for the use of the lap tray. The lap tray was not documented on the Care Plan or [NAME] (CNA care guide). During an interview on 11/14/23 at 01:34 PM, CNA G reported they knew of resident care needs by looking at the [NAME] but had never personally reviewed R60's [NAME]. If they did not know the resident, then they reviewed the [NAME]. CNA G reported coming to work one day, and the lap tray was on R60's wheelchair, with permission from R60's family member. CNA G reported R60 needed the lap tray, otherwise they would be toppled over. During an interview that began on 11/14/23 at 01:08 PM, Director of Nursing (DON) B reported R60's family member ordered their wheelchair, which had a lap tray, per the family member's request. DON B reported she did not see an assessment or order for the lap tray in R60's medical record. DON B acknowledged that the lap tray was not noted on R60's Care Plan or [NAME] but should have been. Based on observation, interview, and record review the facility failed to revise care plans for four (Resident #6, #48, #60, #61) of 16 reviewed, resulting in the potential for unmet care needs. Findings include: Resident #6 (R6) Review of the medical record revealed R6 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease. Review of R6's [NAME] (care guide) revealed R6 was on a 1500 milliliter (mL) fluid restriction. R6's Fluid Overload care plan also revealed R6 was on a 1500 mL fluid restriction as of 1/29/21. On 11/13/23 at 12:26 PM, R6 was observed feeding herself in the dining room. Review of R6's tray ticket revealed no mention of a fluid restriction. Review of the Physician's Order revealed R6's fluid restriction was discontinued on 7/22/22. In an interview on 11/13/23 at 1:37 PM, Certified Dietary Manager (CDM) E reported R6 was no longer on a fluid restriction. In an interview on 11/13/23 at 2:08 PM, Minimum Data Set (MDS) Coordinator D reported R6 was no longer on a fluid restriction and that it should no longer be on her care plan. Resident #61 (R61) Review of the medical record revealed R61 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included cerebral infarction and dysphagia. On 11/13/23 at 9:04 AM, R61 was observed in her room eating lunch. R61 used a communication board to communicate and reported she was no longer fed through her feeding tube. Review of the Nursing Summary dated 10/21/2023 revealed R61 has a feeding tube in place but does not use it. Review of R61's nursing care plans revealed she was unable to tolerate food and/or fluids by mouth and required the use of a feeding tube. The nursing care plans revealed R61 was NPO (nothing by mouth). Review of the dietary care plans revealed R61 ate a puree texture diet. Both care plans were active. In an interview on 11/13/23 at 1:37 PM, CDM E reported R61 was eating oral foods and no longer fed through her feeding tube. In an interview on 11/13/23 at 2:08 PM, MDS Coordinator D agreed R61's care plans contained conflicting information and reported the dietary care plans were updated, but the nursing care plans were not updated. MDS Coordinator D reported R61 was no longer fed through her feeding tube and was eating food orally.

Based on observation, interview, and record review the facility failed to follow acceptable professional practice for maintaining controlled medication for three out of four medication carts resulting in the potential for controlled medication diversion. Findings included: During observation the 100 hall Controlled Substance Shift to Shift Count Sheet, on 11/14/2023 at 01:12 p.m., demonstrated that Signature On coming was left blank for the date of 11/14/2023 at the time of 06:35 a.m The document did contain Signature Off going for the same date and time. During an interview on 11/14/2023 at 01:12 a.m. Registered Nurse (RN) Q explained that she was the ongoing nurse for the day shift on 11/14/2023. She explained that it was professional practice to count the controlled mediation, of the mediation stored in the controlled medication drawer, of the cart at the beginning and end of each shift or when a control of the medication cart was changed. RN Q confirmed that she had not signed the Controlled Substance Shift to Shift Count Sheet for 11/14/2023 at 06:35 a.m. but stated her and the nurse that was the off going nurse did do a control count. RN Q was observed signing the Controlled Substance Shift to Shit Count Sheet at the conclusion of interview. During observation of the 300 hall Controlled Substance Shift to Shift Count Cheet on 11/14/2023 at 01:22 p.m., demonstrated that the signature for both off going and on coming was last signed at 11/14/2023 at 08:20 a.m. The nurse that currently had control of the 300 hall medication cart was not the person that had signed as the on coming nurse. Durinn and interview on 11/14/2023 at 01: 23 p.m. Registered Nurse D explained that she was given control of the 300 hall medication cart sometime around 12:00 a.m. by Director of Nursing B. She explained that a controlled medication count was not conducted at that time. During observation of the 400 hall Controlled Substance Shift to Shift Count Sheet, on 11/14/2023 at 01:24 p.m., demonstrated that the signature of off going on 11/14/2023 at 11:00 a.m. was not signed. A signature was present for the same date and time of the on coming. During an interview on 11/14/2023 at 01:24 p.m. Registered Nurse (RN) O explained that she was the on coming nurse on 11/14/2023 at 11:00 a.m. and that the Director of Nursing (DON) B had been the off going staff member who had control of the medication cart. She explained that DON B and herself had counted the controlled medication at that time but could not explain why DON B had not signed the Controlled Substance Shift to Shift Count Sheet after the control count was completed. In an interview on 11/14/2023 at 02:17 a.m. Director of Nursing (DON) B explained that it was professional practice that nurses would conduct a controlled medication count whenever there was a change in the nurse that had control of the medication cart. DON B explained that the controlled count would be recorded on the Controlled Substance Shift to Shift Count Sheet and both staff members would sign in the appropriate location. DON B confirmed that she had been in control of the 300 hall and the 400 hall medication carts earlier in the day on 11/14/2023. DON B reviewed the Controlled Substance Shift to Shift Count Sheet for the 300 hall but could not explain why a controlled count was not completed after she provided control of the medication cart to Registered Nurse (RN) D. DON B reviewed the Controlled Substance Shift to Shift Count Sheet for the 400 hall and confirmed that her signature was not present as the off going. She explained that a count of the cart was conducted with RN O but could not provide an answer as to why her signature was not present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12 (R12): Review of the medical record reflected R12 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), delusional disorders, major depressive disorder and anxiety disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/19/23, reflected R12 was coded for routine antipsychotic use. The MDS reflected a gradual dose reduction (GDR) had not been attempted and was not documented by a physician as clinically contraindicated. A Physician's Order, with a start date of 6/21/23, reflected Zyprexa (antipsychotic medication) 15 milligrams (mg) was to be given daily, at bedtime. R12's Zyprexa order history reflected a prior dose of 20 mg daily with a start date of 5/12/23 and a stop date of 6/20/23. A Physician's Order dated 6/3/23 reflected, Monitor resident for the following side effects related to antipsychotic medication use and contact practitioner if indicated (Document the number of the side effect(s) observed): (1)Blurred Vision, (2)Confusion, (3)Constipation, (4)Drooling, (5)Dry Mouth, (6)Involuntary Movement, (7)Muscle Rigidity, (8)Restlessness, (9)Sedation, (10)Sleep Disturbance, (11)Stiffness of Neck, (12)Weight Changes, (13) Orthostatic Hypotension, (0)None Observed every shift . R12's medical record was not reflective of an order to obtain orthostatic blood pressures (blood pressures taken when lying, sitting and standing to determine if blood pressure drops with position changes) or evidence of orthostatic blood pressure monitoring. Resident #34 (R34): Review of the medical record reflected R34 admitted to the facility on [DATE], with diagnoses that included unspecified dementia, major depressive disorder and anxiety disorder. The quarterly MDS, with an ARD of 9/10/23, reflected R34 received antipsychotic medication on a routine basis. On 11/13/23 at 02:02 PM, R12 was observed self-propelling his wheelchair out of his room, into the hallway. A Physician's Order, with a revision date of 10/29/23, reflected R34 was to receive Seroquel (antipsychotic medication) 25 mg every morning and every evening. A Physician's Order, with a revision date of 10/28/23, reflected R34 was to receive 100 mg of Seroquel at bedtime. A Physician's Order, dated 9/1/22, reflected, Monitor resident for the following side effects related to antipsychotic medication use and contact practitioner if indicated (Document the number of the side effect(s) observed): (1)Blurred Vision, (2)Confusion, (3)Constipation, (4)Drooling, (5)Dry Mouth, (6)Involuntary Movement, (7)Muscle Rigidity, (8)Restlessness, (9)Sedation, (10)Sleep Disturbance, (11)Stiffness of Neck, (12)Weight Changes, (13) Orthostatic Hypotension, (0)None Observed every shift. R34's medical record was not reflective of orthostatic blood pressure monitoring. During an interview on 11/15/23 at 10:30 AM, Director of Nursing (DON) B reported orthostatic blood pressures had been ordered on 11/14/23 for every resident that was on an antipsychotic medication. Based on observation, interview, and record review, the facility failed to monitor for adverse side effects of antipsychotic medications for four (Resident #12, #31, #34, and #37) of five reviewed, resulting in the potential of adverse medication side effects. Findings include: Resident #31 (R31) Review of the medical record revealed R31 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included Alzheimer's Disease, schizophrenia, and bipolar disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/15/23 revealed R31 received antipsychotic medication on a routine basis. On 11/14/23 at 8:57 AM, R31 was observed awake in bed. Review of the Physician's Order dated 3/8/23 revealed an order for Risperdal (antipsychotic medication) 0.5 milligrams (mg) two times a day. Review of the Physician's Order dated 3/9/23 revealed Monitor resident for the following side effects related to antipsychotic medication use and contact practitioner if indicated (Document the number of the side effect(s) observed): (1)Blurred Vision, (2)Confusion, (3)Constipation, (4)Drooling, (5)Dry Mouth, (6)Involuntary Movement, (7)Muscle Rigidity, (8)Restlessness, (9)Sedation, (10)Sleep Disturbance, (11)Stiffness of Neck, (12)Weight Changes, (13) Orthostatic Hypotension. Review of R31's psychotropic medication care plan revealed an intervention dated 11/13/21 to obtain orthostatic blood pressures monthly. Review of the medical record revealed R31 did not have orthostatic blood pressures documented. Resident #37 (R37) Review of the medical record revealed R37 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included psychosis, dementia, delusional disorders, auditory hallucinations, and visual hallucinations. The MDS with an ARD of 9/7/23 revealed R37 received antipsychotic medication on a routine basis. Review of the Physician's Order dated 10/26/21 revealed an order for Risperdal 0.75 mg at bedtime. Review of the Physician's Order dated 5/27/21 revealed Monitor resident for the following side effects related to antipsychotic medication use and contact practitioner if indicated (Document the number of the side effect(s) observed): (1)Blurred Vision, (2)Confusion, (3)Constipation, (4)Drooling, (5)Dry Mouth, (6)Involuntary Movement, (7)Muscle Rigidity, (8)Restlessness, (9)Sedation, (10)Sleep Disturbance, (11)Stiffness of Neck, (12)Weight Changes, (13) Orthostatic Hypotension. Review of the Physician's Order dated 7/31/23 revealed an order for orthostatic blood pressure. The order did not specify a frequency. Review of R37's antipsychotic and antidepressant care plan revealed an intervention of obtaining orthostatic blood pressure monthly. Review of the medical record revealed R37 did not have orthostatic blood pressures documented. In an interview on 11/14/23 at 1:08 PM, Director of Nursing (DON) B reported residents who were monitored for orthostatic hypotension, should have an order for monthly orthostatic blood pressures. DON B reported orthostatic blood pressures were not documented for R31 or R37.

Based on observation interview and record review the facility failed to monitor medication refrigerators for three of three medication refrigerators resulting in the potential for residents to receive medication that is not providing its effective efficiency. Finding included: During observation of the 100 hall/200 hall medication storage room on 11/14/2023 at 01:17 p.m. it was observed that the medication storage room had one medication refrigerator. Review of the facility Vaccine Storage Temperature Log demonstrated that the temperature of the medication refrigerator was to be documented twice each date. Review of the Vaccine Storage Temperature Log demonstrated that the temperatures were not recorded for: 11/01/2023 a.m. shift, 11/04/2023 a.m. and p.m. shifts, 11/05/2023 a.m. shift, 11/08/2023 p.m. shift, 11/11/2023 a.m. shift, 11/12/2023 a.m. and p.m. shifts, and 11/13/2023 a.m. and p.m. shifts. During observation of the 300 hall/400 hall medication storage room on 11/14/2023 at 01:32 p.m. it was observed that the medication storage room had two medication refrigerators. Review of the facility Vaccine Storage Temperature Log for the refrigerator labeled under counter, demonstrated that temperatures were not record for 11/04/2023 a.m. shift, 11/05/2023 a.m. shift, 11/08/2023 a.m. and p.m. shifts, 11/9/2023 a.m. shift, 11/10/2023 a.m. and p.m. shifts, and 11/12/2023 a.m. and p.m. shifts. During an interview on 11/14/2023 at 02:17 p.m. Director of Nursing (DON) B explained that all mediation storage refrigerators, located in the medication rooms, where to have a recorded temperature twice per each 12-hour shift. DON B explained that those temperatures were to be recorded on the facility Vaccine Storage Temperature Log. DON B reviewed the three Vaccine Storage Temperature Logs, as listed above, and confirmed that the temperatures where not recorded for the dates and times as listed above. Review of facility policy entitled Storage and Expiration Dating of Medications, Biologicals with an implementation date of 12/01/07 and a most revision date of 08/07/2023 demonstrated #10 Facility staff should monitor the temperature of vaccines twice per day. The policy also list #10.3.1 Facility should monitor the temperature of medication storage areas at least once per day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain laboratory draws on four (Resident #11, #34, #37 and #47) of seven reviewed for laboratory monitoring, resulting in the potential for unrecognized and/or untreated abnormal laboratory results. Findings include: Resident #34 (R34): Review of the medical record reflected R34 admitted to the facility on [DATE], with diagnoses that included unspecified dementia, major depressive disorder and anxiety disorder. On 11/13/23 at 02:02 PM, R12 was observed self-propelling his wheelchair out of his room, into the hallway. A Pharmacy Consultation Report with a recommendation date of 3/7/23 reflected R34 received a magnesium supplement but did not have a serum magnesium concentration documented in the medical record in the past 6 months. The recommendation was to monitor a serum magnesium concentration on the next convenient lab day and every six months thereafter. The physician accepted the recommendation on 3/13/23. Review of R34's laboratory reports reflected a magnesium level was drawn on 4/10/23, with a normal result. R34's medical record did not reflect further evidence of magnesium level monitoring after 4/10/23. During an interview on 11/15/23 at 10:30 AM, Director of Nursing (DON) B reported she did not see that a magnesium level had been drawn for R34 since 4/10/23. DON B reported the laboratory specimen should have been drawn in October (2023). Resident #47 (R47): Review of the medical record reflected R47 admitted to the facility on [DATE], with diagnoses that included congestive heart failure and diabetes. On 11/13/23 at 08:36 AM, R47 stated she took insulin sometimes when her blood sugar was too high. Sometimes she felt dizzy, like she was going to pass out when her blood sugar was too high or low. On 11/14/23 at 07:50 AM, R47 was observed lying on her left side, in bed, facing the window. A Pharmacy Consultation Report with a recommendation date of 1/10/23 reflected R47 was on Cozaar (blood pressure medication), which increased the risk for kidney injury and electrolyte abnormalities, but R47 did not have serum creatinine or electrolyte evaluation in the medical record within the previous six months. The recommendation was to obtain a Basic Metabolic Panel (BMP/laboratory test that includes monitoring of kidney function and electrolytes) on next convenient lab day and every six months after. R47's medical record reflected a BMP was drawn on 1/17/23 and not again until 10/16/23 (almost nine months later). A Pharmacy Consultation Report with a recommendation date of 8/15/23 reflected R47 received a medication (Cozaar) that increased the risk for kidney injury and electrolyte abnormalities, but R47 did not have a serum creatinine or electrolyte evaluation documented in the medical record within the previous six months. The recommendation was to obtain a BMP on the next convenient lab day and every six months thereafter. A creatinine level was drawn on 8/29/23. There was no evidence of a BMP being drawn until 10/16/23. During an interview that began on 11/14/23 at 01:08 PM, DON B reported R47 had a BMP on 1/17/23 and should have had another in July 2023. DON B reported R47's next BMP was not until 10/16/23. A Physician's Order, with a revision date of 5/11/23, reflected R47 received seven units of Insulin Glargine (long-acting insulin) daily for diabetes. A Pharmacy Consultation Report with a recommendation date of 3/7/23 reflected R47 had diabetes, but a hemoglobin A1c (laboratory test that measures the three month average of blood sugar levels) was not available in the medical record in the past six months. The recommendation was to monitor hemoglobin A1c on the next convenient lab day and every six months if meeting treatment goals or every three months if therapy changed or goals were not being met. A Physician's Order, with a revision date of 4/10/23, reflected R47 was to have a hemoglobin A1c drawn now and every six months for routine monitoring. R47's laboratory reports reflected a hemoglobin A1c of 7.2 percent (high) on 4/11/23. R47's medical record was not reflective of a hemoglobin A1c after 4/11/23. A Pharmacy Consultation Report with a recommendation date of 11/9/23 reflected R47 had diabetes but a hemoglobin A1c was not available in the medical record in the past 6 months. The recommendation was to monitor hemoglobin A1c on the next convenient lab day and every six months if meeting treatment goals or every three months if therapy changed or goals were not being met. During an interview that began on 11/14/23 at 01:08 PM, DON B reported R47 had a hemoglobin A1c on 4/11/23 and another was being drawn that day (11/14/23). DON B was unsure of why a hemoglobin A1c was not drawn in October 2023 but acknowledged that one should have been. During an interview on 11/14/23 at 11:12 AM, Registered Nurse (RN) O reported laboratory orders usually appeared on the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and they had one to three days to draw the labs. RN O stated some nurses put a paper slip in the laboratory book. If an order was received for labs now and in six months, the order was placed in the electronic medical record, then should populate on the MAR or TAR for the nurse to be aware of the laboratory draw, according to RN O. RN O stated it was the responsibility of the nurse to notify the facility staff member responsible for laboratory draws that one was due. On 11/14/23 at 01:34 PM, Certified Nurse Aide (CNA) G reported being aware of laboratory draw needs based on the orders that were placed in the laboratory book/binder. During an interview that began on 11/14/23 at 01:08 PM, DON B reported the facility staff member in charge of laboratory draws used the laboratory book to determine which laboratory draws were to be completed. When queried on the rationale for laboratory draws not being completed according to their ordered or recommended frequency, DON B reported the paper laboratory system did not trigger reminders. Resident #11 (R11) Review of the medical record revealed R11 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included end stage renal disease. R11 received dialysis. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/11/23 revealed R11 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 11/14/23 at 8:12 AM, R11 was observed awake in bed. Review of the Physician's Order dated 9/13/23 revealed please obtain blood to check phosphorus level on 9/30/23. Review of the telehealth visit note dated 11/6/23 revealed Ordered CXR [chest xray] and CBC [complete blood count] with diff [differential] . R11's medical record did not include phosphorus level completed on 9/30/23, or the CBC completed after 11/6/23. In an interview on 11/14/23 at 1:08 PM, Director of Nursing (DON) B reported the facility had a staff member who drew residents' blood for lab work based on the lab slips that were placed in the lab book. DON B was unable to locate evidence that R11's phosphorus level and CBC were performed. Resident #37 (R37) Review of the medical record revealed R37 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included psychosis, dementia, delusional disorders, auditory hallucinations, visual hallucinations, anxiety, and major depressive disorder. Review of the pharmacy Consultation Report dated 10/17/23 revealed a recommendation to perform an A1C (laboratory blood test) on next convenient lab day and every 6 months. Review of the Physician's Order dated 10/21/23 revealed an order to monitor A1C, CBC, and CMP (all laboratory blood tests) every 6 months. In an interview on 11/14/23 at 1:08 PM, DON B reported R37's lab results from the order dated 10/21/23 were not in the medical record. DON B was unable to locate evidence that the lab work had been performed.

Based on observation, interview, and record review, the facility failed to 1) maintain a sanitary kitchen, 2) properly date mark potentially hazardous foods, 3) properly cool cooked food, and 3) clean food contact surfaces, resulting in the potential biological contamination of food, increasing the risk of foodborne illness. These deficient practices affecting 65 residents who consume food from the kitchen. Findings include: On 11/13/23 at 6:46 AM, food debris and soil was observed to be accumulating at the wall/floor juncture by the right side of the three-compartment sink, and underneath the drain boards of the dish machine. During an interview on 11/13/23 at 12:22 PM, Certified Dietary Manager (CDM) E stated that the floors are deep cleaned weekly if they have a staff member available to do so. According to the 2017 FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. On 11/13/23 at 6:48 AM, an opened package of hot dogs was observed to be stored in a container in the prep cooler with no date mark label to identify the discard date. On 11/13/23 at 6:50 AM, a container of boiled eggs in cooler R2 was observed to be labeled for eight days, 11/13 to 11/20, instead of seven days, when counting the preparation day as day one. A container of pulled pork in cooler R1 was observed to be dated for eight days, 11/8 to 11/15. An opened buffet ham in cooler R1 was observed to have a date label that was soggy and illegible. 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-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Pf On 11/13/23 at 6:52 AM, a florescent light fixture, located in the storage room, was observed to be missing the light shield to prevent the bulb from being shattered. According to the 2017 FDA Food Code Section 6-202.11 Light Bulbs, Protective Shielding. (A) Except as specified in (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. On 11/13/23 at 6:56 AM, two cans, located on the can storage rack in the storage room, were observed to be dented on the seams and not separated from usable cans, allowing for potential use of food product from compromised packaging. At this time, CDM E stated that they have a new employee who put the cans away. On 11/13/23 at 7:15 AM, two large chaffing pans in cooler R2, containing cooked ribs, were observed to be covered with aluminum foil with the lids secured, therefore significant condensation was accumulating indicating improper cooling methods. A temperature of the ribs were taken from each pan, using the Dietary Department's digital probe thermometer, with the highest temperature measuring at 56 and 48 degrees Fahrenheit from each pan. At this time, CDM E stated that yesterday's evening shift cooked the ribs and they are on the menu for tonight's dinner. CDM E was queried on what their process is for the ribs not cooling in the proper amount of time and stated they will discard them. On 11/13/23 at 2:53 PM, CDM E stated that they are substituting chicken for the ribs that were planned for dinner. According to the 2017 FDA Food Code Section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); P and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less. P (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna. P (C) Except as specified under (D) of this section, a TIME/TEMPERATURE CONTROL FOR SAFETY FOOD received in compliance with LAWS allowing a temperature above 5oC (41oF) during shipment from the supplier as specified in 3-202.11(B), shall be cooled within 4 hours to 5oC (41oF) or less. P (D) Raw EGGS shall be received as specified under 3-202.11(C) and immediately placed in refrigerated EQUIPMENT that maintains an ambient air temperature of 7oC (45oF) or less. P According to the 2017 FDA Food Code Section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; Pf (2) Separating the FOOD into smaller or thinner portions; Pf (3)Using rapid cooling EQUIPMENT; Pf (4) Stirring the FOOD in a container placed in an ice water bath; Pf (5) Using containers that facilitate heat transfer; Pf (6) Adding ice as an ingredient; Pf or (7) Other effective methods. Pf (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. On 11/13/23 at 7:55 AM, two cartons of medpass fortified shake, located in the nourishment room fridge, were observed to be opened with no date label. The Manufacturer's label instructs to discard product within 4 days of opening. Additionally, the nourishment room ice machine was observed to have pink biofilm accumulating in between the deflector plate. According to the facility's Logbook Documentation, for ice machine cleaning, it notes, Marked done on-time by [maintenance tech] on October 17, 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a sanitary environment, maintain bathroom floors in good repair (room #'s 107, 110, and 306), and provide backflow protection at the salon hair sink, resulting in the potential for a non-homelike environment and contamination of the domestic water supply, affecting 65 residents in the facility. Findings include: On 11/13/23 at 8:04 AM, the bathroom floor of resident room [ROOM NUMBER] was observed to have missing linoleum flooring, approximately a 4-inch by 6-inch section, near the toilet, exposing the sub floor. On 11/13/23 at 8:08 AM, the bathroom floor of resident room [ROOM NUMBER] was observed to have brown stains. The toilet bowl was observed to have significant hard water mineral deposits accumulating. Additionally, debris and wash cloths were observed to be on the floor of resident room [ROOM NUMBER]. At this time, Resident #46 stated that housekeeping usually comes everyday to clean but didn't on Sunday, I don't stray too far from my room, so if they come, I'll see them. On 11/13/23 at 9:11 AM, food debris was observed on the floor behind Bed 2 of resident room [ROOM NUMBER]. At this time, ants were observed accumulating near the food debris. The bathroom floor of resident room [ROOM NUMBER] was observed to have rips in the linoleum where two different flooring materials meet, making the floor not easily cleanable. Additionally, dried urine was observed around the toilet pedestal and on the back rim of the toilet bowl. On 11/13/23 at 10:23 AM, the salon hair sink sprayer was observed to not be provided with a backflow protection device. At this time, Maintenance Director W stated that the hair sink looks like it was pieced together. On 11/13/23 at 10:30 AM, excessive food debris accumulation and a serving of coleslaw was observed under Bed 1 in resident room [ROOM NUMBER]. A review of the facility's menu indicates that coleslaw was last served on 11/10/23. On 11/13/23 at 10:35 AM, dust, debris, and supplies were observed on the floor in the 400 hall nursing storage room. At this time, Maintenance Director W stated that the storage room needs to be cleaned. On 10:52 AM, food debris was observed to be accumulating under Bed 2 of resident room [ROOM NUMBER]. Additionally, the resident room [ROOM NUMBER] bathroom floor was observed to be peeling up at the wall/floor juncture, resulting in large gaps that make the floor not easily cleanable. At this time, Maintenance Director W stated they are working on repairing floor when they are able to. A record review of the facility's policy, Housekeeping Services, revised 2/22/2023, it notes, II. ROUTINE CLEANING OF HORIZONTAL SURFACES A. In guest/resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake numbers MI00133063 and MI00133264. Based on observation, interview and record review, the facility failed to ensure a clean and sanitary environment for two (Resident #3 and #6) of four reviewed and room [ROOM NUMBER], resulting in unsanitary conditions and the potential for bacterial harborage and cross-contamination. Findings include: During an interview on 4/12/23 at 9:25 AM, Housekeeper E reported daily cleaning of resident rooms included cleaning bathrooms, dusting, taking out trash, sweeping and mopping. During an interview on 4/12/23 at 9:42 AM, Housekeeper F reported their shift times were 7:00 AM to 3:30 PM. Daily cleaning of resident rooms included cleaning the bathroom, wiping down tables, walls and windowsills. If a resident was not in their room, cleaning included moving and sweeping under the bed and sweeping and mopping the floor. On 4/12/23 at 9:47 AM, a dried spill on the floor, beneath the foot of Resident #3's (R3) bed, was observed from the hallway. On 4/12/23 at 9:55 AM, the floor in front of a recliner in room [ROOM NUMBER] was observed with dark, granule-like debris. On 4/12/23 at 4:12 PM, the floor of room [ROOM NUMBER] was observed with the same debris in front of the recliner. The floor did not appear to have been swept or mopped since the earlier observation on 4/12/23. On 4/12/23 at 4:16 PM, R3 was observed in bed. The same dried spill was observed on the floor under the foot of the bed. The brown, dried spill spanned across three floor tiles and into the three tiles below them (at least six tiles total). The foot board of the bed was observed to have dried, red liquid running from the top to bottom. The pump for the air mattress was observed to have dried, red liquid on it, extending to the hose connection. The foot board and the air mattress pump were also noted to have dried, brown liquid on them. R3's floor did not appear to have been swept or mopped since the earlier observation on 4/12/23. On 4/13/23 at 10:13 AM, R3's air mattress pump and floor at the foot of the bed were noted to be in the same soiled condition as 4/12/23, with a dried, brown spill on at least six floor tiles, a dried brown liquid on the foot board of the bed, a red liquid spill on the foot board of the bed and on the side of the air mattress pump, extending to the hose connection. On 4/17/23 at 8:59 AM, R3's foot board was observed to have dried brown liquid and dried, red colored liquid. The side of the air mattress pump was noted to have dried, red colored liquid that extended to the hose connector. The floor under the foot of the bed continued to have a dried, brown spill on at least six floor tiles. The floor did not appear to have been swept or mopped since the prior observations on 4/12/23 and 4/13/23. The foot board and air mattress pump did not appear to have been cleaned since the prior observations on 4/12/23 and 4/13/23. On 4/17/23 at 9:01 AM, the floor of room [ROOM NUMBER] was observed to have dark colored debris in front of the recliner. The floor did not appear to have been swept or mopped. During an observation that began on 4/17/23 at 9:36 AM, the wall to the left of R6's bathroom door was observed to have three smears of what appeared to be dried blood. The exterior of the room door and the exterior door handle were observed to have what appeared to be dried blood. The Housekeeping Services Policy, with a revision date of 2/22/23, reflected, .In guest/resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Long-Term Care Ombudsman of transfer to the hospital for one (Resident #29) of two reviewed for hospitalization, resulting in the potential for the Ombudsman not being aware of facility transfers/discharges. Findings include: Review of the medical record reflected R29 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included anoxic brain damage, post-traumatic stress disorder, hallucinations, muscle weakness, unsteadiness on feet, unspecified lack of coordination and difficulty walking. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/28/22, reflected R29 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Progress Notes reflected R29 was transferred to the hospital on 6/9/22 and returned to the facility on 6/14/22. The list of transfers and discharges provided to the Ombudsman for 6/2022 and 7/2022 did not include R29. During an interview on 09/16/22 at 1:32 PM, Social Worker (SW) D reported the list of transfers and discharges was sent to the Ombudsman monthly and included discharges to home and hospital, whether the resident was expected to return or not. SW D checked the May, June and July 2022 Ombudsman notification lists and reported she did not see R29 listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party of the facility's bed hold policy upon transfer to the hospital for two (Resident #29 and #40) of two reviewed for hospitalization, resulting in the potential for not being aware of the bed hold policy. Findings include: Resident #29 (R29): Review of the medical record reflected R29 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included anoxic brain damage, post-traumatic stress disorder, hallucinations, muscle weakness, unsteadiness on feet, unspecified lack of coordination and difficulty walking. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/28/22, reflected R29 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Progress Notes reflected R29 was transferred to the hospital on 6/9/22 and returned to the facility on 6/14/22. R29's medical record did not reflect their Responsible Party had been notified of the facility's bed hold policy upon transfer to the hospital. During an interview on 09/16/22 at 11:13 AM, Director of Nursing (DON) B reported if a resident had a Guardian, the bed hold policy was emailed to them. When asked if that was documented, DON B stated it probably was not. Resident #40 (R40): Review of the medical record reflected R40 was admitted to the facility on [DATE] and was readmitted [DATE], with diagnoses that included major depressive disorder, hypertension and pulmonary embolism. The MDS, with an ARD of 7/4/22, reflected R40 scored 13 out of 15 (cognitively intact) on the BIMS. During an interview on 09/14/22 at 10:20 AM, R40 stated that about a month and a half to two months prior, she went to the hospital and was gone for seven to eight days. R40 reported she was not informed of the facility's bed hold policy. R40's medical record did not reflect their Responsible Party had been notified of the facility's bed hold policy upon transfer to the hospital on 7/31/22. During an interview on 09/16/22 at 11:13 AM, DON B reported R40 was not her own Responsible Party. DON B reported she did not see any documentation in the Progress Notes, the Transfer Form or the Miscellaneous section of R40's Electronic Medical Record, reflective of the bed hold policy being provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #29 (R29): Review of the medical record reflected R29 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included anoxic brain damage, post-traumatic stress disorder, hallucinations, muscle weakness, unsteadiness on feet, unspecified lack of coordination and difficulty walking. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/28/22, reflected R29 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 09/15/22 at 11:02 AM, R29 was observed in a high-back wheelchair, returning to his room from another area of the facility. A Progress Note for 6/1/22 reflected R29 was seen by Psychiatric Services, and a Gradual Dose Reduction (GDR) of Seroquel (antipsychotic medication) was recommended. A Progress Note for 6/29/22 reflected the Seroquel GDR was successful. R29's Quarterly MDS with an ARD of 7/28/22 reflected R29 had not had a GDR. R29's Incident Reports reflected a fall on 4/27/22 (no injury), a fall on 5/31/22 (scratch to left forehead and redness to left knee and left shoulder), a fall on 7/10/22 (abrasion to top of head and swelling to finger on left hand), a fall on 8/9/22 (no injury) and a fall on 8/12/22 (abrasions to three toes of the right foot). R29's medical record reflected the fall on 7/10/22 resulted in acute third and fourth metacarpal fractures. A Discharge Return Anticipated MDS with an ARD of 6/9/22 reflected one fall without injury and one fall with injury (except major) were coded. The Quarterly MDS with an ARD of 7/28/22 reflected two falls with no injury and one fall with major injury were coded. During an interview on 09/16/22 at 10:45 AM, MDS Nurse H reported Social Worker (SW) D kept the dates of GDRs and failed GDRs, and she (MDS Nurse H) used that to code GDRs on the MDS. MDS Nurse H stated she should not have coded the 4/27/22 and 5/31/22 falls on the 7/28/22 Quarterly MDS, as those falls were captured on the Discharge Return Anticipated MDS with an ARD of 6/9/22. MDS Nurse H reported she should have only coded the fall with major injury on the 7/28/22 MDS. Resident #14(R14) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R14 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included paraplegia (paralyzed below waist), contractures of hip and knee, hypertension (high blood pressure), peripheral vascular disease (decreased blood flow in legs), chronic pain, neurogenic bladder, pressure ulcer stage 4, anxiety and depression. The MDS reflected R14 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required two person physical assist with bed mobility, transfers, toileting, hygiene, bathing and one person physical assist with dressing. Further review of the MDS reflected R14 did not have any behaviors including refusal of care. During an observation and interview on on 9/14/22 at 10:10 AM, R14 was observed sitting in a wheelchair. R14 appeared well groomed and able to answer questions appropriately. R14 reported was seen by dentist about 6 month ago for pain and was told needed tooth extraction and still waiting and now new problem bottom left side with ongoing pain. During an interview on 9/15/22 at 4:26 PM Social Worker (SW) D reported involved with scheduling dental services for facility residents. SW D reported R14 was seen by contracted dental service in facility in May 2022 with referral to recent to {named hospital] in July 2022. SW D reported would follow up with this surveyor related to delay in R14 dental follow up. During an interview on 9/16/22 at 10:16 AM, SW D reported no evidence was located to reflect dental follow up for R14 since May 2022 request for dental referral. During an interview and record review on 9/16/22 at 10:33 AM, MDS Nurse H verified R14 MDS, dated [DATE] reflected no dental concerns and was unsure why and reported would need to follow up. MDS Nurse H reported she was responsible for completing that section after completing interviews with resident and staff, review of Medical Record including Medication Administration Record and Treatment Record because those areas are added for monitoring presupposes. During an interview on 9/16/22 at 10:45 AM, MDS Nurse H report had not seen that R14 had dental concerns prior to 6/19/22 MDS. MDS Nurse H verified had reviewed R14 medical record and verified R14 dental visit was uploaded to R14 medical record on 5/6/22 from the dental appointment on 5/5/22 that indicated dental pain and broken teeth with need for dental referral. Based on observation, interview, and record review, the facility failed to accurately complete Minimum Data Assessments (MDS) for three (Resident #14, #29, and #42) of 18 reviewed, resulting in inaccurate MDS assessments and the potential for unmet care needs. Findings include: Resident #42 (R42) Review of the medical record revealed R42 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, dysphagia, vascular dementia with behavioral disturbance, mood disorder, history of falling, Parkinson's disease, and anxiety. On 09/14/22 at 12:42 PM, R42 was observed sitting in a high back wheelchair in the main area near the nurses' station. Review of the medical record revealed on 1/4/22, R42 fell out of her wheelchair which resulted in a laceration to her forehead that required sutures and a closed C4 (cervical vertebra) fracture. Review of the Emergency Department Note dated 1/4/22 revealed R42 had a nondisplaced fracture of the fourth cervical vertebra. Review of the MDS with an Assessment Reference Date (ARD) of 2/17/22 revealed R42 had a fall with injury (except major). In an interview on 09/15/22 at 03:00 PM, MDS Nurse H reported a fracture would be coded as a fall with major injury on the MDS. MDS Nurse H reported R42's MDS with a ARD of 2/17/22 was coded incorrectly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to include activities of daily living (ADL) information on the Baseline Care Plan for one (Resident #29) of 18 reviewed for Care Plans, resulting in the potential for unmet care needs. Findings include: Review of the medical record reflected R29 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included anoxic brain damage, post-traumatic stress disorder, hallucinations, muscle weakness, unsteadiness on feet, unspecified lack of coordination and difficulty walking. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/28/22, reflected R29 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R29 required total assistance for eating via use of a feeding tube and required limited to extensive assistance for most ADLs. On 09/15/22 at 11:02 AM, R29 was observed in a high-back wheelchair, returning to his room from another area of the facility. Two staff members were observed to enter R29's room to assist him to the bathroom. On 09/15/22 at 11:24 AM, R29 was observed in bed, looking for a movie to watch. R29's Baseline Care Plan for ADLs reflected interventions pertaining to bed mobility, dressing, range of motion (lower extremity impairments), toileting and transfers were initiated 4/23/22 (3 days after admission). During an interview on 09/16/22 at 11:13 AM, DON B reported Baseline Care Plans were formulated by the nurses, based on the comprehensive assessment on admission. When the assessment was closed out, the Care Plan was triggered. Regarding the types of things to be included on a Baseline Care Plan, DON B reported items included pain, skin, cardiac, and it also depended on what the nurses triggered. When asked if ADLs should be included on the Baseline Care Plan, DON B reported that was triggered as well. She reported the facility did the Baseline Care Plan within 24 hours, then they had seven days to get it personalized and up to date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise Care Plans for one (Resident #29) of 18 reviewed for Care Plans, resulting in inaccurate Care Plans and the potential for unmet care needs. Findings include: Review of the medical record reflected R29 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included anoxic brain damage, post-traumatic stress disorder, hallucinations, muscle weakness, unsteadiness on feet, unspecified lack of coordination and difficulty walking. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/28/22, reflected R29 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R29 required total assistance for eating via use of a feeding tube and required limited to extensive assistance for most activities of daily living. On 09/15/22 at 11:02 AM, R29 was observed in a high-back wheelchair, returning to his room from another area of the facility. Two staff members were observed to enter R29's room to assist him to the bathroom. On 09/15/22 at 11:24 AM, R29 was observed in bed, looking for a movie to watch. A Physician's Order, dated 4/20/22, reflected to elevate the head of the bed at least 30 degrees during feeding. R29's Care Plan reflected an intervention that was initiated 4/21/22 and revised on 5/20/22 for, Elevate the HOB [head of bed] 45 degrees during and thirty minutes after tube feed. A Care Plan intervention dated 4/27/22 reflected, Elevate HOB 30-45 degrees during tube feeding administration. During an interview on 09/16/22 at 11:13 AM, Director of Nursing (DON) B reported R29 should be sitting up (during tube feedings) and for 30 minutes (following tube feeding). DON B stated she would have to review the facility's policy. The facility's Enteral Feeding: Bolus Method policy, revised 12/13/21, reflected .Ensure guest/resident is positioned at 30-45 degrees .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #33(R33) Review of the Face Sheet, dated 9/15/22, reflected R33 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), heart disease, kidney disease, diabetes, and depression. During an observation and interview on on 9/14/22 at 10:30 AM, R33 was sitting in wheelchair self propelling self in hall with left leg and had right above the knee amputation. R33 reported concerned he was no longer receiving therapy now and staff will not assist with exercise or walking and needs to get stronger. R33 reported plan to discharge home soon and concerned he will not be strong enough and had spoke to both Administrator A and Director of Nursing B about concerns. Review of Physician Orders, date 8/31/22, reflected order for restorative therapy. Review of the Electronic Medical Record, dated 8/31/22 to current(9/15/22) reflected to evidence R33 received restorative therapy. During an interview on 9/15/22 at 5:33 PM, Registered Nurse (RN) H reported was facility restorative program nurse. RN H reported R33's physical therapy ended 8/29/22 and restorative therapy started 8/31/22. RN H reported was unable to located evidence R33 received ordered restorative therapy. RN H reported management team meets weekly to discuss therapy residents and if therapy recommends restorative therapy Therapy Department adds orders and RN H adds restorative task to resident care needs. RN H reported recent change in restorative staff over past 6 to 8 weeks and new restorative aid gets pulled to the floor more days than not over past month. Resident #37 During an observation and interview on 9/14/22 at 9:40 AM, R37 was laying in bed and appeared well groomed and able to answer questions appropriately. A sign was posted on the wall located by head of bed to use knee braces and hip orthosis 9a-12p, 3p-6p. R37 braces were observed sitting in chair on other side of room. R37 reported staff never helps him put braces on and can not do alone and should be on now. R37 reported was told by staff that all staff do Range of Motion(ROM) and reported routine to go weeks without ROM. R37 reported would like staff to assist with use of braces because he would like to be able to discharge but knows he can't in current condition. R37 reported staff to no offer to put braces on and he does not refuse and reported he has loosen braces in past but does not refuse to use. During an observation on 9/14/22 at 3:00 p.m. and 3:35 p.m., R37 was laying in bed with no braces in place. Review of the Treatment Administration Record(TAR), dated 9/14/22, reflected R37's knee braces were documented as in place for 9/14/22 morning and evening shift(observed not in place on both shifts) Review of R37 Care Plans, dated 5/3/22, reflected, Per the orthotic Specialist, [named specialist], Resident is recommended to wear knee braces and hip orthosis for 3 hours in the morning and 3 hours in the afternoon with skin integrity to be checked before and after each application. Review of R37 Physician Orders, dated, 5/3/22, reflected, Knee braces and hip orthosis to be worn 3 hours in the am and 3 hours in the afternoon. Perform skin checks prior to and after wearing. Apply at 9am and remove at noon, Apply at 3pm and remove at 6pm Daily. two times a day related to MERALGIA PARESTHETICA, BILATERAL LOWER LIMBS During an observation and interview on 9/15/22 at 1:35 PM, R37 was sitting in bed with no braces in place. R37 reported had requested staff assist and no one put braces on. During an interview on 9/15/22 at 1:45 PM, Certified Nurse Aid (CNA) G reported knows how to care for residents by verbal report from previous shift and reported they do have access to [NAME] if they have time to read. CNA G reported R37 should have braces on 2 times daily if he does not refuse. CNA G reported R37 did not refuse that day and reported CNA staff do not have ability to document. During an interview on 9/15/22 at 3:02 PM, Registered Nurse (RN) H reported was also restorative nurse. RN H reported facility has restorative therapy five days per week who also helps on the floor and reported if restorative staff pulled to the floor no one does restorative therapy. RN H reported R37 on restrictive program for ROM and fine motor since 5/25/22 and lower extremity braces since 5/3/22. RN H reported braces are documented on Medication Administration Record or Treatment Administration Record (MAR/TAR), [NAME], Care Plans so nurses and CNA staff can implement. RN H reported nurses are responsible overall to ensure orders are being followed. RN H reported R37 should receive ROM five times weekly and would expect staff to document accurately on MAR/TAR. Based on observation, interview, and record review, the facility failed to ensure positioning equipment was in place for three (Resident #33, #37, #42) of five reviewed resulting in the potential for decreased range of motion, worsening contracture, and pain. Findings include: Review of the medical record revealed Resident #42 (R42) was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, dysphagia, vascular dementia with behavioral disturbance, mood disorder, history of falling, Parkinson's disease, and anxiety. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/22 revealed R42 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-cognitive screening tool), required extensive assistance of two staff for activities of daily living, and had a functional range of motion impairment on one side of upper and lower extremities. Review of the Occupational Therapy Treatment Encounter Notes dated 2/1/22 revealed donning of rt [right] hand orthotic to decrease tissue tightness and reduce risk of further contracture in hand. Patient tolerates donning of orthotic well and able to wear approximately 20 minutes secondary to meal arriving . Review of the Therapy Communication To Restorative Nursing Program dated 3/31/22 revealed R42 had a contracture to her right hand and had a right hand brace that was to be worn at all times except for meals as tolerated. Review of the [NAME] (Nurse Aide Care Guide) revealed Monitoring or [sic] Right hand brace. To be worn at all times as tolerated, except for meals .Utilize right hand brace as tolerated throughout the day except at meals. On 09/14/22 at 12:42 PM, R42 was observed sitting in a high back wheelchair in the main area near nurses' station. R42 was leaning to left, her right hand was contracted, and R42 was not wearing a splint. On 09/14/22 at 01:50 PM, R2 was asleep in bed without a splint on her right hand. On 09/14/22 at 03:31 PM, R42 was observed awake, lying in bed. R42 did not have a splint on her right hand. On 09/15/22 at 09:47 AM, R42 was observed sitting in her wheelchair in the hallway. R42 was finished with breakfast and did not have her right hand splint in place. In an interview on 09/15/22 at 09:53 AM, Certified Nursing Assistant (CNA) E reported they worked with R42 three days per week. CNA E reported they were not aware of a splint for R42. When asked where the splint would be if R42 had one, CNA E the nsearched R42's dresser and found a splint. CNA E reported they had no idea how to even put it on. CNA E reported they never received education on donning R42's splint. In an interview on 09/15/22 at 09:59 AM, Licensed Practical Nurse (LPN) O reported they were assinged to care for R42 on this day. When asked if R42 had a splint or brace, LPN O stated, Nope .She doesn't have anything. In an interview on 09/15/22 at 10:45 AM, CNA S reported they were the facility's only Restorative Aide. CNA S reported they were pulled work the floor when staffing was low and restorative programs had not been completed in approximately one and a half weeks. When asked how they knew specific restorative programs for each resident, CNA S reported they had a binder that was kept in their locker. CNA S reported all restorative documentation was written in the binder because there was not a place in the electronic medical record to document the completion of restorative tasks. When asked about R42, CNA S reported they were not sure if R42 was still on a restorative program. When asked about R42's splint, CNA S reported she donned R42's splint every day I can. CNA S reported R42 did not have her splint on today because it probably just didn't get put on. Review of the Restorative Binder revealed the Therapy Communication To Restorative Nursing Program dated 3/31/22. R42 did not have any restorative notes in the binder. On 09/15/22 at 10:43 AM, R42 was asleep in bed. R42's right hand splint was on top of her dresser. On 09/15/22 at 03:34 PM, R42 was sitting in a wheelchair near the nurses' station. R42's hand splint was not in place. The splint was still on top of her dresser. On 09/16/22 at 08:12 AM, R42 was observed sitting in her wheelchair near the nurses' station. R42's hand splint was not in place. The splint was still on top of the dresser. R42 had already finished eating breakfast. Review of the NURSING REHAB: Eating: Self feeding tasks encouraging Pat to complete as independently as possible. Monitoring or Right hand brace. To be worn at all times as tolerated, except for meals task revealed the task was completed one time in the last 30 days on 8/23/22. No refusals were documented. In an interview on 09/15/22 at 03:00 PM, Registered Nurse (RN) H reported she was the facility's Restorative Nurse. RN H reported CNA S was scheduled to work restorative nursing five days a week, but there were times when CNA S was pulled to assist working on the floor. When asked who performed restorative nursing tasks when CNA S was working the floor, RN H reported the facility did not have someone else to assist. When asked about the task documentation that reflected not applicable, RN H reported it was either that staff did not work with R42 for that task or that R42 did not need assistance with that task. RN H agreed that the documentation reflected R42 had only worn the right hand splint once in the last 30 days. In an interview on 09/15/22 at 03:37 PM, CNA G reported R42 was supposed to wear a splint every day, but she refused it. CNA G reported the last time they tried to put R42's brace on her, R42 screamed her head off like she was in a lot of pain. When asked when the last time CNA G attempted to don R42's splint, CNA G stated, probably two weeks ago. In an interview on 09/16/22 at 09:40 AM, Director of Nursing (DON) B reported she was not sure where staff documented R42's splint use. In an interview on 09/16/22 at 10:22 AM, RN H reported she just learned that the restorative CNA did not document in the electronic medical record and had been documenting on paper in the restorative binder. RN H reported she was not aware of the paper documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer tube feeding according to Physician's Orders for one (Resident #29) of one reviewed for tube feeding, resulting in tube feedings not being administered via the ordered method or at the ordered rate. Findings include: Review of the medical record reflected R29 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included anoxic brain damage, post-traumatic stress disorder, hallucinations, muscle weakness, unsteadiness on feet, unspecified lack of coordination and difficulty walking. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/28/22, reflected R29 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R29 required total assistance for eating via use of a feeding tube and required limited to extensive assistance for most activities of daily living. R29's medical record reflected they were transferred to the hospital on 6/9/22 and returned to the facility on 6/14/22. A Progress Note for 6/16/22 reflected R29 had readmitted after a hospital stay for aspiration pneumonia. On 09/15/22 at 11:24 AM, R29 was observed in bed, looking for a movie to watch. When asked how often he received feedings, he stated three times a day and showed three fingers. On 09/15/22 at 1:55 PM, R29 was observed in bed with his eyes closed. The head of his bed was slightly elevated. There was no tube feeding running. A graduated cylinder and syringe were observed at the bedside. When asked if he had a recent feeding administered, R29's response was unclear/unable to be understood. On 09/15/22 at 2:02 PM, Licensed Practical Nurse (LPN) O was queried about R29's 2:00 PM scheduled tube feeding. LPN O reported the off-going nurse said everything was done. On 09/16/22 at 9:43 AM, R29 was observed in bed with his eyes closed and the head of the bed elevated. A tube feeding pump was observed at the right bedside. There was no tube feeding actively infusing. On 09/16/22 at 11:01 AM, R29 was observed in bed, with the head of the bed elevated. A gravity bag was observed hanging from the tube feeding pump, however, the line from the bag was not connected to the pump. Feeding tube formula was observed in the line. A Physician's Order, dated 6/15/22, reflected, Enteral Feed Order five times a day for [sic] put in gravity bag and set pump to 237 mL/hr [milliliters per hour] at each bolus related to DYSPHAGIA [difficulty swallowing] .bolus 237 mL .via PEG [Percutaneous Endoscopic Gastrostomy]. During a phone interview on 09/15/22 at 4:25 PM, Registered Nurse (RN) P reported R29 received 237 mL of the tube feeding formula twice a day on her shift. RN P reported administering R29's tube feeding around 1:00 PM that day. RN P stated R29's feeding could be administered via a drip from a bag or to gravity. For the bag method, there was a bag to hang from the tube feeding pump, that was dated and initialed. RN P acknowledged that the pump would be set with a rate to infuse the feeding. For the gravity method, RN P described attaching a syringe to the feeding tube, pouring the formula into the syringe and allowing it to slowly flow in (bolus method). RN P reported that method took about 15 to 20 minutes. RN P reported the pump was not used with the gravity method. When asked which method was to be used for R29's tube feedings, RN P stated either method was appropriate. That day, she administered the feeding using the gravity method, per her report. During an interview on 09/16/22 at 11:05 AM, LPN F reported hanging R29's tube feeding at 10:00 AM that day. She stated from what she knew, R29's feedings were a bolus, without the use of a pump. There was no rate, and the feeding was administered by gravity. During an interview on 09/16/22 at 11:13 AM, when queried on how R29's tube feedings should have been administered, Director of Nursing (DON) B stated the order needed to be changed. DON B reported they could not use the (tube feeding) pump with the bags the facility had. They sent a message to the Dietitian the day prior to review R29's orders, according to DON B. When asked if they should have been using the pump or a bag to administer R29's tube feedings, DON B stated that according to the order, it said to do both. It was brought to her attention the day prior that the line for the bag did not connect to the pump the facility had. When asked if R29 should have had a system that allowed for use of the tube feeding pump, DON B stated the facility would be talking to the Physician and Dietitian about that, as they had to follow the Physician's orders. DON B reported it looked like R29's tube feeding order changed on 6/15/22 to the current order. When asked if staff would have been using the current method since the order was changed, DON B stated she would say yes. When asked if a nurse should have been pouring the feeding into a syringe (connected to R29's feeding tube), DON B stated they should have been following the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow up with a dental consult in a timely manner, for one sampled Resident (R14) out of one reviewed for consults, resulting in the potential for unmet care needs, pain, and feelings of frustration. Findings include: Resident #14(R14) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R14 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included paraplegia (paralyzed below waist), contractures of hip and knee, hypertension (high blood pressure), peripheral vascular disease (decreased blood flow in legs), chronic pain, neurogenic bladder, pressure ulcer stage 4, anxiety and depression. The MDS reflected R14 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required two person physical assist with bed mobility, transfers, toileting, hygiene, bathing and one person physical assist with dressing. Further review of the MDS reflected R14 did not have any behaviors including refusal of care. During an observation and interview on on 9/14/22 at 10:10 AM, R14 was observed sitting in a wheelchair. R14 appeared well groomed and able to answer questions appropriately. R14 reported was seen by dentist about 6 month ago for pain and was told needed tooth extraction and still waiting and now new problem bottom left side with ongoing pain. Review of the Dental Consult, dated 5/5/22, reflected R14 was seen for initial visit with referal to oral surgeon for #4 tooth extraction related to broken tooth. Review of Physician Progress Note, dated 8/5/2022, for R14 reflected, Noted with broken upper first molar on right side. Facility working on dental appointment, poor dentition throughout, continue with current pain medications . Review of the Dietary Progress Note, dated 8/1/2022 at 1:38 p.m., for R14 reflected, Recent report of oral mouth pain d/t broken molar from 8-9 months ago per NP prog note from 7/28. Facility working on dental appt. Resident states mouth pain comes roughly once a month as a result of eating too much candy . Review of the Physician Progress Notes, dated 7/28/22, reflected, Visit Type: Acute .CHIEF COMPLAINT Dental pain .General: Pt is a 41 yo male w/ past medical hx of Obstructive sleep apnea,history of spinal cord injury with resulting in quadriplegia, neurogenic bladder status post suprapubic catheter placement, chronic pain syndrome, history of DVT, stage IV sacral decub who is a long term resident in our facility. Patinet was complaining of dental pain and states that he broke his right upper first molar 8-9months ago and about once a month it will hurt if he eats too much candy (currently eating a hard candy lolipop) and no signs of abscess noted and facility is working on dental appointment. No non verbal signs of pain and states that he is eating well at meals . ASSESSMENTS AND PLANS . Noted with broken upper first molar on right side. Facility working on dental appointment, poor dentition throughout, . Review of Social [NAME] Note, dated 7/26/2022 at 11:07 a.m., for R14, reflected, U of M Dental referral re-sent. Review of the Nursing Progress Note, dated 6/30/2022 at 5:51 p.m., for R14, reflected, Resident continues on antibiotic therapy for tooth infection . Review of the Physician Progress Note, dated 6/30/2022, for R14, reflected Visit Type: Acute .CHIEF COMPLAINT .ED follow up for dental pain .Patient recently went to the ED at his request for dental pain and returned with antibiotics and was given a dose of lodine with relief per patient. Denies dental pain today and will continue with current pain regimen .ASSESSMENTS AND PLANS .Periapical abscess without sinus: Patient was started on antibiotics and will have follow up with dental . Review of Nursing Progress note, dated 6/27/2022 at 1:01 a.m., for R14, reflected resident was complaining of tooth pain, asked to brush teeth, stated the pain was still there, writer offered ibuprofen which was refused, resident is being insistent on going to the hospital, notified on call, she ordered oral ABT and Tylenol with codeine, refused treatment and stated that he would just call the hospital himself, guardian was called, voicemail left to return call. During an interview on 9/15/22 at 4:26 PM Social Worker (SW) D reported involved with scheduling dental services for facility residents. SW D reported R14 was seen by contracted dental service in facility in May 2022 with referral to recent to {named hospital] in July 2022. SW D reported would follow up with this surveyor related to delay in R14 dental follow up. During an interview on 9/16/22 at 10:16 AM, SW D reported no evidence was located to reflect dental follow up for R14 since May 2022 request for dental referral. During an interview and record review on 9/16/22 at 10:33 AM, MDS Nurse H verified R14 MDS, dated [DATE] reflected no dental concerns and was unsure why and reported would need to follow up. MDS Nurse H reported she was responsible for completing that section after completing interviews with resident and staff, review of Medical Record including Medication Administration Record and Treatment Record because those areas are added for monitoring presupposes. During an interview on 9/16/22 at 10:45 AM, MDS Nurse H report had not seen that R14 had dental concerns prior to 6/19/22 MDS. MDS Nurse H verified had reviewed R14 medical record and verified R14 dental visit was uploaded to R14 medical record on 5/6/22 from the dental appointment on 5/5/22 that indicated dental pain and broken teeth with need for dental referral. During an interview on 9/16/22 at 2:53 PM, Director of Nursing (DON) B verified no evidence of dental referral for R14 sent 7/26/22 as indicated in Progress notes including no evidence of dental referral sent with look back to 4/26/22 for R14. DON B reported would expect to see evidence that referral had been sent and followed up on since original 5/5/22(four months) request for dental referral.

Based on observation, interview, and record review the facility failed to maintain infection control practices for four residents (residents #8, #10, #30 and #51) out of four residents sampled during observation of blood glucose level testing, with a glucose meter, resulting in the potential for the development of infection. Findings Include: Resident #51 Review of the medical record revealed R51 was admitted to the facility 08/19/2021 with diagnoses that included osteomyelitis (infection in bone), type II diabetes, and hypertension. During observation on 09/15/2022 at 07:26 a.m. Registered Nurse (RN) R entered R51's room to obtain a blood sample to determine his blood glucose level with the use of a glucose meter (a medical device used to determine blood glucose levels). At the conclusion of that interaction with R51, RN R returned to the medication cart at the nurse's station and wiped the glucose meter with an alcohol wipe. RN R did not let the glucose meter set and proceeded to the room of R30 with the same glucose meter. Resident #30 (R30) Review of the medical record revealed R30 was admitted to the facility 10/20/2021 with diagnoses that included type II diabetes, hypertension, and systemic inflammatory response. During observation on 09/15/2022 at 07:42 a.m. Registered Nurse (RN) R entered R30's room to obtain a blood sample to determine his blood glucose level with the use of a glucose meter (a medical device used to determine blood glucose levels). At the conclusion of that interaction with R30, RN R returned to the medication cart at the nurse's station and wiped the glucose meter with an alcohol wipe. RN R did not let the glucose meter set and proceeded to the room of R10 with the same glucose meter. Resident #10 (R10) Review of the medical record revealed R10 was admitted to the facility 03/08/2022 with diagnoses that included type II diabetes, hypertension, and acute kidney failure. During observation on 09/15/2022 at 07:46 a.m. Registered Nurse (RN) R entered R10's room to obtain a blood sample to determine his blood glucose level with the use of a glucose meter (a medical device used to determine blood glucose levels). At the conclusion of that interaction with R10, RN R returned to the medication cart at the nurse's station and wiped the glucose meter with an alcohol wipe. RN R did not let the glucose meter set and proceeded to the room of R8 with the same glucose meter. Resident #8 (R8) Review of the medical record revealed R10 was admitted to the facility 08/29/2019 with diagnoses that included type II diabetes, acute kidney failure, morbid obesity, hypertension, and edema. During observation on 09/15/2022 at 07:50 a.m. Registered Nurse (RN) R entered R10's room to obtain a blood sample to determine her blood sugar level with the use of a glucose meter (a medical device used to determine blood glucose levels). At the conclusion of that interaction with R10, RN R returned to the medication cart at the nurse's station and wiped the glucometer with micro kill bleach. During interview on 09/15/2022 at 07:56 a.m. Registered Nurse (RN) R explained that after using the glucose meter and between residents use it was necessary to clean the glucose meter with Micro Kill Bleach (germicidal bleach wipe) and let it set for a one minute before using again. RN R could not explain why she only used Mico Kill Bleach after the final use of the glucose meter. During an interview on 09/15/22 at 01:19 p.m. the Director of Nursing (DON) B explained that it is policy that glucose meters are disinfected between each resident use. She explained that the glucose meters are to be cleaned using bleach wipes but that she was aware that some staff had only used alcohol wipes and explained that this was not appropriate. Review of the facility policy titled Glucometer and PT/INR Decontamination with an implementation date of 12/01/2022 and last revised date of 06/24/2022 demonstrated in the section entitled cleaning and disinfection the glucometer stated, After performing the glucometer or PT/INR testing, the nurse shall perform hand hygiene, apply gloves, and use the disinfectant wipe to clean all external parts of the glucometer or PT/INR machine allowing the meter to remain wet for the contact time required by the disinfectant label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement care plans for 4 of 18 residents (Resident #16, #14, #9, and #37) reviewed for Care Plans, from a total of 18 sampled residents, resulting in unmet care or the potential for inadequate/inappropriate care. Findings Include: Resident #9 (#9) R9 was admitted on to the facility on [DATE] with a Brief interview for mental status (BIMS) of 15 out of 15, as indicated on minimum data set (MDS) dated [DATE]. admitted with diagnosis of metabolic encephalopathy, difficulty walking, history of falling, muscle weakness, Pulmonary Fibrosis, weakness. R9 admitted to hospice on 05/25/22 with diagnosis Metabolic encephalopathy. During an interview on 09/14/22 at 12:00 PM with Social Worker (SW) D, regarding R9 hospice admission. Niece brought R9 here from Illinois, R9 lived in [NAME] County Michigan when the niece was granted guardianship, moved R9 to Illinois which terminated guardianship in Michigan. Niece moved R9 back to Michigan, durable power of attorney (DPOA) was put in place, with niece being one of them. R9 was on hospice in Illinois, her health was very poor and was not expected to make it. When R9 was admitted to facility, she was also admitted to Heart-to-Heart hospice with diagnosis a brain disease. Competency evaluation completed and R9 was deemed competent by 2 doctors. Then R9 became her own responsible party. R9 still depends on her niece to assist with some decisions. R9 was discharged from Hospice no longer meeting criteria. R9 did not want to be on hospice to begin with. Hospice was never a part of her care plan. During an interview on 09/15/22 at 02:42 PM with SW D, she was able to show order for admission and private pay on 05/25/22. Hospice services started on 06/01/22 through 06/09/22. 06/10/22 R9 able to independently decide to stop hospice and start rehab services. During an interview on 09/15/22 at 02:53 PM with MDS nurse H was asked about order to admit. We typically do, she came out of state to us. Hospice from 05/25/22 (private pay) to 06/09/22 when services stopped. Care plan created on 06/01/22. There was a lot going on with her, she was deemed incompetent when we got her, then she was re-evaluated and deemed competent to make own decisions. When she re-assessed her choices, she did not want to be on hospice, so she was able to be discharged . During record review on 09/15/22 02:50 PM, MDS admission included hospice with diagnosis of Metabolic encephalopathy on 05/25/22. R9's care plan did not reflect hospice having any active interventions included. Facility failed to include hospice to the initial care plan, putting her at risk for unmet needs. Resident #14(R14) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R14 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included paraplegia (paralyzed below waist), contractures of hip and knee, hypertension (high blood pressure), peripheral vascular disease (decreased blood flow in legs), chronic pain, neurogenic bladder, pressure ulcer stage 4, anxiety and depression. The MDS reflected R14 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required two person physical assist with bed mobility, transfers, toileting, hygiene, bathing and one person physical assist with dressing. Further review of the MDS reflected R14 did not have any behaviors including refusal of care. During an observation and interview on on 9/14/22 at 10:10 AM, R14 was observed sitting in a wheelchair. R14 appeared well groomed and able to answer questions appropriately. R14 reported was seen by dentist about 6 month ago for pain and was told needed tooth extraction and still waiting and now new problem bottom left side with ongoing pain. Review of the Dental Consult, dated 5/5/22, reflected R14 was seen for initial visit with referal to oral surgeon for #4 tooth extraction related to broken tooth. Review of Physician Progress Note, dated 8/5/2022, for R14 reflected, Noted with broken upper first molar on right side. Facility working on dental appointment, poor dentition throughout, continue with current pain medications . Review of the Dietary Progress Note, dated 8/1/2022 at 1:38 p.m., for R14 reflected, Recent report of oral mouth pain d/t broken molar from 8-9 months ago per NP prog note from 7/28. Facility working on dental appt. Resident states mouth pain comes roughly once a month as a result of eating too much candy . Review of the Physician Progress Notes, dated 7/28/22, reflected, Visit Type: Acute .CHIEF COMPLAINT Dental pain .General: Pt is a 41 yo male w/ past medical hx of Obstructive sleep apnea,history of spinal cord injury with resulting in quadriplegia, neurogenic bladder status post suprapubic catheter placement, chronic pain syndrome, history of DVT, stage IV sacral decub who is a long term resident in our facility. Patinet was complaining of dental pain and states that he broke his right upper first molar 8-9months ago and about once a month it will hurt if he eats too much candy (currently eating a hard candy lolipop) and no signs of abscess noted and facility is working on dental appointment. No non verbal signs of pain and states that he is eating well at meals . ASSESSMENTS AND PLANS . Noted with broken upper first molar on right side. Facility working on dental appointment, poor dentition throughout, . Review of Social [NAME] Note, dated 7/26/2022 at 11:07 a.m., for R14, reflected, U of M Dental referral re-sent. Review of the Nursing Progress Note, dated 6/30/2022 at 5:51 p.m., for R14, reflected, Resident continues on antibiotic therapy for tooth infection . Review of the Physician Progress Note, dated 6/30/2022, for R14, reflected Visit Type: Acute .CHIEF COMPLAINT .ED follow up for dental pain .Patient recently went to the ED at his request for dental pain and returned with antibiotics and was given a dose of lodine with relief per patient. Denies dental pain today and will continue with current pain regimen .ASSESSMENTS AND PLANS .Periapical abscess without sinus: Patient was started on antibiotics and will have follow up with dental . Review of Nursing Progress note, dated 6/27/2022 at 1:01 a.m., for R14, reflected resident was complaining of tooth pain, asked to brush teeth, stated the pain was still there, writer offered ibuprofen which was refused, resident is being insistent on going to the hospital, notified on call, she ordered oral ABT and Tylenol with codeine, refused treatment and stated that he would just call the hospital himself, guardian was called, voicemail left to return call. During an interview on 9/15/22 at 4:26 PM Social Worker (SW) D reported involved with scheduling dental services for facility residents. SW D reported R14 was seen by contracted dental service in facility in May 2022 with referral to recent to {named hospital] in July 2022. SW D reported would follow up with this surveyor related to delay in R14 dental follow up. During an interview on 9/16/22 at 10:16 AM, SW D reported no evidence was located to reflect dental follow up for R14 since May 2022 request for dental referral. During an interview and record review on 9/16/22 at 10:33 AM, MDS Nurse H verified R14 MDS, dated [DATE] reflected no dental concerns and was unsure why and reported would need to follow up. MDS Nurse H reported she was responsible for completing that section after completing interviews with resident and staff, review of Medical Record including Medication Administration Record and Treatment Record because those areas are added for monitoring presupposes. During an interview on 9/16/22 at 10:45 AM, MDS Nurse H report had not seen that R14 had dental concerns prior to 6/19/22 MDS. MDS Nurse H verified had reviewed R14 medical record and verified R14 dental visit was uploaded to R14 medical record on 5/6/22 from the dental appointment on 5/5/22 that indicated dental pain and broken teeth with need for dental referral. During an interview on 9/16/22 at 2:53 PM, Director of Nursing (DON) B verified no evidence of dental referral for R14 sent 7/26/22 as indicated in Progress notes including no evidence of dental referral sent with look back to 4/26/22 for R14. DON B reported would expect to see evidence that referral had been sent and followed up on since original 5/5/22(four months) request for dental referral. Review of the Complete Care Plan, dated 5/1/22 through 9/15/22, reflected no mention of dental issues, including pain, or broken teeth, infection, or need for surgical dental referral. During an observation and interview on on 9/14/22 at 10:10 AM, R14 was observed sitting in a wheelchair with both legs positioned towards the right side of chair with right lateral knee and upper leg resting directly on unpadded frame of wheelchair. R14 appeared well groomed and able to answer questions appropriately. R14 reported worsening of right upper leg facility acquired pressure ulcer and reported concern that physicians will want to amputate leg if would does not improve. R14 reported facility had not provided functional offloading options with current wheelchair or discussed options for more appropriate sized wheelchair for improved positioning. R14 reported seen by wound nurse weekly on Tuesdays and reported constant pain controlled by routine pain medications. During an observation and interview on 9/14/22 at 2:29 PM, Licensed Practical Nurse (LPN) P reported plans to perform R14 wound treatments after R14 returned from shower room and observed several items obtained for treatments form treatment cart. R14 entered room at 2:32 PM with assist from Certified Nurse Assistant (CNA) U. At 2:42 PM, LPN P and this surveyor donned full Personal Protective Equipment including gown, mask, eye protection, and gloves related to R14 enhance precautions related to wounds. -R14 had a wound located on the right medial thigh, just above knee, that appeared to be stage 3 pressure wound with about 10% to 20% slough(non viable tissue) that was about the size of a fifty cent coin. LPN P performed wound care to R14 right medial thigh including, Dakins wound wash, pad dry, Asasep gel, non stick gauze and cover with border gauze. -R14 had open small deep wound to Right hip area with treatment that included Dakins quarter strength(QS), pat dry, Z-guard to peri wound, -R14 had wound located on right lateral thigh, just above knee, that appeared to be about 5cm by 4cm in size with slough and escar(non viable tissue) covering 80% of wound bed. LPN P applied Dakins solution, pat dry, santyl(debridement gel), covered with non stick gauze and bordered gauze. -R14 had open wound noted to coccyx about size of nickel that was cleaned with Dakins solution and left uncovered. -R14 had open wound to right upper ischium that appeared about 8cm by 2cm in size with slough present in about 50% of wound bed. LPN P applied Dakins solution, pat dry, santyl gel, cover with non stick gauze and border gauze. -R14 had triangle dime size open area below anus. LPN P applied dakins solution and pat dry and left uncovered. R14 reported increased pain related to muscle spasms and refused wound treatment to left ischium. -R14 had open wound to right lateral lower leg, just below knee, that was about 3 to 4 inches in length and 1/2 inch wide that appeared to have slough and escar present over 50% of area that was red overall. LPN P did not mention that area or perform treatment to area. LPN P reported did not routinely perform R14 wound care. Total of eight observed open wounds Review of the physician orders, dated 8/10/22, reflected R14 had treatment orders that included: -Coccyx: cleanse with 1/4 strength Dakins solution, pat dry, apply santyl to wound bed, apply adaptic (cut to size), cover with border gauze dressing. Change daily. every day shift for Stage 3 pressure ulcer-start date-8/10/22. -Left ischium: cleanse with 1/4 strength Dakins solution, pat dry, apply santyl to wound bed, apply adaptic (cut to size), cover with bordered gauze dressing. Change daily. every day shift for Stage 4 pressure ulcer-Start Date-9/14/2022. -Right ischium: cleanse with 1/4 strength Dakins solution, pat dry, apply santyl to wound bed, apply adaptic (cut to size), cover with border gauze dressing. Change daily. every day shift for Stage 4 pressure ulcer -Start Date-8/31/2022. -Right lateral thigh: cleanse with 1/4 strength Dakins solution, pat dry, apply santyl to wound bed, apply adaptic (cut to size), cover with border gauze dressing. Change daily. every day shift for Stage 3 pressure ulcer-Start Date-7/27/2022. -Right medial thigh: cleanse with 1/4 strength Dakins solution, pat dry, apply anasept gel to wound bed, apply adaptic (cut to size), cover with border gauze dressing. Change daily. every day shift for Stage 3 pressure ulcer -Start Date-8/31/2022. -Right trochanter: Cleanse with 1/4 strength Dakins solution, pat dry, apply zguard to wound bed and leave open to air daily. every day shift for Stage 4 pressure ulcer -Start Date-9/07/2022. -Sacrum: apply chamosyn and leave open to air daily. every day shift for Protection -Start Date-4/06/2022. -Santyl Ointment 250 UNIT/GM (Collagenase) Apply to affected areas topically every day shift for wound care right lateral thigh, coccyx, right ischium, and left ischium wounds -Start Date-9/14/2022. Review of the physician orders reflected treatments for seven wounds not including right lateral lower leg observed by this surveyor 9/14/22. Review of R14's Skin Care Plans, revised 8/31/22 , reflected, [named R14] is at risk for skin breakdown/pressure ulcers or further breakdown r/t stage 4 pressure ulcer to right ischium, stage 3 pressure ulcer to right medial thigh, stage 4 pressure ulcer to left ischium, stage 3 pressure ulcer to right lateral thigh, stage 4 pressure ulcer to right trochanter, stage 3 pressure ulcer to coccyx, and diagnosis of Peripheral Vascular Disease & depression. He has impaired mobility AEB: requires a wheelchair for mobility r/t his diagnosis of paraplegia secondary to history of GSW. He has a colostomy & a s/p catheter. Urine voids from penis and fistula site from bladder to outside of ischial/scrotal pressure site at times. He often chooses not to lay down/chooses to stay up in his WC for long periods of time. He chooses not to get wound dressings changed at times [named R14] to have wedged cushion on right side of WC vertically to provide support and decrease pressure of RLE when in WC Date Initiated: 05/18/2022 .Knee adductor attached to wheelchair, check for proper placement, pad right wheel chair arm to assist in pressure reduction r/t resident non compliance/moving of knee adducter on wheelchair Date Initiated: Revision on: 06/09/2022 .Knee pressure pillow on as tolerated Date Initiated: 05/18/2022 .Observe skin with showers/care. Notify nurse of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Revision on: 5/18/2022 .Turn/reposition [NAME] at least every 2 hours, more often as needed or requested. Date Initiated: 05/18/2022 . During an interview on 9/16/22 at 2:58 PM, Director of Nursing (DON) B and WN W reported R14 had several documented refusals and therapy notes to reflect equipment review and they would provided to this surveyor prior to survey exit. WN W verified had not provided requested documents of R14 refusals or therapy notes as requested 9/15/22 at 5:10 p.m. WN W reported did observe R14 wound to right lateral leg below the knee that day and reported had 100% necrotic(escar) over wound bed that appeared to be consistent with wheelchair frame related to positioning. Review with the facility provided documents, most recently dated 4/27/22, to support R14 refusal of care planned interventions and therapy evaluation, revealed facility Skin & Wound Evaluation with notes that included, Seen by NP in house. Verbal education completed with resident. Will meet with therapy r/t res. request removal of knee adductor & alternate options for positioning/pressure reduction. Continues to choose not to follow POC in relation to offloading pressure, turning/repositioning, supplements for wound healing. Frequently gets up during night and stays in wheelchair for hours at a time Knee adductor to wheelchair noted pushed out from w/c. Res. states he did it because it was messing with the brake for the wc . The facility provided documents reflected no evidence that R14 was evaluated by therapy, including for proper fit of equipment and positioning, or evidence of resident refusals of care after 4/27/22. Resident #16(R16) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R16 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), Alzheimer disease with dementia, and anxiety. The MDS reflected R16 had a BIM (assessment tool) which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with bed mobility, walking in room and corridor, locomotion on unit and off unit, dressing, hygiene, bathing and two person physical assist with transfers and toileting. The MDS reflected R16 had no hallucinations or delusions and had not rejected care. The MDS also reflected R16 was not on a toileting program and had occasional urinary incontinence. During an observation on 9/14/22 at 9:11 AM R16 was noted laying in bed with eyes closed. R16 had significant bruising noted to left arm and call light was not in reach and was clipped to the top left corner side of the bed. Review of the Nursing Progress Notes, dated 8/31/2022 at 11:17 a.m., for R16, reflected, Resident was readmitted on [DATE] after having a fall on 8/25/22 that resulted in a fracture of the left hip and dislocation of the left shoulder. Res had a successful ORIF and a close reduction on the left shoulder. Resident will be readmitting to hospice. She continues to attempt to self transfer and can be combative at times . Review of the Nursing Progress Note, dated 8/24/22 at 8:51 p.m., for R16, reflected, resident had an observed fall in the hallway. No injuries noted, but resident c/o of left elbow painful. On -call [three named providers] notified of fall. X-ray ordered for left elbow. Staff and this writer made multiple attempts to have resident sit in wheelchair as her gait was unsteady. Resident response was beligerent and aggressive behavior. Resident was resistant to care. Review of the facility, Resident At Risk Progress Note, dated 8/24/2022 at 11:28 a.m., for R16, reflected, Reviewed Clinical Indicator: Res had an additional fall on 8/21/22 She was sitting on her bed linen on the floor next to her bed, she appeared to have slid off the edge of the bed. Resident was seen by [mental health provider group] and there was a recommendation to start Seroquel related to afternoon agitation. Action Taken: No injury noted. However did complain about left foot pain when CNA was assisting with her sock, no additional complaints of pain since that day. Resident needs assistance but has very poor safety awareness related to cognition and gets upset with redirection. Physician and guardian agreed to the medication change, order was placed. Will continue to monitor in RAR for fall and medication change . Review of the Fall Care Plans, initiated 8/21/21, reflected R16 was at risk for falls related to history of falls, cognitive status and medication use. The Care Plans goals, revised on 12/4/21, reflected R16 will be free from injury related to falls through review date. The interventions included, Dycem to wheelchair .created 8/18/22 .Encourage Resident to lay down between lunch and dinner .created 8/18/22 .Encourage the [named R16] to use toilet when completing room rounds as resident allows .created 3/23/22 .Encourage the [named R16] to wear appropriate footwear as needed. 10/19/21 education given to not sit on edge of chair and to reposition as resident allows .created 8/21/21 .make frequent checks on resident when she is up in w/c to ensure she is sitting properly. Encourage and readjust as she tolerates/allows .created 4/7/22 .Put the [named R16] call light within reach and encourage her to use it for assistance as needed .created 8/21/21 . Continued review of the Fall Care Plans reflected no evidence of review or changes after R16 falls on 8/21/22, 8/24/22 or 8/25/22(fall with fracture). During an interview on 9/15/22 at 5:00 p.m., Director of Nursing (DON) B reported she was responsible for resident Incident and accident(I/A) reports. This surveyor requested past three months of all I/A reports including complete investigations. DON B provided file folder for R16 fall on 8/25/22 and reported would work on the additional requested documents. Review of R16 Fall Incident and Accident Reported, dated 8/25/22 at 1:51 p.m., reflected under incident description, Hospice Shower assistant approached the nurses desk to notify nurse that resident was on the ground in the dining room. Resident was observed laying in the recovery position with her wheelchair more than 5 feet away. Resident grimacing in pain. Continued review of the fall report reflected R16's fall was unwitnessed and R16 had a history of frequent falls related to her dementia status. The report reflected R16 was sent to the hospital after 911 was called and wad determined to have left hip fracture as well as left shoulder injury. Continued review of the provided complete investigation reflected no evidence of through investigation including when R16 was last seen by staff, last toileted, staff interviews, interventions that were in place or not in place at time of fall. During an interview on 9/16/22 at 1:47 PM, Registered Nurse Unit Manager (RNUM) K reported nurses were expected to completes fall incident and accident report and management team meets every Wednesday to review falls at Resident at Risk Meetings. RNUM K reported nurses are expected to assess resident to determine cause of fall and immediately implement interventions. RNUM K reported team reviews all interventions at weekly Resident at Risk Meetings. RNUM K reported R16 has declined significantly after recent re-admission from the hospital after fall with fractures on 8/25/22 in facility. RNUM K reported prior to fall R16 was at increased risk for fall related to unsteady on feet and need for assistance with several attempts to self transfer. RNUM K reported since R16 return to the facility, post left hip fracture and shoulder dislocation, R16 has not even tried to get up on own and reported R16 has had increased pain with frequent changes in pain management . During an interview on 9/16/22 at 2:02 PM, Certified Nurse Aide (CNA) E reported not present for R16 fall on 8/25/22 but reported was not a witnessed fall. CNA E reported R16 often self transferred prior to fall and was usually wet or had to go to the bathroom at the time of falls. CNA E reported did not complete witness statement because he did not witness fall. During an interview on 9/16/22 at 2:07 PM, DON B reported had forgot to provided this surveyor with requested falls for R16 for past three months that had been requested 9/15/22. DON B reported R16 had started to decline with increased falls and often self transferred and ambulated unassisted looking for kids or looking for husband. DON B reported R16 had fall from bed on 8/21/22 with note to encourage R16 to use call light. This surveyor reported if that intervention was effective or appropriate. DON B reported reminding a resident to use a call light was a baseline care plan standard and was already in place and was not effective to because of R16 advanced dementia. DON B reported did not see evidence of new interventions added after 8/21/22 fall. DON B reported R16 had fall on 8/24/22 in hall outside room [ROOM NUMBER] after being observed self ambulating unassisted and slipped and fell resulting in left elbow pain. DON B reported fall occurred at 8:37 p.m. according to the Incident/Accident report. DON B reported an the provider was notified at 8:37 p.m. and an X-Ray was ordered at 10:56 p.m. according to the Electronic Medical Record and reported was not completed prior to R16 fall on 8/25/22 at 1:51 p.m. DON B reported interventions were in place at time of R16 fall on 8/24/22 with new interventions to continue to redirect R16. DON B reported that is all they could do with resident like R16 was continue to redirect because she had no purpose to actions and reported R16 had increased need for redirection as day went on and did not like people in her space. DON B reported only so many interventions they could do for R16 because R16 did not like to sit down. DON B reported no evidence to support all interventions had been in place at time of the falls and reported this surveyor had been provided complete investigations for falls. DON B reported recent change in Incident reports from paper to electronic with challenges including details of incidents that DON B was aware of and working on plan. DON B reported R16 fall on 8/25/22 occurred in the main Dining Room at 1:51 p.m. according to the report and reported was unsure if anyone was in the Dining Room at the time of the R16 fall, when resident was last observed prior to fall, that resulted in left hip fracture. DON B confirmed no evidence that care planned intervention were in place at time of R16 8/25/22 fall. Review of R16 provided Fall Incident and Accident Reports reflected R16 had an additional unwitnessed fall on 8/12/22 in hall from the wheelchair, unwitnessed fall 8/2/22 in hall from wheelchair with root cause mood and mental status with interventions to lay down between lunch and dinner(added to care plan 8/18/22), and unwitnessed fall 8/1/22 in hall out of wheelchair with intervention documented as dycem added to wheelchair(added to care plan until 8/18/22). Resident #37(R37) Review of the Face Sheet, dated 9/15/22, reflected R33 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), difficulty walking, unilateral osteoarthritis left hip, meralgia paresthetica bilateral lower limbs and recurrent dislocation left hip. During an observation and interview on 9/14/22 at 9:40 AM, R37 was laying in bed and appeared well groomed and able to answer questions appropriately. A sign was posted on the wall located by head of bed to use knee braces and hip orthosis 9a-12p, 3p-6p. R37 braces were observed sitting in chair on other side of room. R37 reported staff never helps him put braces on and can not do alone and should be on now. R37 reported was told by staff that all staff do Range of Motion(ROM) and reported routine to go weeks without ROM. R37 reported would like staff to assist with use of braces because he would like to be able to discharge but knows he can't in current condition. R37 reported staff to no offer to put braces on and he does not refuse and reported he has loosen braces in past but does not refuse to use. During an observation on 9/14/22 at 3:00 p.m. and 3:35 p.m., R37 was laying in bed with no braces in place. Review of the Treatment Administration Record(TAR), dated 9/14/22, reflected R37's knee braces were documented as in place for 9/14/22 morning and evening shift(observed not in place on both shifts) Review of R37 Care Plans, dated 5/3/22, reflected, Per the orthotic Specialist, [named specialist], Resident is recommended to wear knee braces and hip orthosis for 3 hours in the morning and 3 hours in the afternoon with skin integrity to be checked before and after each application. Review of R37 Physician Orders, dated, 5/3/22, reflected, Knee braces and hip orthosis to be worn 3 hours in the am and 3 hours in the afternoon. Perform skin checks prior to and after wearing. Apply at 9am and remove at noon, Apply at 3pm and remove at 6pm Daily. two times a day related to MERALGIA PARESTHETICA, BILATERAL LOWER LIMBS During an observation and interview on 9/15/22 at 1:35 PM, R37 was sitting in bed with no braces in place. R37 reported had requested staff assist and no one put braces on. During an interview on 9/15/22 at 1:45 PM, Certified Nurse Aid (CNA) G reported knows how to care for residents by verbal report from previous shift and reported they do have access to [NAME] if they have time to read. CNA G reported R37 should have braces on 2 times daily if he does not refuse. CNA G reported R37 did not refuse that day and reported CNA staff do not have ability to document. During an interview on 9/15/22 at 3:02 PM, Registered Nurse (RN) H reported was also restorative nurse. RN H reported facility has restorative therapy five days per week who also helps on the floor and reported if restorative staff pulled to the floor no one does restorative therapy. RN H reported R37 on restrictive program for ROM and fine motor since 5/25/22 and lower extremity braces since 5/3/22. RN H reported braces are documented on Medication Administration Record or Treatment Administration Record (MAR/TAR), [NAME], Care Plans so nurses and CNA staff can implement. RN H reported nurses are responsible overall to ensure orders are being followed. RN H reported R37 should receive ROM five times weekly and would expect staff to document accurately on MAR/TAR.