**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to 1228847. Based on observation, interview and record review, the facility failed to prevent verbal abuse from staff for one resident (R39) of two residents reviewed for abuse resulting in the resident feeling upset and rights being violated. Findings include: On 07/29/2025 at 9:00 AM, R39 was observed sitting on the bed. R39 was interviewed and asked about their interaction with Certified Nursing Assistant (CNA C) on 5/19/25. R39 stated that CNA C told (R39) to shut up and called (R39) a (profanity word). R39 didn't want to take a shower and said that CNA C was in her business. A review of R39's electronic medical record revealed a re-admission to the facility on [DATE] with a diagnosis of Type 2 Diabetes, Hypertension, Major Depressive Disorder, Hyperlipidemia, Asthma, Neuromuscular Dysfunction of Bladder. R39 had a Brief Interview for Mental Status (BIMS) dated 4/25/25, which revealed a score of 15/15 (intact cognitive function). On 07/30/2025 at 11:25 AM, the Director of Nursing (DON) was interviewed and queried about the incident with R39 and CNA C. The DON stated that after the investigation, CNA C was terminated for Disorderly Conduct. A review of the facility's Investigation Report revealed the incident with R39 was witnessed by three facility staff. On 07/30/2025 at 1:15 PM, the Nursing Home Administrator (NHA) was interviewed and asked about the incident with R39 and CNA C. The NHA said CNA C had an inappropriate response towards a resident which led to a termination. The NHA stated, (CNA C) crossed the line and (their) behavior was against their abuse policy. On 07/30/2025 at 1:30 PM, the Minimum Data Set (MDS) Coordinator A said that on 5/19/25, loud raised voices were heard in the hallway. MDS Coordinator A reported that R39 refused a shower and both R39 and CNA C began yelling at one another. R39 told CNA C to Shut Up and CNA C responded in a loud voice saying No, You Shut Up! R39 then called CNA C a dumb bitch! and CNA C responded by telling R39 No, You are one! MDS Coordinator A stated, It's inappropriate to go back and forth with a resident like that.My mother use to be in a facility, I wouldn't want anyone talking to her like that! On 07/30/2025 at 1:45 PM, Dietician B was interviewed and said on 5/19/25, she overheard CNA C getting loud with a resident. Dietician B stated that she was sitting in her office and heard voices escalating near the elevator which is adjacent to her office. She went to assess the commotion and witnessed CNA C instructing R39 to go to the shower room. R39 responded by telling CNA C not to worry her, leave her alone and to shut up! In response, CNA C told resident to Shut Up! R39 called CNA C a Bitch to which, CNA C replied, No, you are one! She stated that CNA C responded negatively and was yelling. Dietician B stated, I was concerned because that's not how you handle residents. On 07/30/2025 at 2:09 PM, a voicemail message was left for CNA C and for CNA D. CNA C and CNA D did not return the phone call prior to survey exit. On 07/30/2025 at 3:29 PM, the DON was interviewed regarding the alleged incident. The DON stated, Staff should not speak to residents like that. DON also stated, That was not professional behavior of an employee. As per the DON and the NHA, CNA C was immediately placed on suspension pending an investigation and the allegation was reported to the State Agency. CNA C was terminated following the investigation. Review of the Abuse Policy, updated on 3/24/2023, documented, It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse . Verbal abuse includes but not limited to humiliation, harassment, threat of bodily harm, punishment, isolation or deprivation to provoke fear or shame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00145543. Based on interview and record review, the facility failed to ensure staff to resident verbal abuse did not occur for one resident (R2), resulting in verbal abuse. Findings include: A review of the facility's incident reported to the State Agency documented on 6/25/24 at approximately 6:50 AM, Housekeeping Aide (HA) T heard CNA S use profane language towards R2 and told R2 that he was irritating and annoying. A review of the clinical record revealed R2 was admitted to the facility on [DATE]. R2's diagnoses included dementia with agitation and sensorineural hearing loss. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment, minimal difficulty in ability to hear, and did not exhibit behaviors towards others. Further review of the abuse investigation documented that HA T informed Staffing Coordinator (SC) U that CNA S was yelling at R2. SC U heard CNA S say, You're going to make me clock the (expletive) out. You're getting on my (expletive) nerves. SC U reported CNA S appeared aggravated and frustrated. R2 looked a little shaken up. SC U reported the incident to the Nursing Home Administrator (NHA) and Director of Nursing (DON). The NHA and DON immediately placed CNA S on suspension pending investigation. R2 was assessed for injury and there were none. The local police were notified. The following employee interviews were conducted regarding the abuse allegation, and documented in part: - SC U: Around 6:50 AM she came up to C floor to go to the storage room and the housekeeper (HA T) told her CNA 'S' was yelling at the (R2). As (SC 'U') approached, she listened and heard CNA 'S' yelling at (R2). She said it was loud and disturbing. She heard her say, 'You're going to make me clock the (expletive) out. You're getting on my (expletive) nerves.' She appeared aggravated and frustrated and while handling (R2's) catheter bag. (R2) was looking at her while she was yelling at him and looked a little shaken up. - Staff V: Can't say verbatim what she (CNA 'S') said. In computer room charting, but heard yelling all the way down the hall from (R2's) room. She could tell it was aggressive. The housekeeper (HA 'T') said she said, 'You are (expletive) irritating, you are gonna make me punch out from this (expletive). - Housekeeping Aide T, Stated hearing yelling coming from (R2's) room and (CNA 'S') said, shut the (expletive) up, you are so irritating and annoying. I've been telling you all night, I'm not about to tell you again. I'm gonna leave you like this and leave out this room. - CNA S: Stated that she was frustrated with (R2) because he was repeatedly putting on his light and calling for help despite her every effort to assist him. She was struggling to empty his catheter bag and he was not cooperating. She said she was frustrated and raised her voice and shouldn't have but did not use profanity. She knew that (SC 'U') saw her and felt that (SC 'U') told on her to get her in trouble for some reason. The abuse investigation documented five residents in the vicinity who were cognitively able to participate in interviews reported not hearing any yelling or profanity. These residents had also been under the care of CNA S previously. None reported any mistreatment by the staff. On 6/25/24 Social Services met with R2 and no signs of symptoms of distress were noted. There were no reports of issues with mood, sleep, or appetite. He mentioned the skin assessment and the police but did not have any issues with the staff. The facility verified that verbal abuse occurred in term of yelling and profane language toward the resident. A review of CNA S employee file documented a hire date of 12/3/23, participation in abuse education, and did not have any previous disciplinary write-ups. CNA S was terminated from employment at the facility on 7/2/24. On 8/29/24 at 11:15 AM, the NHA said CNA S should have backed away and gotten some help when she became frustrated. CNA S should not have raised her voice at R2. The NHA provided in-service education on triggers to all staff. A review of the facility policy titled, Abuse and Neglect, dated 3/24/23, documented in part the following: Verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: identification of affected and like residents. Completed resident assessment and interviews. Provision of staff education on abuse and how to care for residents with behaviors. Wellness visits to R2 from social service staff. Termination of CNA S. Ongoing resident interviews/audits to ensure no resident concerns with abuse. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the Preadmission Screening/ Annual Resident Review (PASARR) forms for Mental Illness/ Intellectual Disability/ Related Conditions Identification (DCH-3877) documents were reviewed, revised, and sent to the local state agency for annual evaluation for a Level II determination for one (R46) of three residents reviewed for PASSARs, resulting in the potential for unmet psychosocial care needs. Findings include: A review of R46's electronic medical record (EMR) did not reveal a Level ll evaluation. There was not a Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification (DCH-3878) form. (The DCH-3878 is a State of Michigan Department of Health and Human Services (MDHHS) form used to claim exemption for level ll screening). R46 was admitted to facility on 11/24/2022 with most recent readmission on [DATE] with pertinent diagnoses of schizophrenia, visual hallucinations and bipolar disorder. Review of a Minimum Data Set (MDS) assessment, with a reference date of 7/10/2024, revealed R46 had moderate impaired cognition with a Brief Interview for Mental Status (BIMS) score of 8/15. On 8/28/24 at 1:27 p.m., Social Service Director F was interviewed and said the 3877 was not submitted to the Health Department timely. It should have been submitted on 11/29/23. On 8/29/24 at 11:38 AM the Director of Nursing was interviewed and agreed PASARRs should be completed thoroughly and timely. On 8/29/24 at 9:17 AM a facility Pasarr policy was requested. The facility provided material referencing the State Operating Manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement an individualized comprehensive seizure disorder care plan for one resident (R25) Findings include: A review of the admission Record for Resident #25 (R25) documented an initial admission date of 2/24/20 and readmission date of 5/14/24. R25's diagnoses on 2/27/2020 included unspecified convulsions. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. Current physician's orders for R25 documented Levetiracetam (medication used to treat seizure disorders) oral tablet 750 mg. Give 2 tablets by mouth two times a day for anticonvulsant. Order date 5/14/24. R25's clinical record documented in part the following: - R25 was discharged to the hospital on 5/6/24 and returned to the facility on 5/14/24. - Nursing progress note dated 5/6/24 documented the following: The CENA (Certified Nurse Aids) yelled for help, when entering the room the patient was having a seizure. The seizure lasted 1 minute and 45 seconds. The patient was in his bed and safety was maintained throughout. After the seizure stopped the patient opened his eyes but did not respond to verbal or pain stimuli. NP (Nurse Practitioner) was notified and gave order to send to the hospital. VS (vital signs): 155/76, 98.8, 18, 98, 98% RA (room air). (R25's Guardian) notified via voicemail, also attempted to call patient's sister .left message for her to return phone call. The patient was transferred to (local hospital by ambulance) at 0830. On 8/29/24 at 12:30 PM, a review of R25's current care plans was conducted with the Director of Nursing (DON). R25 did not have a focused care plan related to resident's seizure disorder. Rather R25's seizure disorder was included as part of a Risk for Falls, Activities, and Nutrition care plans. The Fall, Activity, and Nutrition care plans provided the following interventions related to a seizure disorder: administer medication as directed and keep bed in lowest position. The DON indicated that R25 had a seizure disorder, was on a anti-seizure medication, and had seizure activity, he should have a seizure care plan. The DON said the care plan drives the care the resident receives. R25's care plan should include more specific interventions related to his seizure disorder and it did not. On 8/29/24 at 4:00 PM, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of observation, interview, and record review, the facility failed to document the application of a WHFO (wrist, hand, finger orthotic) as ordered for one resident (R44). Findings include: On 8/28/24 at 8:30 AM, R44 was observed sitting in a wheelchair. R44 did not have a splint on his right hand. A review of the admission Record for R44 documented an original admission date of 7/17/19 and readmission date of 3/28/23. R44's diagnoses included atherosclerotic heart disease, anoxic brain damage, and aphasia. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A current physician's order documented: Splint: type R (right) WHFO location: Right wrist wear schedule patient to wear up to 4 hours daily, monitoring for skin breakdown, to position and protect R hand. Ordered 4/3/24. On 8/29/24 at 11:32 AM, Certified Nurse Aide (CNA) P said she was unaware R44 wore a splint. CNA P located R44's splint in his closet drawer. CNA P said she would chart the application of R44's splint as part of her CNA tasks. CNA P said if she attempted to apply R44's splint and he refused to wear it, she would document his refusal. CNA tasks were reviewed with CNA P and did not reveal a task related to R44's splint use. On 8/29/24 at 12:00 PM, the Director of Nursing (DON) said the Therapy Department put the order in for the splint use. Record review of R44's care plans documented in part the following: - Focus: (R44) has limited physical mobility related to weakness. I have a right resting hand splint that I wear during the day. (R44) can remove the splint and take it off. Dated 6/21/24. - Interventions included: Provide encouragement and reassurance during mobility activities. Dated 4/26/23. Nursing rehab/restorative: Restorative to continue PROM B LE (passive range of motion bilateral lower extremity) in available planes as tolerated 10-15 repetitions. Dated 5/25/23. Nursing rehab/restorative: Restorative to continue PROM B UE (passive range of motion bilateral upper extremity) in available planes as tolerated 10-15 repetitions. Dated 5/25/23. A review of R44's care plans did not list interventions related to the application of R44's wrist, hand, finger orthotic. The DON indicated when the splint application was attempted, the nurse or CNA should document it. A review of R44's CNA tasks with the DON did not reveal a task related to splint use. The DON said the system canceled the tasks on 3/27/23. The way the current order was written did not specify charting the application of R44's splint on the Medication Administration Record or Treatment Administration Record. The DON said maybe restorative was documenting the application of the hand splint. Restorative CNA R was queried and said restorative had no documentation of hand splint use for R44. The DON indicated that if the application and removal of R44's right hand splint was on the CNA tasks list, it would trigger the CNAs that it was part of his care. On 8/29/24 at 12:03 PM, the Director of Rehab (D.Rehab) Q said at one point R44 began to cradle his arm and they did not want a contracture to develop. The order for the splint was to prevent a contracture. On 8/29/24 at 4:00 PM, the Nursing Home Administrator and DON was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not.

Based on observation, interview, and record review, the facility failed to properly dispose of rubbish and ensure proper maintenance of outside disposal containers. Findings include: On 8/27/24 at 11:50 AM, during an observation of the exterior refuse area with Food Service Director (FSD) I, three dumpsters, approximately 4 to 6 cubic yards in size, were observed. The two side doors of one of the dumpsters were observed opened. The top lid on a second dumpster was completely broken off and a side door was opened. FSD I stated the broken and opened doors leaves the garbage inside exposed to pest and rodents can be attracted to the smells. On 8/28/24 beginning at 12:49 PM, the Nursing Home Administrator (NHA) said the doors of the dumpsters should be closed to avoid wind causing the garbage to fall out and to keep out rodents and pests. NHA added that it was not effective to have half the lid gone. We want to get that taken care of to avoid garbage spilling out. On 8/29/24 at 4:00 PM, the NHA and DON was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not. According to the 2013 FDA Food Code, Section 5-501.110 Storing Refuse, Recyclables, and Returnables: Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.

Based on observation, interview, and record review, the facility failed to: 1. Ensure pans and lids were properly cleaned and allowed to air dry before stacking; 2. Ensure the ice machine and three-compartment sink were properly air gapped; 3. Effectively clean surfaces in the kitchen; 4. Ensure proper drainage of floor drains; 5. Ensure thermometers were available in all refrigerators and coolers; 6. Ensure moldy food items were not stored in the walk-in cooler; 7. Remove expired, undated, unlabeled food from the kitchen walk-in cooler and resident refrigerators; and 8. Properly seal food in the freezer to prevent freezer burn (a condition that occurs when frozen food has been damaged by dehydration and oxidation due to freezer air reaching the food. Findings include: On 8/27/24 at 8:50 AM, during the initial tour of the kitchen with Food Service Director (FSD) I the following was observed: 1. In the clean pot/pan area, three one-third size pans, two half-size pans, and two full-size pans, were stored wet and nestled together. Also, eight steam table lids, nestled together, and a 24-cup muffin pan were observed soiled with food debris. 2. AM [NAME] N was observed putting cleaned, but wet, cooking/serving utensils in a storage drawer with cleaned, dry cooking/serving utensils. Later during the kitchen tour, a sticky-appearing substance was observed inside the drawer. FSD I indicated the sticky substance appeared to be honey or syrup. 3. FSD I said the three-compartment sink was still being used even though the garbage disposal was under repair. The drain line from the three-compartment sink was observed to not have the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain). 4. The drain line from the ice machine was not properly air gapped. 5. Pipes attached to the wall underneath the dishmachine drain board were observed soiled with grime. FSD I said a dietary aide recently power washed this area. Dirt was visible on a wet paper towel used to wipe the pipes. FSD I stated the power wash was ineffective because it's still dirty. 6. A puddle of water, approximately two feet in diameter, was observed in the cook's prep area. The cook and dietary aides in the kitchen said the floor drain backs up. When Maintenance Director (MD) H arrived in the kitchen, he said the drain gets clogged. It was not sewage. 7. A thermometer was not available inside the reach-in cooler. 8. The following was observed inside the walk-in cooler: - A thermometer was not available. - A box contained a moldy orange and fresh strawberries inside two 16 oz. containers were moldy. - An opened one-gallon container of Caesar dressing had a use-by-date of 8/4/24, opened one gallon container of mayonnaise and a five-pound container of sour cream did not have a use-by-dates. - Floor tiles were missing in the threshold leading into the walk-in cooler resulting in a floor surface that was stained and not easily cleanable. 9. The following was observed inside the walk-in freezer: - Opened and undated containers of pepperoni and breadsticks - A package, container approximately twelve hotdogs, was unsealed and open to the freezer air. 10. On 8/27/24 beginning at 12:00 PM with FSD I, the following was observed regarding the following residents' refrigerators - A Floor resident refrigerator: a 46 oz. opened container of cranberry juice with a use-by-date of 7/21/24, a six-ounce container of yogurt was not labeled with a resident name, and food in a fast-food bag not labeled with a resident name or a use-by-date. - B Floor resident refrigerator: a temperature log was not available. An opened 46 oz. container of cranberry juice was not labeled with a use-by-date. The following items were not identified with a resident's name: a four-ounce container of yogurt, 16 oz. container of yogurt, and 20 oz. opened bottle of ginger flavored soda. - C Floor resident refrigerator: an opened container of thickened apple juice was not labeled with a use-by-date and ten-ounce fruit-flavored beverage pouch was not identified with a resident's name. On 8/28/24 at 12:49 PM, the Nursing Home Administrator (NHA) indicated he expected kitchen staff to maintain a daily cleaning schedule and weekly deep cleaning schedule because sanitation was key and essential for the well-being of the residents. A review of the following facility policies documented in part the following: 1. Sanitation, dated 7/11/18. - All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. - Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. - Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 2. Food Brought by Family/Visitors, dated 7/11/28. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. The nursing staff is responsible for discarding perishable foods on or before the use by date. On 8/29/24 at 4:00 PM, the NHA and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not. According to the following sections of the 2013 FDA Food Code: 3-101.11, entitled, Safe, Unadulterated, and Honestly Presented, was reviewed and revealed, Food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 4-602.13, Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 4-903.11. Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying. 5-202.13: An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch. 6-201.11 Floors, Walls, and Ceilings. Except as specified under § 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable.

Based on observation, interview, and record review, the facility failed to properly maintain the commercial dishmachine. Findings include: On 8/27/24 at 8:50 AM, during the initial tour of the kitchen the side panel of the dishmachine was not properly attached and was observed situated on top of a drainpipe leaving the mechanicals of the dishmachine exposed. Food Service Director I said the panel has been off the dish machine for over four months. Maintenance had reattached the panel, but it keeps falling off. On 8/29/24 at 1:28 PM, the Nursing Home Administrator (NHA) said the panel needs to be in place and maintenance needs to get it fixed properly. On 8/29/24 at 4:00 PM, the NHA and Director of Nursing was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately investigate and report allegations of abuse for one resident ( R72) of 21 residents reviewed for abuse, resulting in an incomplete investigation, an unreported allegation of abuse to the State Agency timely, and the potential for further allegations of abuse to go unreported and not thoroughly investigated. Findings include: Review of the medical record reflected R72 was an initial admission to the facility on [DATE], readmission on [DATE]. Diagnoses of Malignant Neoplasm of Oropharynx, Neurogenic Bowel, spinal cord injury, functioning quadriplegic, Neuromuscular Dysfunction of Bladder. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/12/2023, revealed R72 had a Brief Interview of Mental Status (BIMS) of 15 out of 15 (cognitively intact) and requires 2-person assistance for transfer, toileting and showers. During an interview on 08/07/23 at 03:26 PM, R72 stated he was in the shower, the CNA took a picture of him. R72 stated he told management, they fired her. During an interview on 08/09/23 at 07:57 AM, Human Resource (HR) J stated they did had a past employee by the name of I, was given personal file. During an observation on 08/09/23 at 11:46 AM, observed Licensed Practical Nurse (LPN) H working on B floor. This writer asked her if she had a minute to come to the conference room after resident care was completed. During an interview on 08/09/23 at 11:51 AM over the phone with previous employee I, she stated her employment was terminated. I stated she was called into the Director of Nursing's (DON) office. Also stated the DON B asked I about taking her phone in the shower taking pictures. I stated she did not take any picture. I stated R72 saw her phone out, R72 had accused staff of stealing money, so they would take 2 people in the shower. I stated that she took a picture R72's purse as evident of the purse and how much was in it. I stated that she was talked to by another CNA and then she went to LPN H and told her everything. LPN H told I not to take her phone in the shower. LPN H talked to R72, and he said nothing happened and he was ok. I stated that 2 days later she was called up by the DON B who told her to never take the phone in the shower. I also stated that she got a suspension from working on that floor but kept working on other floors before getting terminated. During an interview on 08/09/23 at 12:10 PM, LPN H stated R72 denied it, and CNA did not do it. LPN H also stated she did not do anything because R72 said she didn't do anything like that. On 08/09/23 at 12:45 PM, writer requested via email to DON B all incident reports, investigations and facility reported incidents (FRI's) involving R72 and previous employee I. During an interview on 08/09/23 at 01:33 PM, DON B stated she didn't recall that incident, would have to speak to Administrator A. During an interview on 08/09/23 at 03:52 PM, Administrator A stated he did not report this, read off his investigation to writer. Administrator A stated the other CNA looked through I phone pictures. Administrator A stated he educated staff regarding keeping their phones out of patient care area. Administrator A also stated he talked to R72, and he was fine with the outcome. Administrator A stated R72 didn't get hit, it was black and white so no reason to report. Administrator A again explained his process he followed, added he reported everything, and this didn't need to be reported. During the interview on 08/09/23 at 03:52 PM, Administrator A was asked to provide copies of his investigation, as previous request was not fulfilled at this time. On 08/09/23 at 05:08 PM, writer received two pages via email of his investigation. This investigation included a half page of typed notes and a Teachable Moment dated 01/09/23 and an unidentified signature on a document that was not part of the past employee's personal file. Administrator A failed to follow facilities policies and procedures- Nursing Administration. Section: Resident Rights Subject: Abuse and Neglect Policy: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. This includes but is not limited to freedom from any physical or chemical restraint not required to treat the resident's medical symptoms. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. If abuse/neglect is suspected the facility will: 1. Take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care. 2. Notify the appropriate/designated organization/authority (State Agencies) that an investigation is being initiated immediately following intervention for the resident's safety. 3. Conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses. 4. Conduct the investigation with clear communication processes to ensure all relevant information is reported and recorded. 5. Take actions related to resolving resident and family issues/concerns/allegations, educating staff, communicating with families and others (as relevant) and record. 6. Notify law enforcement authorities and press charges, if indicated. 7. Report the investigation findings to the appropriate State Agencies, as required by law. 1150 B Posting Any owner, operator, employee, contractor, or manager of the LTC facility has the obligation to report to the State Agency and at least one local law enforcement agency, any reasonable suspicion of a crime against an individual who is a resident of or is receiving care from the facility. The Administrator is the Abuse Coordinator. Preliminary Investigation Report: The abuse coordinator must submit a preliminary investigation report to the appropriate State Agencies immediately once assurances for the resident's or other resident's safety have been established. However, if the event that caused the allegation involved abuse or resulted in serious bodily injury, the allegation of abuse must be reported to appropriate state agencies immediately and not later than 2 hours after receiving the allegation of abuse or not later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury. Final Investigation Report: The abuse coordinator must submit a final investigation report to the appropriate State Agencies within five (5) working days of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure that resident's care plan included the collaboration of the hospice plan of care, description of the services furnished by hospice, and failed to ensure hospice orders were implemented for one of one resident (R4) who received hospice services resulting in the potential of care not being provided to resident. Findings Include: Resident #4 (R4) Review of the medical record reflected R4 was an initial admission to the facility on [DATE]. admission to hospice program on 01/27/23. Diagnoses include Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Rheumatoid Arthritis and history of falls. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/28/2023, revealed R4 had a Brief Interview of Mental Status (BIMS) of 5 out of 15 (severely impaired cognition) and was dependent of all care. During an interview on 08/07/23 at 04:45 PM, family of R4 stated they have sat in the room for more than 4 hours and nobody came in to check on R4. R4 was not being repositioned every two hours as order by hospice on 11/16/22. Family also reported R4 had an increase of little sores on her skin from not being cleaned and dried with every brief change. Also added that the hospice team finds her saturated in urine laying in her bed. During an interview on 08/07/23 at 04:16 PM, DON B stated the hospice visit notes were in PPC (electronic medical record). DON B also stated they had a hospice binder in the nurse's station that also had visit notes, care plan, orders and calendar of scheduled upcoming visits. DON B was unable to locate any hospice documents in PCC and stated she did not know why hospice notes couldn't be found. During observation and record review the hospice binder with R4's name on it was empty. There was not a hospice plan of care, care plan, medication list, communication notes or calendar stating who would be making visits on which day. During an interview on 08/08/23 at 12:51 PM, Social Worker (SW) K stated they collaborate with hospice social worker during the quarterly case conference. SW K stated that family of R4 had voiced concerns regarding R4 skin issue, taking a long time to clear up. During an interview on 08/09/23 at 08:43 AM, Hospice Nurse M stated she was making skilled nursing visits once a week but had increased her visits to two times a week due to skin integrity, rash is not healing the way it should be. Hospice Nurse M stated even after she placed an additional order to be repositioned every two hours, at times she had a red sacral area, indication of decreased repositioning. Hospice Nurse M also stated the family of R4had reported to her that R4 was not getting turned often enough. Also stated visits were scheduled out through the month for coordination of care. During an interview and observation on 08/09/23 at 12:50 PM, Certified Nursing Assistant (CNA) N stated she didn't have a task sheet or way to document when she repositioned R4. CNA N also stated caregivers were supposed to check her brief and reposition her every 2 hours. Writer asked CNA N if she was aware of an order written on 11/16/22 from hospice Medical Director to reposition R4 every 2 hours. CNA N stated it was not added to the care plan, task sheet or [NAME]. Documentation does not support that the order was initiated or followed. During an interview on 08/09/23 at 01:20 PM, DON B, stated she would expect to see the hospice order for repositioning every two hours be put on the care plan, [NAME] and task sheet. Observation of DON B looking at R4's care plan for initiation of that order. DON B stated that order was not put on the care plan. DON B also stated care plans should be updated during quarterly case conferences and was not done. Record review revealed R4 was to receive bathes two times a week on Tuesdays and Fridays with skin assessments on a form called shower sheets. During a 60 day look back R4 received bathes on 07/14/23, 07/18/23, 07/21/23, 07/28/23, 08/01/12 and 08/08/23. Not on 07/18/23, 07/25/23, 08/04/23. Hospice CNA's provided bathes on Wednesdays and Fridays. Bathing schedule revealed R4 was to receive showers on Friday by the facility and hospice. Documentation did not reveal if R4 received duplicate showers on Fridays. Record review revealed that hospice notes were being scanned into the chart after requested information on R4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement effective individualized interventions to prevent falls, in four of four residents reviewed for falls (R36, R47, R51, and R69), resulting in fractures (Resident #36) and injuries (Resident #47, #51 and #69). Findings Include: Resident #36 (R36) On 08/07/23 at approximately 10:15 AM R35 was observed lying in bed with swelling, a laceration and multiple bruised areas on her face; R35 was observed with a cast on her right wrist. R35 stated in an interview that she fell the day prior and had fallen multiple times at the facility. R36's Minimum Data Set (MDS) assessment dated [DATE] revealed she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short cognitive screener, score of 15 (13-15 Cognitively Intact). The same MDS assessment revealed R36 had functional range of motion limitations on one side of her lower extremity (hip, knee, ankle, foot); she used a walker and a wheelchair for locomotion. R36's same MDS indicated she was occasionally incontinent of bladder and a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission/reentry or since urinary incontinence was noted in the facility. Physical Therapy Evaluation and Plan of Treatment dated 3/28/23 indicated she had the diagnoses of status post joint replacement aftercare, lung disease, Parkinson's Disease and difficulty walking. Treatment approaches included gait training and exercise four to six times a week for four weeks. R36 required partial to moderate (50 percent) assist to roll from lying on her back to her side; transfer from back to sitting on the side of the bed with feet flat on the floor; and safely and efficiently transfer from bed to a chair or wheelchair. The same evaluation revealed R36 was worried about falling, felt unsteady when walking and standing. R36 had impaired strength in both lower extremities and had poor/fair sitting balance. The same evaluation indicated R36's decision making ability was moderately impaired and she lacked insight into condition and risk factors. Occupational Therapy Evaluation and Plan of Treatment dated 3/28/23 revealed that R36 was at risk for falls, her upper extremity strength, balance, mobility, problem solving skills were impaired. Progress Note dated 3/28/23 at 5:13 PM revealed R36 planned to remain in facility until her second knee surgery was completed and would need assistance in finding housing once she recovered from surgery. In review of R36's Fall Risk Care Plan dated 3/30/23, interventions included to educate the resident/family/caregivers about safety reminders and what to do if a fall occurred and to administer medications as directed. The same care plan instructed to refer to current physician orders and/or medication administration record (MAR) and to report any abnormal signs or symptoms. Orthopedic consult letter dated 4/05/23 indicated R36 was seen for left total knee revision. The same letter indicated R36 needed to be working with a physical therapist two times a day on range of motion exercises, strengthening, and gait training. R36 should be up and ambulating, as tolerated with a walker and continuing to wean off assistive devices and was crucial for recovery from her procedure. The plan was to follow-up again in four weeks. Physical Therapy Discharge summary dated [DATE] indicated R36 was discharged from physical therapy services due to exhausted benefits. R36 required supervision/touching assistance when going from lying to sitting on the edge of the bed, and with chair to bed transfers. R36 was able to ambulate 30 feet with contact guard assistance at the time of discharge. Restorative therapy for range of motion services only were planned. There was not a plan related to strengthening or gait training twice daily as recommended by her orthopedic physician on 4/05/23. Occupational Therapy (OT) Discharge summary dated [DATE] indicated R32's dynamic sitting balance (able to sit unsupported and shift weight) was fair. R32 required minimum assistance with dressing and standby assist/supervision with toilet hygiene. Speech Therapy Discharge summary dated [DATE] indicated R32 was discharged due to exhaustion of benefits. The same summary indicated R32 completed delayed recall with 0 percent (%) accuracy with verbal cues and instruction in use of strategies. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, October 2019, manual, indicated as inactivity increases, complications such as pressure ulcers, falls, contractures, depression, and muscle wasting may occur. A previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls. Incident report dated 4/06/23 at 1:09 PM indicated R36 reported she had slipped out of bed a week prior; a skin tear was noted on her left shin. R36 reported she did not remember what she was trying to do, but slipped out of bed onto her bottom, then got herself back up. R36 stated she didn't report it because she was not hurt. There were no new interventions added to the report to prevent additional falls. In review of R36's fall risk care plan, interventions dated 4/06/23, included R36 was to request for help when needed; be sure call light was within reach and to provide cueing and reminders for use as appropriate due to level of cognition. Incident Report dated 4/14/23 at 10:30 AM revealed R36 slid from her wheelchair when reaching for telephone. No new interventions were documented on R36's incident report to prevent reoccurrence. In review of R36's fall risk care plan, an intervention was created on 4/14/23 included to anticipate and meet needs; the intervention was not individualized. The same fall care plan had an intervention created on 4/17/23, to ensure R36's personal items were within reach. Incident Report dated 4/25/23 at 7:30 PM revealed R36 was found on the floor in her room and stated she was trying to reach her phone when she fell, and her left leg was bleeding. R36 was educated to use the call light. R36's fall risk care plan included an intervention created on 4/26/23 to remind and cue to request for assistance when reaching for items. Incident Report dated 4/27/23 at 1:30 PM revealed R36 slid from her wheelchair when trying to pick popcorn off floor. R36 had multiple bruises on both arms. The same report indicated one of R36's left wheelchair break was not functioning correctly, and maintenance was to check her wheelchair breaks. R36 was reminded to lock her wheelchair breaks during transfers or when picking up items from the floor. R36's fall risk care plan included an intervention created on 4/27/23 for frequent checks on resident when not in sight or in common areas, laboratory work, and maintenance was to evaluate wheelchair brakes. During an interview with Registered Nurse/Unit Manager (RN/UM) E, on 8/09/23 at 2:42 PM she stated frequent checks were every two hours. When asked if all residents were checked on every two hours, RN/UM E stated all residents were checked and changed if needed every 2 hours. Incident Report dated 5/02/23 at 2:19 PM revealed R36 was sitting on floor in her room with her left leg slightly under wheelchair and her wheelchair was not locked. R36 reported she had tried to pick up something off the floor. R36's fall risk care plan included an intervention created on 5/04/23 to educate R36 on ensuring that she was sitting all the way back in her wheelchair. Incident Report dated 5/15/23 at 12:34 PM, R36 reported that she had fell in the hallway the day prior, was able to get herself off the floor, and requested pain medication due to right hip pain. R36 reported her pain was a 6 out of 10, with 0 being no pain and 10 being the worst pain imaginable. The immediate intervention to prevent reoccurrence was to educate R36 to report falls as soon as they occur to be assessed for injuries. R36's fall risk care plan included an intervention created on 5/18/23 to follow facility fall protocol; and was not an individualized intervention. R36's fall risk care plan included an intervention created on 5/19/23 to minimize risk factors in environment: areas free of spills and clutter; adequate, glare-free light; bed in low position at night; personal items within reach when in bed/chair, etc. Incident report dated 5/18/23 at 8:43 PM indicated R36 fell from her wheelchair in the hall. R36 reported she was trying to go into her room. There were no immediate interventions included in the report to prevent future falls. R36's fall risk care plan included an intervention created on 5/19/23 was for maintenance to assess her wheelchair for seat malfunctioning. R36's fall investigation did not include information regarding her wheelchair seat malfunctioning. Incident report dated 5/20/23 at 9:45 PM revealed R36 was observed on the floor in her room and reported she slipped from her bed when attempting to get something from her drawer. The same report indicated R36 had sustained a hematoma to the top of her scalp and was transferred to the emergency room for further treatment. After Visit Summary dated 5/20/23 indicated R36 was seen in the emergency room following a fall with head injury. R36 screened positive for depression on the Geriatric Depression Scale (30 item assessment for depression) and returned to the facility. R36's admission MDS assessment dated [DATE] revealed a Patent Health Questionaire-9 (PHQ-9, 9 question screen for depression) score was 00, no depression. R36's fall risk care plan included an intervention created on 5/20/23 included to position bedside nightstand so drawers are facing her. Incident report dated 5/23/23 at 3:09 PM R36 was observed falling headfirst from her wheelchair in the hallway and then proceeded to get herself back up into her wheelchair. The same incident report indicated R36 reported she did not hit her head. The same incident report indicated R36 was observed with a light pink area on her forehead and orders were received to transfer her to the emergency room for further assessment and treatment. R36's fall risk care plan included an intervention created on 5/23/23 for Benzodiazepine (Restoril) medication be discontinued. Incident Report dated 5/25/23 at 1:30 PM indicated at 2:30 PM, R36 reported to the nurse that an hour prior she had fell in her bathroom and hit her right shoulder on the toilet paper dispenser and her left arm on her wheelchair arm. R36 was observed with bruises to her right shoulder and left arm. There were no immediate interventions included on the incident report. Incident Report dated 5/26/23 at 6:56 PM indicated R36 was on the floor in her room. The same reported indicated the charge nurse asked R36 how she fell when her call light was within reach. R36's response was she did not fall but found herself on the floor. R36 was encouraged to use her call light when she needed help; despite being educated to use her call light had been unsuccessful in the past. R36's fall risk care plan included an intervention created on 5/30/23 to encourage R36 to maintain safety and use call light whenever help was needed. PT Evaluation and Plan of Treatment dated 6/02/23 revealed R36 was referred by nursing after decline in strength and frequent falls. R36 had exacerbation of decrease in strength, decreased coordination, decreased neuromotor control, decreased postural alignment, reduced static balance and reduced dynamic balance. There were no changed to R36's care plan to address her need for increased assistance in activities of daily living (ADL) care. OT Evaluation and Plan of Therapy dated 6/02/23 indicated R36 had a decline in upper extremity muscle strength, lower body dressing and dynamic sitting balance. There were no changes to R36's care plan to address her need for increased assistance in activities of daily living (ADL) care. Incident Report dated 6/03/23 at 1:50 PM indicated R36 was observed on the floor in her room attempting to get herself back up. R36 reported she did not fall; she was trying to reach her drawer for her clothes. R36 reported she did not know what happened and found herself on the floor. The same report did not include any immediate interventions to prevent reoccurrence. R36's fall risk care plan included an intervention created on 6/05/23 to continue on therapy services. Incident Report dated 6/10/23 at 5:07 PM indicated R36 reported she had fallen in the dining room and hit her head on the fish tank. A bruise was noted on R36's forehead. The same report indicated R36 stated she forgot to lock her breaks, and the wheelchair rolled away from her when she was looking at the fish. R36 was transferred to the emergency room for further assessment and treatment. R36's fall risk care plan included an intervention created on 6/16/23 for therapy to evaluate R36's wheelchair for proper seating. Incident Report dated 7/06/23 at 2:40 PM revealed R36 was observed in the hallway on her knees in front of the elevator. R36 reported she was waiting on the elevator and let herself down on her left knee. The same report did not include any immediate interventions to prevent further falls. R36's fall risk care plan included an intervention created on 7/10/23 indicated she was referred to neurology for evaluation related to dementia and falls. Incident Report dated 7/14/23 at 4:20 PM revealed R36 was observed on the floor in the hallway bleeding from her forehead. R36 reported she was reaching for the handrail on the wall, slipped out of her wheelchair and hit her head on the floor. R36 was transferred to the emergency room for further assessment and treatment. R36's fall risk care plan included an intervention created on 7/18/23 for therapy to evaluate and treat for soft helmet while up in her wheelchair. There were no instructions to don the helmet or that she recevied a helmet. Incident Report dated 7/20/23 at 1:15 PM revealed R36 was observed sliding from her wheelchair to her knees when attempting to reach for her toothbrush. R36's hand was caught in the top drawer for her three-drawer storage unit, and she was getting ready for an appointment. R36's wheelchair was unlocked. The same report indicated R36 sustained an abrasion to her left knee and was alert and orientated to person, place and time. The same report did not include an immediate intervention to prevent further occurrences or injuries. Physician Consult Visit Notes/Orders dated 7/20/23 indicated R36 was seen for follow-up for revision of left total knee arthroplasty (TKA, total knee replacement). R36 was diagnosed and treated for a right fifth metacarpal neck fracture (right hand fracture) and severe osteoarthritis in her right knee. Orders included splint to R36's right hand, follow-up with neurology as soon as possible due to balance issues, cognition and memory recall; as well as physical therapy (PT) two times a day. Incident Report dated 7/26/23 at 9:36 AM revealed R36 reported she fell in her bathroom the day prior and reported pain in her right hand, arm and shoulder. R36 requested an x-ray. The same incident report revealed R36 reported she had been rushing to get ready when she fell. The immediate intervention to prevent further occurrences was to educate R36 to take her time and report falls as soon as they occur. R36's fall risk care plan included an intervention created on 7/26/23 that R36 was educated on not rushing and reporting falls as soon as they happen. R36's fall risk care plan included an intervention created on 7/27/23 to educate R36 to lock wheelchair prior to reaching for stuff. Incident Report dated 7/31/23 at 11:34 PM revealed R36 was observed on the floor on the right side of her bed. R36 reported she had leaned on her table. The same incident report did not include any immediate interventions to prevent reoccurrence. R36's fall risk care plan included an intervention created on 8/02/23 to offer R36 a reacher to aid in obtaining items. Incident Report dated 8/06/23 at 11:41 PM revealed R36 was observed on the floor on the right side of her bed. The same report revealed R36 had a bruise above her right eyebrow. R36 reported she was trying to fix her bed. R36 was transferred to the emergency room for further assessment and treatment. After Visit Summary dated 8/06/23 indicated the reason for her visit was for a closed head injury (strong force of blow caused brain to shake in the skull; movement could cause the brain to bruise, swell or tear) due to a fall. R36 had a scalp laceration that required stitches; diagnostic reports indicated R36 had a up to 9-millimeter (mm) hematoma (injury caused blood to collect and pool under the skin) to her right scalp, right nasal bone fracture, and a suspected left sided nasal bone fracture. R36's fall risk care plan included an intervention created on 8/07/23 to complete orthostatic blood pressures for three days and to ensure her bed was made at bedtime. During an interview with RN/UM E on 8/09/23 at 2:42 PM, stated she reviewed incident reports every morning with the interdisciplinary team (IDT) and then again after 72 hours and documents effectiveness of interventions on the incident report. RN/UM E indicated if a resident fell during the weekend, she would review the incident report on Monday. RN/UM E stated some, not all nurses will implement an immediate intervention to prevent further accidents. RN/UM E stated in the same interview that anti-roll back wheelchair breaks, as well as an anti-slip pad on the wheelchair seat to prevent slipping were considered, but not implemented; RN E stated did not recall why the anti-roll back breaks weren't implemented. Resident #47 (R47) R47's MDS assessment dated [DATE] revealed she admitted to the facility on [DATE], had a BIMS score of 04 (00-07 Severe Cognitive Impairment); transferred with and walked in her room and in corridor with limited assistance. The same MDS indicated R47 was occasionally incontinent of urine and frequently incontinent of bowel; a trial of a toileting program (e.g., scheduled toileting, prompted voiding or bladder retraining) had not been attempted on admission/reentry or since urinary incontinence was noted in the facility. During an observation and interview on 8/07/23 at10:42 AM, R47's family member indicated R47 had recently fell from her bed and complained of back pain. Incident Report dated 6/12/23 at 5:02 AM, revealed R47 was observed lying on her back in front of her bed on floor. The nurse assistant (NA) noted R47's wheelchair at the time of the occurrence was across the room and out of reach. R47 had a discoloration on the lower back. R47 stated she was attempting to use the bathroom when she fell. No immediate intervention was indicated on the incident report. In review of R47's Fall Risk care plan, creation date of 6/13/23, staff was to ensure residents wheelchair was close to bed when not in use. The same care plan indicated an intervention created on 2/17/22 and resolved on 5/02/23; R47 was to be offered to use the bathroom while awake between 4 and 6 AM. The same care plan had an intervention created on 2/18/22 to reorient to own bed and ensure wheelchair was locked at bedside; this intervention was marked as resolved on 4/22/23. During an interview with RN/UM E on 08/09/23 at 3:25 PM stated placement of the wheelchair next to bed was technically a standard practice and had been used as an intervention before. RN/UM E indicated in the same interview R47 took herself to the bathroom and had urinary urgency. An incontinence assessment including bladder and bowel diary was not considered following R47's fall. Resident #51 (R51) R51 was observed on 8/09/23 at 10:37 AM wearing a pink helmet and propelling herself in a wheelchair with her feet. During an interview with Licensed Practical Nurse (LPN) P, she stated if R51 was not active, she was place in a reclined geriatric chair (large, padded chairs with wheeled bases used for those with mobility issues and for bedridden resident that have difficulty sitting upright in a conventional wheelchair). LPN P stated in the same interview R51 was active on day of interview, so she was placed in her wheelchair. R51's MDS dated [DATE] revealed she admitted to the facility on [DATE], her cognitive skills for daily decision making was severely impaired, never/rarely made decisions. R51's same MDS revealed she required extensive assistance of one person for transfers, bed mobility, and locomotion. In review of R51's Risk for Falls care plan dated 9/17/20 revealed no geriatric chair or Broada chair (specialty positioning chair) was ever care planned for positioning/locomotion. Physical Therapy Evaluation and Plan of Treatment dated 5/16/23 indicated R51 used a wheelchair for mobility. Incident Report dated 6/03/23 at 4:08 AM indicated R51 was found lying on the floor next to her bed on her right side, with her feet still up in her bed. Bruising was noted on her left hip and left elbow. The same incident report indicated R51's bruising may have not been caused from the incident and no new interventions were documented on the same incident report. In review of R51's Risk for Falls care plan, a new intervention was created on 6/05/23 to offer R51 to get up early and be common areas when agitated. The same intervention did not specify a time frame for early. Incident Report dated 6/07/23 at 8:30 AM indicated R51 was on the floor in her room. The report did not indicate if R51 was in bed or a chair prior to the fall. R51 was transported to the emergency room for further assessment and treatment. In review of R51's Risk for Falls care plan, no new interventions were added to the care plan. Incident Report dated 6/25/23 at 6:52 AM revealed R51 was observed lying on the floor mat between the wall and the bed. There were no immediate interventions included in the report to prevent further falls. In review of R51's Risk for Falls care plan, an intervention was added and resolved on 6/26/23, to provide R51 with a bigger bed. According to an incident report dated 6/03/23 at 4:08 AM, R51 had a larger mattress in place at that time. Incident Report dated 6/29/23 at 1:00 PM revealed at 12:45 PM R51 was observed on the floor beside the wall of hallway in her room. The same report indicated R51's bed was in lowest position; a floor mat was beside her bed, and she was transferred to a geriatric chair after she was dressed. Nurses progress note dated 6/30/23 at 6:43 PM revealed R51 was very agitated during the shift, she started screaming out and tried to climb out of bed since she woke up at 9:00AM. R51 was placed in a geriatric chair at 9:30 AM, but she still was very agitated, screaming, pulling and shacking her geriatric chair. Scheduled clonazepam (used for anxiety), Seroquel (anti-psychotic), Tramdol (pain medication)and extra dose of Clonazepam, and as needed Oxycodone (opioid pain medication) given without effectiveness. In review of R51's Risk for Falls care plan, revised on 7/03/23 indicated to offer to bring resident from room to hallway and monitor when agitated. This intervention was similar as the intervention on 6/05/23; offer R51 to get up early and be common areas when agitated, in which was not effective. In review of Incident Report dated 6/29/23 at 2:30 PM, R51 was observed on the floor in the hallway face down; the geriatric chair had flipped over on the floor bedside her. The same incident report revealed R51 was very agitated and kept pushing her geriatric chair. Ativan (anti-anxiety) medication was given at 1:15 PM and was not effective. The same report indicated R51 had been sitting in a geriatric chair that was lighter than the regular geriatric chair and she was placed in the regular geriatric chair after the fall. R51 was transferred into another geriatric chair and then transferred to the emergency room per the same incident report. The same incident report indicated R51 had new open areas, redness and swelling, but did not include location or extent of injuries. During an interview with RN/UM E on 8/09/23 at 2:42 PM, she stated R51 was supposed to be in a Broda chair, the nurse wrote geriatric chair by mistake. RN/UM E stated R51 was transferred to the hospital and treated for an infection. RN/UM E did not update R51's Risk for Falls care plan. Incident Report dated 7/06/23 at 4:00 PM indicated R51 was observed agitated and on the floor in her room. The same report did not include any immediate interventions implemented to prevent further occurrences. Incident Report dated 7/06/23 at 5:23 PM revealed R51 was observed on the floor in her room next to her wheelchair. The same report indicated she had a skin tear on her face and was bleeding and R51 was transferred to the hospital. Incident Report dated 7/27/23 at 6:07 PM revealed R51 climbed out of the geriatric chair at 1:40 PM in the hallway and fell to the floor, hitting the right side of her head against the crash cart. The same report indicated R51 was wearing a soft helmet at the time of the fall. Physicians progress not dated 7/28/23 at 1:00 PM indicated R51 had complained of neck and back soreness and x-rays were ordered. R51's Risk for Falls care plan indicated a specialty wheelchair was provided. During an interview with RN/UM E on 8/09/23 at 2:42 PM, she stated R51 used a Broda chair on 6/20/23 and prior to that used a geriatric chair. RN/UM E stated R51 was supposed to be in a geriatric chair at the time of the fall on 7/27/23. RN/UM E confirmed use of a Broda chair and/or geriatric chair was not on R51's ADL or Fall Risk care plan. RN/UM E stated the month prior to interview therapy had recommended a new wheelchair, in which R51 was currently using. Resident #69 (R69) R69's admission MDS assessment dated [DATE] revealed he admitted to the facility on [DATE], had a BIMS score of 14 (13-14 Cognitively Intact), and required extensive assistance for bed mobility and transfers. The same MDS assessment revealed R69 was frequently incontinent of bladder and always incontinent of bowel and no toileting programs were implemented to improve continence. Incident Report dated 6/16/23 at 5:17 PM revealed R69 was observed on the floor in his room and stated he wanted to go to the bathroom. A raised area was observed on his forehead. R69 was transferred to the emergency room for further assessment and treatment. In review of R69's care plan, the was no toileting program implemented or other interventions implemented to prevent further occurrences. Incident Report dated 6/24/23 at 9:56 PM revealed R69 was observed on the floor in his room and complained of pain to his head, neck and back. R69 stated he did not know how he fell, that he was asleep. R69 was transferred to the emergency room for further assessment and treatment. R69's fall risk care plan dated 6/26/23 indicated frequent checks on resident while asleep. The same care plan did not indicate frequency of checks. Incident Report dated 7/17/23 at 6:55 PM indicated R69 was on the floor in his room calling for help. The same report indicated R69's call light was on at the time and R69 reported he was attempting to reach his washcloths and call light prior to the fall. The same report revealed R69 had an injury to his forehead and a dressing was applied. There were no immediate interventions documented on the incident report. In review of R69's Risk for Falls care plan, dated 7/18/23, instructed to ensure personal items and call light were kept within reach prior to leaving room. During an interview with RN/UM E on 8/09/23 at 2:42 PM, she stated R69 returned from the emergency room with a diagnosis of pneumonia and more frequent checks were effective. RN/UM E stated in the same interview she did not review staffing on 7/17/23 at 6:55 PM, because that would not change.

Based on interview, observation and record review the facility failed to provide sufficient staff to meet 5 of 8 residents' needs, as voiced during a confidential Resident Council meeting, , resulting in unmet needs and frustration. Findings include: During a resident council meeting on 08/07/23 at 01:54 PM, residents voiced concerns with staffing. CNAs told us to just pee in the bed and they would have to change us. 3 out of 8 residents stated that they are neglected by staff disappearing on their shift and not providing care as needed. 5 out of 8 residents stated they were told CNA was not their aide, or that not my job. 3 out of 8 residents stated they have waited over an hour for someone to answer their call light, when the CNA comes in, if the resident fell asleep waiting, staff will turn off the call light and leave the room. 1 out of 8 residents stated the CNA will come in to see what they need and then say they cannot help the resident because they have a bad back or sore wrist. 4 out of 8 residents stated they have only had one CNA working on their floor and they are a 2 person assist, they had to go to another floor to get help. Needs not getting made, when they have 2 staff, they had to rush from one resident to another, especially when we are all 2-person assistance. During an interview and observation on 08/08/23 at12:45 PM, observation of Rm C1-was still in her pajamas in bed, lunch on her over the bed table, Rm C7 was wearing his pajamas in bed sleeping with his lunch on his over the bed table, Rm C11-was still wearing her pajamas in bed. During an interview on 08/09/23 at 08:01 AM, scheduler R stated they schedule based of the census. Also stated she leaves the schedule at front desk. Scheduler R stated everything is based off census, has had between 85-91 residents since March 2023. Writer asked if they take acuity of the resident into consideration when scheduling caregivers. Scheduler R stated she would they have to get approval from administration before she could do that. Scheduler R stated she scheduled 2 CNAs on A floor, 3 CNAs for B floor and 3 CNAs for C floor on day shift. When asked if she had residents complain about the need for more staff. Scheduler R stated she had a couple residents complain about not having enough staff to meet their needs and the CNA's they preferred. During an interview on 08/09/23 at 09:27 AM facility resident S stated some staff were good, could see they were stressed and could see it in their face and attitude. During an interview on 08/09/23 at 09:32 AM, CNA T stated they were short staffed, not uncommon to have 1 CNA and 1 nurse on A floor, added it was a hard floor and nobody wants to work it. CNA T had been left alone on this floor many times. Had to go get a CNA from other floor to help with resident care. During an interview and observation on 08/09/23 at 09:54, R72 stated he didn't get the care he needed due to staffing, the CNA would not help him get up to the bathroom, they gave him a bedpan to use. R72 stated he was supposed to get up to the bathroom with 2-person assistance, rarely had 2 CNAs to do it. During an interview on 08/09/23 at 11:30 AM, Restorative Aide (RA) U stated she was able to get her work done, even if she had to come in on Saturday, may get behind on her paperwork and needed to catch up. RA U also stated she gets pulled to other floors to help due to staffing need. During an interview on 08/09/23 at 02:30 PM, DON B stated they staff according to the budget and census. DON B stated they had a conversation with Administration daily. Also added the CNAs and Nurses have voiced the need for more help, brought up on room rounds with residents. Writer asked what their recruitment plan. DON B stated they were not doing anything, no agency staff are used, they offer no bonuses. During an interview on 08/09/23 at 04:40 PM, Administrator A stated they were not understaffed, over staffed if anything, stopped using agency staff. Staffing based off acuity and budget. Administrator A stated he spreads out the higher acuity residents throughout the building. Added if there was a reason we need more staff, they would go to corporate and would have to validate the need, they could always have that conversation.

Based on observation, interview and record review, the facility failed to ensure a clean, comfortable and homelike environment, resulting in excessively worn and soiled furniture, increased risk for infections. This deficient practice had the potential to affect the 90 residents who reside within the facility. Findings include: During a dining room observation during lunch on 8/07/23 at 12:03 PM on the C level floor, a resident was observed sitting in a chair that was not a dining chair, the table was positioned above elbow level for the resident. Two residents were observed sitting in dining chairs at the same table and at an appropriate height for eating. All residents that were served lunch were served on cafeteria type trays. The living area in the same dining room was observed with a couch and loveseat that were heavily soiled with water stains, what appeared to be milk stains, and dirt on the seat cushions and arm rests. One resident was observed sitting on the sofa eating his lunch on an over-the-bed table. Two light brown vinyl covered chairs were excessively worn through vinyl exposing the cushion and was black in color, on both arms of each chair and the headrest of both chairs. A half round side table was observed next to the television with medium-density fiberboard (MDF) exposed with water damage on the edge of the table. A dorm-sized refrigerator was observed in the cabinet area that was soiled with food/liquid spills. The cupboards were observed with dried liquid spills. Inside three cupboards were several sheets wadded up and a soiled napkin. The gold hardware on the cupboards were worn, exposing a silver color. During an interview on 8/09/23 at 8:50 AM, Housekeeping supervisor (HS) W, stated the dining rooms were cleaned every day, and sheets were removed from cupboards. HS W stated he did not know why sheets were in the cupboards. HS W stated he had reported the condition of the furniture in the dining room and that the facility had ordered new furniture but was not sure when the furniture had been ordered.