**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** All times are in Eastern Daylight Time (EDT) unless otherwise noted Based on interview and record review, the facility failed to honor the advanced directive for one Resident (R20) of four residents reviewed for advance directives. This deficient practice resulted in the potential for residents' decisions regarding end-of-life care and medical care to not be followed by the facility. Findings include: Resident #20 (R20) R20's medical record included an order for Do Not Resuscitate (DNR). R20 signed an Advanced Directive (AD) on July 2, 2014. The AD documented, in part: .I want my life to be prolonged by life-sustaining treatment unless I am in a coma or vegetative state which my doctor reasonably believes to be irreversible . A Minimum Data Set (MDS) assessment dated [DATE] documented R20 was not in a vegetative state or coma. The AD further read, in part: . Once my doctor has reasonably concluded that I will remain unconscious for the rest of my life, I do not want life-sustaining treatment to be provided or continued . A review of physician documentation in R20's record revealed documentation of R20 being alert and responding appropriately to the physician during examination. R20 appointed a Patient Advocate (PA) in the AD dated 7/2/2014. The designation of PA and directions for health care documented, in part: .To my family, doctors, and all concerned with my care: These instructions express my wishes about my health care. I want my family, doctors, and everyone else concerned with my care to act in accord with them . . c. A Patient Advocate may make a decision to withhold or withdraw treatment which would allow a Patient to die only if the patient has expressed in a clear and convincing manner that the Patient Advocate is authorized to make such a decision, and that the Patient acknowledges that such a decision could or would allow the Patient's death . No such clear and convincing power was granted to allow the PA to change the code status through this document. A medical determination form of competency was signed by two physicians on January 19, 2024, deeming R20 incapable of participating in medical treatment decisions. A Patient Advocate Consent form for DNR code status was signed and dated by R20's PA on 2/14/24. The form read, in part: .I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant . The Social Services Coordinator (Staff B) was interviewed on 7/24/24 at 12:50 p.m. Staff B confirmed she oversaw advanced directives in the facility. Documentation including R20's AD, code status order, and physician determination of capacity was reviewed with Staff B. After reviewing the documents, Staff B said, (R20's name) was competent to make his own decisions at the time he signed his Advanced Directive. Staff B was asked why the PA was offered a DNR option if R20 declared his choice of code status when he was cognitively competent to make his own choices and decisions. Staff B responded, I don't think (the PA's name) can sign for (R20's name) to be a DNR. Staff B confirmed there were no court-issued or legal documents allowing the PA to amend R20's choice of code status. Staff B attested there were no additional documents indicating R20 amended or rescinded his choice of code status as outlined in the AD. An undated policy Residents' Rights Regarding Treatment and Advance Directives read, in part: .It is the policy of this facility to support and facilitate a resident's right to request . medical or surgical treatment and to formulate an advance directive . Advanced directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under state law relating to the provision of health care when the individual is incapacitated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report potential abuse to the State Agency as required for two Resident (R23 and R45) of three Residents reviewed for abuse reporting. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. Resident #45 (R45) According to the Minimum Data Set (MDS) assessment, dated 4/10/24, R45 had a Brief Interview for Mental Status (BIMS) assessment and scored 03/15 which indicated severe cognitive impairment, with diagnoses including dementia and anxiety. On 7/25/24 at 9:45 AM, an observation was made of R45 in her bathroom being toileted with Certified Nurse Aide (CNA) P and CNA Q. R45 was sitting on the toilet and was noted to have a quarter sized circular bruise on her right thigh. Both CNA P and CNA Q were asked how long the bruise had been on R45's right thigh and if it was reported to management and replied, We are not sure. Neither of us had worked in the last couple of days. Review of the facility incident and accident report, dated 4/25/24, read in part, .found a bruise during morning care .there are 2 small skin discolorations on right upper thigh. It looked like in different stages of healing. Approximately 2 cm (centimeters) in circumference bigger area and approximately 1 cm next to it. Resident unable to give description. Further review of the report revealed that it was also reported to the family, Director of Nursing, and physician. Review of the facility incident and accident report, dated 5/27/24, read in part, .observed red bruising on left arm .bruises measuring 2.6 x 1.1 cm, 2.1 x 1.8 cm, and 1.0 x 2.1 cm, with multiple pin point red area's. Resident unable to give description. On 7/25/24 at 10:22 AM, an interview was conducted with the ADON/RN A and the Nursing Home Administrator (NHA) regarding the 4/25/24 and the 5/27/24 incident and accident reports from R45. The ADON/RN A and the NHA were both asked if either incident involving R45 were reported to the State Agency and replied, We did not report these, and we should have but we were not made aware of this incident. The ADON/RN A stated that, We are not getting the calls from the incident and accident reports. Sometimes they are not filled out correctly. The floor nurses don't know what's reportable and don't always call and get clarification. Review of policy titled, Abuse, Neglect, and Exploitation, dated 5/2/23, read in part, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Identification of Abuse, Neglect and Exploitation .B. Possible indicators of abuse include, but are not limited to .2. Physical marks such as bruises or pattered appearances such as a hand print .Investigation of Alleged Abuse, Neglect and Exploitation .Written procedures for investigations include .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation . Resident #23 (R23) R23 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's dementia, anxiety and depression. Review of R23's Minimum Data Set (MDS) assessment, dated 4/26/2024, revealed she required substantial/maximal assistance with toileting, bathing, dressing and personal hygiene. Further review of the MDS assessment revealed R23 scored three out of 15 (3/15) on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of R23's electronic medical record (EMR) revealed the following: 2/22/2024, 14:30 [2:30 p.m. Central Savings Time, CST]. Incident Note . CNA [Certified Nursing Assistant] noted a bruise to resident's left bicep during her bath this afternoon. [CNA] stated that resident did not bump her arm while getting into the tub . unaware of resident bumping her arm today. Resident was a partial this morning and therefore was dressed early this morning by night shift . DON . ADON notified. Review of R23's Injury report, dated 2/22/2024 at 2:22 p.m. CST, revealed the following written statements: CNA X, dated 2/22/2024: No known injuries while I was with [R23] today 2/22/24 or any days earlier. CNA CC, dated 2/22/2024: I was giving [R23] a bath when I noticed a red area on her upper left arm and a Band-Aid a little above the red area. CNA DD, dated 2/22/2024: I worked on 400 [Special Care Unit] from [7:00 a.m. - 3:00 p.m.] and became aware of [R23's] arm redness at 2:20 p.m. when I started for the day she was already dressed. CNA EE dated 2/22/2024: I partialed [sic] resident in her bed [at] approx. 5:30 a.m. she stayed in bed until 6:30ish [sic]. I did not see any red marks on her arm at any time during this period. Further review of R23's EMR revealed the following: 2/22/2024 at 2:18 p.m. Skin & Wound Evaluation V7.0 . Type: Bruise . Location: Upper left arm (inner) . New . Wound Measurements: Area 26.3 cm2 [cubic centimeters]. Length 5.7 cm. Width 5.5 cm .? During an interview on 7/24/2024 at 4:18 p.m., the ADON reported the facility had not determined the cause of R23's bruising and application of a Band-Aid on 2/22/2024. The ADON confirmed an abuse investigation was not initiated and the incident was not reported to the SA. The DON, present during the interview, reported someone had to know what happened to cause the injury because R23 did not have access to Band-Aids and did not have the cognitive ability to apply a Band-Aid to her left inner arm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to investigate potential abuse to the State Agency as required for two Resident (R#23 and R#45) of three Residents reviewed for abuse investigating. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. Resident #45 (R45) According to the Minimum Data Set (MDS) assessment, dated 4/10/24, R45 had a Brief Interview for Mental Status (BIMS) assessment and scored 03/15 which indicates severe cognitive impairment, with diagnoses including dementia and anxiety. On 7/25/24 at 9:45 AM, an observation was made of R45 in her bathroom being toileted with Certified Nurse Aide (CNA) P and CNA Q. R45 was sitting on the toilet and was noted to have a quarter sized circular bruise on her right thigh. Both CNA P and CNA Q were asked how long the bruise had been on R45's right thigh and if it was reported to management and replied, We are not sure. Neither of us had worked in the last couple of days. Review of the facility incident and accident report, dated 4/25/24, read in part, .found a bruise during morning care .there are 2 small skin discolorations on right upper thigh. It looked like in different stages of healing. Approximately 2 cm (centimeters) in circumference bigger area and approximately 1 cm next to it. Resident unable to give description. Further review of the report revealed that it was also reported to the family, Director of Nursing, and physician. Review of witness statement, dated 4/25/24, from CNA V, read in part, I had not did cares on resident since Monday noc (night) 4/22/24 - I had not seen anything as of that date . Review of witness statement, dated 4/25/24, from CNA U, read in part, .I noted two bruises on (R45's) upper right thigh near vagina reported to (nurse) . Review of the facility incident and accident report, dated 5/27/24, read in part, .observed red bruising on left arm .bruises measuring 2.6 x 1.1 cm, 2.1 x 1.8 cm, and 1.0 x 2.1 cm, with multiple pin point red area's. Resident unable to give description. Review of witness statement, dated 5/27/24, from CNA W, read in part, .Left arm bruise .I did not notice bruise all day as she (R45) was wearing sweatshirt all day . Review of witness statement, dated 5/27/24, from CNA Q, read in part, .bruise left lower arm .daughter noticed the bruise she (R45) had a sweater on all day and didn't notice . Review of R45's two incident and accident reports, dated 4/25/24 and 5/27/24, revealed the lack of any other facility employees being interviewed for witness statements to include a full investigation was conducted per facility policy. Interviews were only done with immediate staff working R45's hallway and not all staff from that day on other halls worked, or the prior two days to rule out any type of abuse or neglect. On 7/25/24 at 10:22 AM, an interview was conducted with Assistant Director of Nursing (ADON)/Registered Nurse (RN) A and the Nursing Home Administrator (NHA) regarding the 4/25/24 and the 5/27/24 incident and accident reports for R45. RN A and the NHA were both asked if either incident involving R45 were fully investigated and replied, We did not fully investigate these, and we should have but we were not made aware of this incident. We would have interviewed all staff working the days the bruising had been discovered and the prior two days before those days. RN A stated that, We are not getting the calls from the incident and accident reports. Review of policy titled, Abuse, Neglect, and Exploitation, dated 5/2/23, read in part, .Investigation of Alleged Abuse, Neglect and Exploitation .Written procedures for investigations include .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation . Resident #23 (R23) R23 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's dementia, anxiety and depression. Review of R23's MDS assessment, dated 4/26/2024, revealed she required substantial/maximal assistance with toileting, bathing, dressing and personal hygiene. Further review of the MDS assessment revealed R23 scored three out of 15 (3/15) on the BIMS, indicating severe cognitive impairment. An observation on 7/24/2024 at 9:58 a.m. revealed CNA X and CNA DD assisting R23 with toileting in the shower room on the Special Care Unit (SCU). R23 was observed to have a large, linear purple bruise on the inner aspect of the back of her right lower leg. CNA X and CNA DD reported they were unaware of the bruising. CNA DD reported R23 often bumped herself. When care was completed, R23 was transferred from the toilet to her wheelchair which was positioned facing her. Upon standing, R23 was assisted to pivot so her buttocks were facing the chair. CNA DD placed a gait belt around R23's midsection and stood on the right side of the wheelchair with CNA X standing on the left. After R23 was pivoted so her buttocks were positioned over the wheelchair seat, CNA X lowered R23 to the seat by using her left hand and holding tightly onto the R23's left upper arm and lowered R23 to a seated position. Review of R23's electronic medical record (EMR) revealed the following: 7/18/2024 [7:53 a.m. Central Daylight Time] Skin/Wound Note . Resident noted to have a dark purple bruise to the back of left lower leg. Fading noted Resident noted to have a dark purple bruise to the back of right lower leg. Fading noted . Review of the Injury report, dated 7/13/2024 at 6:00 a.m., revealed the following: [CNA FF] found 2 bruises on resident while giving her her [sic] weekly shower. One to left, lower inner leg that measures 3 cm [centimeters] by 4.5 cm and back of right lower leg that measures 3 cm by 3.5 cm. Resident unable to give description. Review of CNA FF's written statement, attached to the Injury report, revealed the following: 7/13/2024 . Bruises found on back of legs where foot pedals located. Noticed bruises on back of lower legs during her shower. Bruises located right where foot pedals of wheelchair hit. During review of R23's Injury reports on 7/24/2024 at 4:18 p.m., RN A reported no investigation was conducted to look into the cause of R23's bruises found on 7/13/2024. RN A stated CNA FF's written statement was not obtained until the current day, 7/24/2024. The ADON confirmed R23 had severe cognitive impairment and could not account for how the bruising occurred. The DON, present at the time of the interview, reported the injury should have been investigated to rule out abuse or mistreatment.

. Based on interview and record review, the facility failed to provide written transfer notification to the resident and resident's representative including reason, effective dates, and the location to which the resident was being transferred for one Resident (R39), of two residents reviewed for transfers out of the facility. Findings include: All times are recorded in Eastern Daylight Time (EDT) unless otherwise noted. Resident #39 (R39) The medical record for R39 revealed a transfer to the hospital on 7/9/23. The medical record did not indicate a written notification of transfer was given to R39 or sent to her representative. During an interview on 7/25/24 at 10:58 AM, Administrative Staff C stated she did not send written notifications of hospitalization stays to any residents or their representatives. She was not aware this was required. Staff C stated the previous person in her position had retired. The facility policy titled Transfer and Discharge dated 7/2024 was provided and read in part: 12. Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident . g. Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #41 (R41) R41 was admitted to the facility on [DATE] and had diagnoses including dementia and anxiety disorder. Review of R41's Minimum Data Set (MDS) assessment, dated 6/18/2024, revealed he was independent with mobility and walking. Further review of the MDS assessment revealed R41 scored five out of 10 (5/10) on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. An observation on 7/22/2024 at 2:05 p.m., revealed R41 walking up and down the hallway near the entrance/exit of the SCU. At 2:08 p.m., Certified Nurse Assistant (CNA) X and an unidentified staff member entered the hallway from behind a closed door. CNA X turned to R41 and told the Resident to, come here, waving her hand down the hall toward the nurses' station. CNA X and the unidentified staff member continued down the hall to the dining room area. R41 stopped at the unattended nurses' station and was heard asking, will someone let me out, please while attempting to open the locked door leading to the nurses' station. R41 proceeded to walk down the hall and sat in a chair in the hallway between rooms [ROOM NUMBERS]. At 2:16 p.m., CNA X entered the hallway and approached R41 at which time R41 asked CNA X to, let me out, please. CNA X asked R41 where he wanted to go and R41 answered, home. During an interview outside the SCU medication storage room, on 7/24/2024 at 9:45 a.m., RN E reported R41 was noted to be more anxious and difficult to redirect during the previous shift. RN E stated R41's wandering and exit-seeking behavior seemed to worsen with the current attempt to reduce his psychotropic medications. During the interview, the SCU exit door alarm sounded and CNA X was observed running down the hall toward the exit door. Further observation revealed R41 pushing through the exit door and stepping off the unit as CNA X approached and redirected R41 back onto the unit. It was noted the exit door led to an unused portion of the building's second floor, the elevator and stairway. An observation on 7/24/2024 at 7:46 a.m., revealed R41 sleeping in a reclining chair across from the nurses' station. CNA F was seated in a chair near the nurses' station window. During an interview at the time of the observation, CNA F reported she was seated in the living room to supervise R41. CNA F reported R41 was going in other resident's rooms and she consistently needed to redirect him throughout her shift. Review of R41's EMR revealed the following, in part: 6/15/2024, 23:00 [11:00 p.m.]. Progress Note. Patient was admitted to [acute care hospital] for advancing dementia with behavioral disturbance . now admitted to the facility for long-term care in the memory unit where he will be able to ambulate in a controlled environment . Review of R41's care plan revealed no focus area, goals or interventions related to his wandering, exit-seeking behavior, or elopement risk. During an interview on 7/24/2024 at 4:16 p.m., RN A confirmed R41's care plan did not include a focus area, goal or interventions related to his wandering, exit-seeking behavior, or elopement risk. The DON (Director of Nursing), who was present at the time of the interview, reported R41 was admitted to the facility for the primary reason of requiring increased supervision related to unsafe wandering. Review of the undated facility policy titled Comprehensive Care Plans, revealed the following, in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . that The comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Based on interview and record review, the facility failed to develop comprehensive care plans for two Residents (R41 and R54) of 17 residents reviewed for care planning. This deficient practice resulted in the lack of care plan goals and interventions, with the potential for unmet needs. Findings include: All times are recorded in Eastern Daylight Time (EDT) unless otherwise noted. Resident #54 (R54) R54 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, congestive heart failure, diabetes, major depressive disorder, panic disorder, anxiety disorder, dementia and multiple fracture history. On 7/22/24 the facility presented a matrix with all residents listed which included conditions and concerns. R54 was listed as End of Life Care/Comfort Care/ Palliative Care. The Electronic Medical Record (EMR) reflected weights of: 7/22/24 187.0 pounds 6/24/24 199.0 pounds 4/22/24 220.0 pounds 1/22/24 232.0 pounds These weights indicated a 6% weight loss in one month, a 9% weight loss over three months, and a 19% weight loss over six months (all significant weight losses). On 7/22/24 at 1:28 PM, the lunch tray arrived in the room of R54, but he was sleeping and showed no interest in lunch. Certified Nurse Aide D stated, Right now he is not eating much at all. On 7/22/24 At 2:19 PM, R54's tray was observed as he was finished with lunch. R54 had eaten nothing. The lid remained on the beverage of milk and although the salisbury steak was cut up, nothing had been consumed. On 7/23/24 at 1:23 PM, family members were present and trying to encourage R54 to eat lunch. He was belligerent and non-compliant. R54's family member spoke to this surveyor in private and stated R54 was declining and the family wanted R54 comfortable on palliative care. The EMR for R54 was reviewed. No physician order or care plan for palliative care was found. On 7/25/24 at 11:25 AM, Registered Nurse (RN) E reviewed the EMR and stated, We don't have an order or a care plan for palliative care (for R54), but we probably should. On 7/25/24 at approximately 11:45 AM, Assistant Director of Nursing (ADON)/RN A stated R54 had a significant change assessment completed in March 2024 due to his decline. RN Aagreed a care plan for palliative care should have been written. The facility policy titled Providing End of Life Care dated 5/24/24 read in part, Recognition: Residents will be evaluated for end of life care concerns upon admission, during scheduled assessments, and upon change of condition or status . Preferences for palliative care, hospice care, and advance directives will be identified and documented in the medical record . The facility and resident/family will coordinate a plan of care, and will implement interventions in accordance with the comprehensive assessment, and the resident's needs, goals, and preferences. The plan of care will identify the care and services that each discipline will provide. .

Based on observation, interview, and record review, the facility failed to provide medication administration to meet professional standards 1.) administer antibiotics according to physician order and 2.) flush peripherally inserted central catheter (PICC) for one Resident #32 of four residents reviewed for medication administration. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. Resident #32 (R32) Review of R32's physician order, dated 6/27/24, revealed an order for vancomycin 750 mg (milligrams) / 150 ml (milliliters), intravenously one time a day for sepsis until 8/6/24. On 7/23/24 at 7:50 AM, medication administration was observed with Licensed Practical Nurse (LPN) R for R32. LPN R accessed R32's PICC line using a 10 ml (milliliter) syringe filled with normal saline solution. LPN R failed to check for a blood return prior to administering the saline solution into the PICC line. R32's PICC line dressing was observed dated 7/10/24 indicating when the last time the dressing was changed. On 7/23/24 at 8:10 AM, an interview was conducted with LPN R and was asked if she checked for placement on R32's PICC line by pulling back on the syringe to watch for a blood return and replied, No, no one ever taught me that. I did not know I had to do that. LPN R was asked if R32's dressing was over due to be changed and replied, Yes, it should have been changed on the 17th last Wednesday. LPN R was asked who was responsible for PICC line dressing changes and replied, The Registered Nurses' (RNs'). LPN R was asked what she would do if she had a physician order that she could not complete and replied, I would go let one of the RN's know I needed them to complete the dressing change. Review of R32's physician order, dated 6/20/24, revealed an order to change PICC line dressing weekly and PRN (as needed), every day shift, every Wednesday. R32's treatment administration record (TAR) lacked PICC line dressing changes on 7/3/24 and 7/17/24. On 7/24/24 at 10:15 AM, medication administration was observed with LPN H for R32. LPN H accessed R32's PICC line using a 10 ml syringe filled with normal saline solution and failed to check for a blood return prior to administering the saline solution into the PICC line. On 7/24/24 at 10:20 AM, an interview was conducted with LPN H and was asked if he pulled back on the saline syringe before administering the saline solution into R32's PICC line and replied, No, I guess I forgot to do that. On 7/24/24 at 11:30 AM, an interview was conducted with the Assistant Director of Nursing/Registered Nurse (ADON/RN) A and was asked if the LPNs are trained on medication pass for PICC lines and replied, Yes. It is part of their nursing competencies. Review of facility document titled, Licensed Practical Nurse Skills Checklist, for LPN H and LPN R, dated 5/20/24, revealed no current competencies for IV skills related to administration and maintenance. Review of policy titled, Peripherally Inserted Central Catheter Flushing, Locking, Removal, undated, read in part, Policy: It is the policy of this facility to ensure that peripherally inserted central catheters (PICC) are flushed, locked and removed consistent with current standards of practice .Compliance Guidelines .3. Peripherally inserted central catheters will be flushed and aspirated for blood return prior to each infusion to assess catheter functionality and prevent complications .Flushing .7. Slowly aspirate for a blood return to confirm device patency. 8. If blood return is not obtained, investigate for external causes of obstruction and notify physician if troubleshooting is ineffective .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to meet the nutritional needs and preferences for two Residents (R29 and R54) of 3 residents reviewed for nutrition. This deficient practice resulted in residents not receiving prescribed diet, food preferences, experiencing thirst, and potential risk for physical decline. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted. Resident #29 (R29) R29 was admitted to the facility on [DATE] with diagnoses including dysphasia (difficulty swallowing) , spasms of the esophagus, dementia, heart failure and stroke with left side paralysis. The Electronic Medical Record (EMR) revealed the physician diet Order Summary: Start dated 11/1/23, Regular diet Pureed texture, Nectar/Mildly Thick consistency . texture varies per DPOA (Durable Power of Attorney) sm (small) portions, gravy w/pureed meat, extra gravy on side, super cereal at B(breakfast), super spuds L (lunch); magic cup thawed or yogurt as dessert, nectar water with all meals; pureed banana . On 7/23/24 at 9:31 AM, the breakfast meal for R29 was observed. The meal tray card indicated a diet order of Puree, nectar mild sm portions HF/HC and contained instructions to give a banana crushed up. This diet order did not match the physician order per the EMR. During an interview on 7/23/24 at 9:45 AM, Dietary Aide (Staff) L stated a banana is difficult to get to the right consistency, so I did not give (R29) one today. The banana was included in the physician's order and was indicated on the meal tray card to be given. Staff L could not explain why dietary staff did not use a mechanical kitchen device to puree the banana if there was really a concern for resident safety. On 7/24/24 at 9:37 AM, the breakfast meal for R29 was observed. No crushed banana was provided. The hand-written instructions on the meal card included yogurt. This surveyor requested CNA O obtain a yogurt for R29. CAN O asked R29 if she would like a yogurt and R29 responded she needed yogurt for her bowels. During an interview on 7/25/24 at 10:13 AM, Certified Dietary Manager (CDM) N discussed R29's preferences and said, She takes a long time to eat and takes small bites and should get it (crushed up banana). CDM N stated if the tray card said yogurt, it should have been on the tray. The EMR care plan read in part, (R29) has potential for unplanned/unexpected weight loss r/t (related to) Poor food/fluid intake with interventions including, Offer substitutes as requested or indicated. The resident prefers : pureed scrambled eggs at breakfast, mushed up banana at breakfast/dinner . Resident #54 (R54) R54 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, congestive heart failure, diabetes, major depressive disorder, panic disorder, anxiety disorder, dementia and multiple fracture history. The current physician diet order as written on 3/1/2024, was Controlled Carb diet, Easy to Chew Texture, Regular/Thin consistency, 5 CHO (Carbohydrates)/meal, Large portions of ground meat; sugar cereal at B (breakfast), Large portions of Regular mashed potatoes at L/D (lunch/dinner). Colored plates. The Electronic Medical Record (EMR) reflected weights of: 1/22/24 232.0 pounds 4/22/24 220.0 pounds 6/24/24 199.0 pounds 7/22/24 187.0 pounds These weights indicated a 6% weight loss in one month, a 9% weight loss over three months, and a 19% weight loss over six months (all significant weight losses). On 7/22/24 at 1:22 PM, R54's lunch tray was observed and contained a salisbury steak which was not ground to the consistency specified in the physician's order. The tray card for R54 indicated a diet of CC, HF/HC and instructions of Large Portions ground meat w/gravy. On 7/22/24 at 1:28 PM, the lunch tray arrived in the room of R54, but he was sleeping and showed no interest in lunch. Certified Nurse Aide (CNA) D stated, Right now he is not eating much at all. The tray card for R54 indicated a diet of CC, HF/HC. CNA D was asked what type of diet R54 was on and could not answer what a CC HF/HC diet was and stated, There is a cheat sheet in the kitchen. I do not know what the diet is. On 7/22/24 at 2:19 PM, R54's tray was observed as he was finished with lunch. He had eaten nothing. The lid remained on the beverage of milk and although the salisbury steak was cut up, nothing had been consumed. During an interview on 7/22/24 at 1:48 PM, Dietary Aide (Staff) I was observed serving the lunch meal and stated those residents with mechanical soft or ground meat diets should have gotten ground chicken or ground salisbury steak. Staff I was asked what the HC/HF part of the diet order was. She thought HC was high calorie but did not know what HF was. Staff I found a sheet in the service area and HC/HF was defined as high calorie but the sheet did not indicate what HF stood for. Staff I said she would ask the dietary manager. During an interview on 7/22/24 at 1:52 PM, Dietary Aide (Staff) K was asked what the HC/HF part of the diet order was. Staff K said she was not sure what it was but maybe HF meant High Fructose? During an interview on 7/25/24 at 10:13 AM, CDM N stated We do not have a defined diet called HF/HC. The facility diet manual did not contain a diet called HF/HC. On 7/22/24 at 1:24 PM, two disposable 8 ounce cups of water and one 8 ounce cup with orange juice were observed on R54's bedside table. The table was across the room approximately 8 feet from the bed and not accessible to R54 who was lying in bed with his eyes closed. On 7/22/24 at 3:21 PM, R54 was heard to be crying out in a loud voice, Water. Water. I need some G** D*** water. CNA D went into the room and assisted R54 with the water and then placed the water back on the bedside table out of reach of R54. One minute later R54 exclaimed, I can't reach it. What good is it. Everyone is walking around doing nothing. On 7/22/24 at 3:24 PM, CNA D returned to R54's room with ice cream and R54 turned it down and said, Give me the water. On 7/22/24 at 3:47 PM, a disposable cup of water with straw was observed on the bedside table. R54 was in his bed. The bed was in the low position and the water was approximately 3 feet away and out of reach. On 7/24/24 at 3:18 PM, housekeeping staff GG stated Did you hear him (R54)? R54 had been crying out for water as he could not get to it. Staff GG said the water was too far from his bed and even when the bedside table was moved toward him his hands could not really reach it. The EMR care plan includes: The resident has potential for dehydration r/t diuretic use. The interventions included, The resident will maintain adequate hydration. Assure beverages of choice are offered to Resident. The facility policy titled Hydration and dated 4/2024 read in part: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health . The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care . Provide assistance with drinking. Ensure beverages are available and within reach. .

Based on interview and record review, the facility failed to ensure nurse aides completed required dementia training and demonstrated the skills and techniques necessary to care for residents for three contracted Certified Nurse Assistants (CNAs F, AA and BB) of three contract nursing staff reviewed for competency evaluation, resulting in the potential for unmet physical and psychosocial needs for all 63 residents residing in the facility. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. A review of CNA F's competency evaluation as provided by Human Resources Director, Staff Z on 7/24/2024 at 3:36 p.m., revealed a Skills Checklist by [contract company], dated 5/03/2024. Further review of the Skills Checklist, revealed the checklist to be a self-evaluation completed by CNA F indicating how frequently she performed tasks and how proficient she felt at the listed tasks. Further review of the documents provided by Staff Z revealed no further evaluation of CNA F's skills. Review of CNA F's education roster titled Core Mandatory Exam - Nursing, dated 4/18/2024, revealed no completion of dementia training prior to or after beginning care provision at the facility. A review of CNA AA's competency evaluation as provided by Human Resources Director, Staff Z on 7/24/2024 at 3:36 p.m., revealed a Skills Checklist by [contract company], dated 4/10/2024. Further review of the Skills Checklist, revealed the checklist to be a self-evaluation completed by CNA AA indicating how frequently she performed tasks and how proficient she felt at the listed tasks. Further review of the documents provided by Staff Z revealed no further evaluation of CNA AA's skills. Review of CNA AA's education roster titled Core Mandatory Exam - Nursing, dated 4/17/2024, revealed no completion of dementia training prior to or after beginning care provision at the facility. A review of CNA BB's competency evaluation as provided by Human Resources Director, Staff Z on 7/24/2024 at 3:36 p.m., revealed a Skills Checklist by [contract company], dated 7/09/2024. Further review of the Skills Checklist, revealed the checklist to be a self-evaluation completed by CNA BB indicating how frequently she performed tasks and how proficient she felt at the listed tasks. Further review of the documents provided by Staff Z revealed no further evaluation of CNA BB's skills. No education roster or Core Mandatory Exam - Nursing, was provided for CNA BB to show proof of completion of mandatory dementia training prior to beginning care provision at the facility. During an interview on 7/25/2024 at 11:35 a.m., Unit Manager, Registered Nurse (RN) E reported new hires were evaluated through utilization of a checklist during two days of orientation. RN E stated CNA staff assigned to new hire orientation were responsible for completing the checklists and determining competency and human resources monitors for completion. RN E confirmed CNAs F, AA and BB were no longer on orientation and provided care throughout the facility. When asked for the orientation/competency checklists for CNA F, CNA AA and CNA BB, RN E reported the staff person responsible for completion of the evaluations was no longer employed by the facility. RN E stated she was unable to determine if the CNAs were deemed competent prior to being allowed to perform resident care activities. Review of the personnel files for CNA F, CNA AA and CNA BB with Staff Z on 7/25/2024 at 12:07 p.m., revealed no further information related to skill evaluations or competency were available. Staff Z reported she accepted the documentation from the contract company and nursing administration would complete the evaluations, if necessary. On 7/25/2024 at 12:30 p.m., Staff Z presented [Facility] CNA Competency, forms for CNA F, AA and BB. Staff Z reported the forms were found in a box with other documents. Staff Z stated the forms were not complete. Review of CNA F's [Facility] CNA Competency, dated 5/15/2024, revealed the following sections were not evaluated: Assisting a resident at meals; catheter care; assisting a male resident with a urinal; assisting resident with a bedpan; cleaning and storage of dentures; assisting with oral care; shower or tub bath; peri-care male; and complete bed bath. Review of CNA AA's [Facility] CNA Competency, dated 5/15/2024, revealed the following sections were not evaluated: Assisting a resident at meals; catheter care; assisting a male resident with a urinal; assisting resident with a bedpan; cleaning and storage of dentures; assisting with oral care; shower or tub bath; peri-care male; and complete bed bath. Review of CNA BB's [Facility] CNA Competency, dated 4/23/2024, revealed the following sections were not evaluated: catheter care; shower or tub bath; and peri-care male. Review of the facility Job Description: Certified Nursing Assistant, revealed the following, in part: Functions and responsibilities of position. Functions related to direct care of the resident: personal hygiene and grooming (special attention or oral hygiene, care of nails . perineal care . offer nourishment and fluids, answering call signals . During an interview on 7/25/2024 at 12:19 p.m., the Assistant Director of Nursing (ADON) reported evaluations should be complete prior to CNA's providing care. The ADON stated it was the facility responsibility to ensure competency and the self-evaluations provided by the contract company did not demonstrate observed competency. Review of the Facility Assessment, dated 3/17/2024, revealed the following, in part: Services and care we offer based on our resident needs: Specific Care and Practices: Bathing, showers, oral/denture care . eating . incontinence prevention and care, intermittent or indwelling or other catheter . care of someone with cognitive impairment . We provide competency checks: Person-centered care . Activities of Daily Living Caring for resident with Alzheimer's and other dementia .

Based on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than five percent, with three errors identified out of 30 opportunities, affecting two Residents (R30 and R32) of four residents observed for medication administration, resulting in a medication error rate of 10.00 percent. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. On 7/23/24 at 7:50 AM, medication administration was observed with Licensed Practical Nurse (LPN) R for R30. LPN R was observed dispensing one torsemide 20 mg tab. LPN R was asked how many she dispensed and replied, One. That is how many he gets. After medications were verified, LPN R was made aware R30 had a recent order change related to drug amount for torsemide dispensed by pharmacy. Prior orders for R30 were to dispense one 40 mg tab and current supply was 20 mg. Review of R30's physician order, dated 7/12/24, revealed the current order for torsemide 20 mg, was to give 2 tablets by mouth one time a day for edema. On 7/24/24 at 10:15 AM, medication administration was observed with LPN H for R32. LPN H was observed accessing R32's PICC line with a 10 ml (milliliter) syringe filled with normal saline solution and failed to check for a blood return prior to administering the saline solution into the PICC line. LPN H was over an hour late in the administration of the antibiotic medication for R32. Review of R32's physician order, dated 6/27/24, revealed an order for vancomycin 750 mg (milligrams) / 150 ml (milliliters), intravenously one time a day for sepsis until 8/6/24. *Note administration timeliness is important in antibiotic delivery to maintain serum concentration for drug levels/dosing/treatment. On 7/24/24 at 1:55 PM, medication administration was observed with LPN H for R30. LPN H had primed two units, then dialed up the insulin pen to 12 units for R30, and set it on top of his medication cart. This Surveyor asked how many units he drew up for R30 and replied, Did I forget to prime it? I think I still need to prime it. LPN H picked up the pen and looked at the dose and then dialed one more unit up to equal 13 units. LPN H was stopped and asked if he had the correct dose and replied, I think so. No, I only need 12 units and I have 13 units. LPN H then primed two units out of the pen to now equal 11 units (administered to R30). During this same medication administration, LPN H was observed dispensing a calcium carbonate with all the rest of R30's medications. LPN H handed R30 all his medications in one cup. LPN H was asked if R30 should take them all at the same time including the calcium carbonate and replied, Oh, no. He takes that one last because he must chew it up. Review of R30's physician order, dated 7/4/24, revealed an order for insulin glargine subcutaneous solution pen-injector, inject 12 unit subcutaneously one time a day. On 7/24/24 at 2:30 PM, an interview was conducted with the Assistant Director of Nursing/Registered Nurse (ADON/RN) A who was made aware of the medication errors during medication pass. RN A replied, We have the sticker that the nurses can use to put on the medication cards when doses or concentrations are different. There should be a sticker on it. Calcium is always placed in a cup by itself and not mixed with all the other meds. LPN H gets very nervous if anyone watches him. We never have him train anyone. I will follow up on the insulin dose administered with him. Review of policy titled, Medication Administration, dated 2/14/24, read in part, Policy: Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .10. Review MAR [medication administration record] to identify medication to be administered. 11. Compare medication source (bubble pack, vial .) with MAR to verify resident name, medication name, form, dose, route, and time .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to provide adaptive dining equipment for two Residents (R22 & R29) of three residents reviewed for adaptive dining equipment needs. This deficient practice resulted in increased difficulty with food consumption and independent eating with the potential for decreased food/fluid intake and risk for weight loss. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted. Resident #22 (R22) On 7/22/24 at approximately 1:20 PM, the lunch meal was observed for R22. The meal tray card indicated Colored Plates be provided. R22 had her meal served on a white plate. During an interview on 7/22/24 at 1:49 PM, when asked for the purpose of the colored plates, Dietary aide (Staff) J explained they were used for those residents who were visually challenged. During an interview on 7/22/24 at 3:07 PM, R22 stated, I need colored plates. I am legally blind. R22 said they did not get one today. The Electronic Medical Record (EMR) for R22 revealed admission to the facility on 3/24/2023 and the care plan included, The resident has impaired visual function with interventions including, The resident will maintain optimal quality of life within limitation imposed by visual function. Monitor/document/report .acute eye problems: . Sudden visual loss, Pupils dilated, gray or milky, c/o (complaints of) halos around lights, double vision, tunnel vision, blurred or hazy vision. On 7/24/24 at approximately 1:30 PM, the lunch meal was observed for R22. The tray card indicated Styrofoam Cups - all beverages. The coffee provided on the tray for R22 was observed in a regular mug and not in a Styrofoam cup. The care plan for R22 included, The resident has potential nutritional problems . with interventions including Provide Styrofoam cups for all beverages. Provide small cups for beverages- has hard time holding onto regular cups. Resident #29 (R29) R29 was admitted to the facility on [DATE] with diagnoses including dysphasia (difficulty swallowing) , spasms of the esophagus, dementia, heart failure and stroke with left side paralysis. The EMR revealed the physician diet order as follows: Order Summary: Start dated 11/1/23, Regular diet Pureed texture, Nectar/Mildly Thick consistency . texture varies per DPOA (Durable Power of Attorney) .nectar water with all meals; . On 7/23/24 at 9:31 AM, the breakfast meal for R29 was observed. The meal tray card indicated a diet order of Puree, nectar mild sm (small) portions HF/HC with instructions to give small plastic teaspoon and straw. The beverages on the meal tray did not have straws. However, there was a straw in the thickened water on R29's bedside table. CNA HH stated R29 should not have straws with thickened liquids and did not know how the bedside beverage had a straw. R29 stated sometimes she does not have enough wind to get the fluid up the straw- it is thick. CNA HH stated they felt straws should not be given because R29 had too much difficulty using straws with thickened liquids and did not give a straw when offering a beverage. Although the tray card instructed straws should be given and the care plan also indicated straws should be given. On 7/24/24 at 9:37 AM, the breakfast meal for R29 was observed and the bedside water had a straw inserted but straws were not in the other beverages. CNA O stated it was standard practice that thickened liquids do not get straws and remarked the straw in the water is an error. CNA O stated they felt straws should not be given because R29 had too much difficulty using straws with thickened liquids and did not give a straw when offering a beverage. Although the tray card instructed straws should be given and the care plan also indicated straws should be given. The EMR care plan read in part, (R29) has a swallowing problem r/t (related to) Complaints of difficulty or pain with swallowing, difficulty with thin liquids, Swallowing assessment results, h/o (history of) stroke which resulted in swallowing problems. The interventions on R29's care plan included, Alternate small bites and sips. Use a teaspoon for eating. Use a straw for beverages and also Provide nectar thick water with meals. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** All times are in Eastern Daylight Time (EDT) unless otherwise noted Based on interview and record review, the facility failed to revise or update care plans to reflect residents' status for five Residents (R50, R39, R20, R32, and R29) of seventeen residents reviewed for care plans. This deficient practice resulted in the potential for inadequate care and unmet care needs. Findings include: The infection surveillance line list for July 2024 documented eleven residents with signs and symptoms of infections. Ten of the eleven residents received antibiotic therapy for infections. During an interview with the facility Infection Preventionist (IP) on 7/24/24 at 10:47 a.m., the IP was asked if care plans were developed for residents with symptomatic infections or if current care plans were amended and updated to include interventions for infections. The IP responded, some of them. Four of the residents listed on July 2024 line-listing were reviewed with the IP for care plans. Resident #50 (R50) was diagnosed with a Urinary Tract Infection (UTI) and subsequently prescribed the antibiotics Keflex on 7/10/24 and Bactrim DS on 7/15/24. R50 was documented on the July 2024 infection line list as having symptoms of increased fatigue and hematuria (blood in the urine). R50's medical record did not contain a care plan for the infection to provide staff with interventions to address R50's symptoms of infection. Resident #39 (R39) was diagnosed with a UTI and prescribed Rocephin and Macrobid starting 7/10/24. R39 had the following symptoms documented on the July 2024 infection line list: urinary urgency, lethargy, painful urination, mental changes, and decreased appetite. R39's medical record did not contain a care plan for the infection to provide staff with interventions to address R39's symptoms of infection. Resident #20 (R20) was diagnosed with a UTI and prescribed Levaquin starting 7/22/24. The documented symptoms on the July 2024 infection line list reflected R20 had painful urination and mental status changes. R20's medical record did not contain a care plan for the infection to provide staff with interventions to address R20's symptoms of infection. Resident #32 (R32) was admitted to the facility 6/6/24. A Minimum Data Set (MDS) assessment dated [DATE] documented R32 was infected with a multi drug resistant organism. R32 required Vancomycin administered via peripherally inserted central catheter (PICC - a tube inserted into a vein in the arm that passes to a larger vein near the heart) for Osteomyelitis (bone infection) of the vertebra. R32 was additionally diagnosed with a UTI on 7/22/24 for which he was started on Levaquin in addition to the Vancomycin. R32's medical record did not contain a care plan for the infections or the PICC to provide staff with interventions to address R32's infection or to maintain R32's PICC. Resident #29 (R29) R29 was admitted to the facility on [DATE] with diagnoses including dysphasia (difficulty swallowing) , spasms of the esophagus, dementia, heart failure and stroke with left sided paralysis. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 of 15 indicating moderate cognitive impairment and the ability to transfer from chair to bed or off toilet required Substantial/maximal assistance - Helper does MORE THAN HALF the effort. This MDS also revealed R29 had a functional limitation in range of motion with impairment on one side for both upper and lower extremities. During an interview on 7/23/24 at 9:06 AM, R29 stated she had hurt her leg during a transfer early in the morning about 5 days ago. There was a question if the lift was used properly or used at all. On 7/23/24 the Nursing Home Administrator (NHA) presented the facility investigation on this concern which had been reported to the State Agency (SA). The investigation revealed that on 7/4/23 R29 had been transferred with the sit-to-stand lift and the resident had reported pain. That same day, R29 was transferred to the hospital for x -rays and further investigation. Upon return to the facility on 7/4/24, the resident had a leg immobilizer and assessed to need transfers with a maxi lift. During a telephone interview on 7/25/24 at 10:38 AM, Certified Nurse Aide (CNA) F stated she recalled the incident on 7/4/24 when she got R29 up as usual. CNA F stated she used the stand-up (sit-to-stand) lift as I always do. During an interview on 7/25/24 at 8:32 AM, CNA G stated R29 was recently changed to a maxi lift after she got the leg immobilizer. CNA G confirmed R29 used to be transferred with a sit-to-stand lift prior to her immobilizer being applied. The care plan for R29 was reviewed and listed an intervention of TRANSFER: The resident requires (Substantial assistance) by staff to move between surfaces as necessary. Use maxi lift until seen by ortho (orthopedics specialty). (Initiated on) 7/22/2024. During an interview on 7/25/24 at 8:27 AM, the Assistant Director of Nursing (ADON)/Registered Nurse (RN) A noted the care plan showed the sit to stand lift was changed to a maxi lift after the hospitalization on 7/4/24. RN A stated the change to non-weight bearing and use of the maxi lift occurred as soon as R29 returned on 7/4/24, but the care plan was not updated until 7/22/24. RN A said the care plan should have been updated with the change in care. The facility policy titled Care Plan Revisions Upon Status Change dated 2023 read in part: The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change . The care plan will be updated with new or modified interventions. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An observation upon entering the Special Care Unit (SCU), the facility's locked dementia/behavioral care unit, on 7/22/2024 at 1:18 p.m., revealed R17 ambulating using a front-wheeled walker, down the hall toward the entrance/exit of the SCU. There were no staff visible in the hallway at the time of the observation. R17 was looking into resident rooms as she walked down the hall and appeared lost. R17 was heard mumbling as she entered the doorway of room [ROOM NUMBER], maybe this is it, I don't know, I need help. R17 continued down the hall toward the nurses' station, found and entered her room then proceeded to lay down in her bed. R17 could be heard calling out from her room, ow, ow. At 1:26 p.m., an unidentified staff member entered the SCU and upon hearing R17 calling out, entered R17's room at which time R17 reported my knees are killing me. The unidentified staff member closed the door to R17's room to provide care for the resident. Further observation revealed nine residents sitting in the living room area outside the nurses' station and one Resident (R41) ambulating in the hallway toward the entrance/exit of the SCU. It was noted there were no staff present in the nurses' station, hallways or living room area at the time of the observation. On 7/22/2024 at 1:27 p.m., R41 was observed ambulating in the hallway of the SCU near the entrance/exit of the unit. R41 stopped in front of a locked utility room near the entrance/exit of the unit and proceeded to turn the doorknob in an attempt to enter the room. R41 then turned and walked back down the hallway toward the empty nurses' station, at which time R23 was observed self-propelling in her wheelchair from the dining room area toward her room across from the nurses' station. R41 followed R23 into her room and proceeded to push R23 in her wheelchair toward her bed and attempted to assist R23 to stand but was unsuccessful. R41 was heard stating we need to get closer [to the bed]. It was noted there were no footrests attached to R23's wheelchair at the time of the observation. R41 then proceeded to push R23 in her wheelchair toward her closet. At 1:33 p.m., the unidentified staff member exited R17's room and proceeded to walk toward the nurses' station at which time she saw R41 in R23's room. The unidentified staff member redirected R41 out of R23's room and toward the dining room area. At 1:37 p.m., R41 was observed ambulating aimlessly and unattended, up and down the hallway of the SCU. An observation on 7/22/2024 at 2:05 p.m., revealed R41 walking toward the entrance/exit of the SCU. No staff were present at the time of the observation. At 2:08 p.m., Certified Nurse Assistant (CNA) X and an unidentified staff member entered the hallway from behind a closed door. CNA X turned to R41 and told the Resident to, come here, waving her hand down the hall toward the nurses' station. CNA X and the unidentified staff member continued down the hall to the dining room area. R41 was observed to stop at the unattended nurses' station and was heard asking, will someone let me out, please while attempting to open the locked door leading to the nurses' station. R41 proceeded to walk down the hall and sat in a chair in the hallway between rooms [ROOM NUMBERS]. At 2:16 p.m., CNA X entered the hallway and approached R41 at which time R41 asked CNA X to, let me out, please. CNA X asked R41 where he wanted to go and R41 answered, home. An observation upon entering the SCU on 7/23/2024 at 9:27 a.m., revealed no staff present in the hallway. R3 was observed ambulating with a front-wheeled walker down the hallway toward the entrance/exit of the unit. R3 appeared lost and confused and was heard saying, there's never anyone to ask . now to find my room. R3 walked to the entrance/exit door, turned and walked back down the hall toward the living room area. R3 stopped and entered R17's room, with R17 sleeping in bed, and looked around before exiting and heading back toward the living room and past her room proceeded to attempt to open the locked door to the empty nurses' station. R3 then walked to the living room and sat down in a chair near the nurses' station window. At 9:32 a.m., CNA X emerged from the dining room area. Further observation revealed CNA Y seated in the dining room providing dining assistance to two unidentified residents. During an interview at the time of the observation, CNA X reported this day there were two CNAs scheduled to work the SCU, herself and CNA Y. When asked if there were always two staff members present on the SCU, CNA X reported some days there was only one CNA scheduled to work on the SCU. CNA X reported a nurse was also assigned to the SCU, but the nurse would be split between the SCU, located on the second floor, and another unit on the first floor of the building, therefore was only present on the unit during medication pass. CNA X reported there are many residents residing on the SCU which required constant supervision. During an interview outside the SCU medication storage room, on 7/24/2024 at 9:45 a.m., Registered Nurse (RN) E reported R41 was noted to be more anxious and difficult to redirect during the previous shift. During the interview, the SCU exit door alarm sounded and CNA X was observed running down the hall toward the exit door. Further observation revealed R41 pushing through the exit door and stepping off the unit as CNA X approached and redirected R41 back onto the unit. It was noted the exit door led to an unused portion of the building's second floor, the elevator and stairway. An observation on 7/24/2024 at 7:46 a.m., revealed nine residents seated in the living area of the SCU. R41 was observed sleeping in a reclining chair across from the nurses' station. CNA F was seated in a chair near the nurses' station window. During an interview at the time of the observation, CNA F reported she was seated in the living room to supervise R41. CNA F reported R41 was going in other resident's rooms and she consistently needed to redirect him throughout her shift. When asked if a nurse was assigned to the SCU, CNA F reported a nurse would come up for medication pass earlier in the evening but then would leave the unit to go downstairs and attend to residents on the first floor of the facility and would come back up to the SCU, if summoned. Review of the facility staff Daily Schedule(s), for June 2024 through 7/25/2024, provided by Unit Manager, RN E, revealed the following: 6/08/2024: Shift 11:00 p.m. - 7:00 a.m. 200 Wing: One CNA worked 11:00 p.m. - 3:00 a.m. and one CNA worked 3:00 a.m. - 7:00 a.m. One charge nurse worked 11:00 p.m. - 7:00 a.m.; 300 Wing: One CNA worked 11:00 p.m. - 7:00 a.m. One charge nurse worked 11:00 a.m. - 3:00 a.m. and one charge nurse worked 3:00 a.m. - 7:00 a.m.; 100 Wing and Rooms 201, 202, 301 and 302: One CNA worked 11:00 p.m. - 7:00 a.m. No charge nurse scheduled. 400 Wing (SCU, Second Floor): One CNA worked 11:00 p.m. - 3:00 a.m. and one CNA worked 3:00 a.m. - 7:00 a.m. No charge nurse scheduled. Review of the Shift Staffing Summary, dated 6/08/2024 revealed a resident census of 61. Comparison of the Daily Schedule, and the Shift Staffing Summary, revealed the facility assessed the need of two licensed nursing staff and 6.5 unlicensed nursing staff for the 11:00 p.m. - 7:00 a.m. shift for a total need for direct care staff of 8.5. It was noted only four unlicensed nursing staff shifts were scheduled/worked and a total of two licensed nurse shifts worked for a total direct care staff of six. 6/22/2024: Shift 11:00 p.m. - 7:00 a.m. 200 Wing: One CNA worked entire shift. One CNA worked 3:00 a.m. - 7:00 a.m. One charge nurse worked entire shift; 300 Wing: Two CNAs worked entire shift. On charge nurse worked 11:00 p.m. - 3:00 a.m. and one charge nurse worked 3:00 a.m. - 7:00 a.m.; 100 Wing and Rooms 201, 202, 301 and 302: No staff worked/scheduled; 400 Wing (SCU, Second Floor): One CNA worked 11:00 p.m. - 3:00 a.m. Review of the Shift Staffing Summary, dated 6/22/2024 revealed a resident census of 62. Comparison of the Daily Schedule, and the Shift Staffing Summary, revealed the facility assessed the need of two licensed nursing staff and five on-duty unlicensed nursing staff for the 11:00 p.m. - 7:00 a.m. shift for a total need for direct care staff of seven. It was noted only four unlicensed nursing staff shifts and two licensed nursing staff shifts were worked for a total direct care staff of six. 6/23/2024: Shift 7:00 a.m. - 3:00 p.m. 200 Wing: Two CNAs worked entire shift. One charge nurse worked the entire shift; 300 Wing: Two CNAs and one charge nurse worked the entire shift; 100 Wing: no staff scheduled/worked; 400 Wing (SCU, Second Floor): One charge nurse worked 7:00 a.m. - 11:00 a.m. and one charge nurse worked 11:00 a.m. - 3:00 p.m. One CNA worked the entire shift. Review of the Shift Staffing Summary, revealed a resident census of 64. Comparison of the Daily Schedule, and the Shift Staffing summary, revealed the facility assessed the need of three licensed nursing staff and six scheduled/on-duty unlicensed nursing staff for the 7:00 a.m. - 3:00 p.m. shift for a total need for direct care staff of nine. It was noted only five unlicensed nursing staff, and three licensed nursing staff shifts were worked for a total direct care staff of eight. 7/06/2024: Shift 11:00 p.m. - 7:00 a.m. 200 Wing: One CNA and one charge nurse worked the entire shift. One CNA worked 11:00 p.m. - 3:00 a.m.; 300 Wing: One charge nurse worked 11:00 p.m. - 3:00 a.m. and one charge nurse worked 3:00 a.m. - 7:00 a.m. One CNA worked the entire shift and one CNA worked 11:00 p.m. - 3:00 a.m.; 100 Wing: no staff scheduled/worked. 400 Wing (SCU, Second Floor): One CNA worked 11:00 p.m. - 3:00 a.m. and one CNA worked 3:00 a.m. - 7:00 a.m. It was noted in review direct care staff scheduled/worked totaled four and one-half (4.5) for a total resident census of 62 per the Shift Staffing Summary, dated 7/06/2024. Further review of the Shift Staffing Summary, revealed an assessed need of six direct care staff for the 11:00 p.m. - 7:00 a.m. shift. Review of the resident population conditions provided by Human Resource Director, Staff Z revealed as of 7/25/2024 the resident population of 63 included the following: Eight residents requiring two-person assistance with transfers/care. Eight residents requiring the use of a sit-to stand lift for transfers. Nine residents requiring the use of a two-person assisted, total mechanical lift for transfers. 54 residents assessed as being at risk for falls. 12 residents assessed at risk for elopement. During an interview on 7/25/2024 at 11:05 a.m., the Director of Nursing (DON) reported staffing needs are based on resident acuity and total census. The DON reported the residents residing on the SCU had dementia or psychological conditions requiring increased safety needs and supervision. The DON stated she was new to the facility and was working on having the SCU fully staffed. The DON acknowledged a safety concern when only one staff member was working on the second-floor unit due to the constant need for supervision and the distance other staff would have to travel when called for assistance. Review of the Facility Assessment, dated 3/17/2024, revealed the following, in part: Our Resident Profile . 400 Wing is our Special Care Unit . accommodates 30 residents in total . To be a member of the Special Care Unit you must have cognitive impairment and/or behavioral issues and benefit from a more structured environment with less stimulation . Based on observation, interview, and record review, the facility failed to provide sufficient staffing to meet the needs of the residents. This deficient practice resulted in an inability to provide needed services as voiced by 10 of 10 residents in attendance at a confidential group meeting and in an inability to sufficiently supervise 4 of 4 residents (R3, R17, R41, and R23) residing on the dementia unit. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted. On 7/23/24 at 11:30 AM, a confidential group meeting was held with ten residents of the facility. In this meeting Resident C1 stated there was a poor attitude among the Certified Nurse Aides (CNAs). C1 stated, the CNAs did not want to listen and would say, they have been doing this for 15 years an implied they knew it all. C2 stated the CNAs do not seem to come in my room. C1 explained when she turns on her call light for help, the staff turn off the light and I have had accidents and have sat in soil for an hour or more. The group said the facility does not have enough staff. C3 stated while there are some awesome aides, others turn off the call lights and never help you. C8 stated we have to wait a long time especially on the weekends. C5 and C10 stated they both had accidents because the light was on, and no one would help them use the bathroom. One resident (who did not even want a confidential identifier as she felt there could be retaliation) said she almost fell as she decided she could no longer wait for a staff member and tried to walk to the bathroom herself. When the question was posed: How many of you feel the facility does not have enough staff, every member of the confidential group meeting stated there were not enough staff to take care of their needs. The minutes from previous Resident Council monthly meetings were reviewed. On 7/23/24 at 7:44 AM, the Resident Council minutes were reviewed. The 4/23/24 minutes noted in new business under the section Nursing/Aides: an issue with timely response to call lights was reported. The following meeting on 5/21/24 there was no mention of resolution or action taken on the call light concern. The June meeting was rescheduled to 7/1/24 and minutes under the section Nursing/Aides: recorded . Don't like them saying they're understaffed; we feel they use it as an excuse. We've heard them in the hallway talking. Beds are not being made completely/Neatly. (Education at the next CNA Meeting will be given). At the following meeting on 7/18/24 the paragraph from the Nursing/Aides section was repeated word for word in the Old Business section of the minutes. There were no responses of resolution, actions taken, or dates when the promised CNA education had occurred or was scheduled to address the staffing issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 1.) safely securing narcotic medications in one of two medication rooms; 2.) not dating biologicals in one of three medication carts reviewed for medication storage. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. On [DATE] at 8:45 AM, an observation was made of the 200-hall medication cart. The 200-medication cart was found to have the following: a. Two undated and opened insulin pens; An observation was made on [DATE] at 8:20 AM, of the first-floor medication storage room. The first-floor medication storage room was found to have the following: a. Two vials and one liquid dropper bottle of lorazepam (scheduled II controlled substance) in a small refrigerator with no secondary lock. LPN T confirmed the lorazepam, which is a controlled substance should be under two locks. On [DATE] at 8:30 AM, an observation was made of LPN H preparing medication pass for a Resident #14 (R14) and LPN H dropped a tablet of carvedilol on top of the medication cart. LPN H picked it up and threw it in the medication cart trash. LPN H proceeded to dispense medications for R14 and dropped a doxycycline on top of the medication cart and again picked it up and threw it in the medication cart trash. LPN H continued to dispense medications for R14 and dropped twice in a row spironolactone on top of the medication cart and after the second time he dropped the medication on top of the medication cart, he picked the second spironolactone up with his bare hands and placed it in the medication cup he was preparing for R14. LPN H was without explanation of why he used his bare hands, did not perform hand hygiene, or used the second dropped spironolactone and placed it in the medication cup for R14. On [DATE] at 9:45 AM, an interview was conducted with the Assistant Director of Nursing/Registered Nurse (ADON/RN) A and was asked what the regulation was for storing controlled substances. RN A replied, They need to be double locked. RN A asked what this Surveyor was referring to and was told about how lorazepam was stored in the first-floor medication room refrigerator. RN A stated I do remember asking about that a little while ago. I told the maintenance guy we needed a lock on that refrigerator months ago. Review of policy titled, Medication Storage, dated [DATE], read in part, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .2. Narcotics and Controlled Substances: a. Scheduled II drugs and back-up stock of Scheduled III, IV, and V medications are stored under a double-lock and key. B. Scheduled II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in refrigerator . Review of policy titled, Destruction of Unused Drugs, undated, read in part, Policy: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations .1. Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. 2. Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed .

All times are in Eastern Daylight Time (EDT) unless otherwise noted Based on observation, interview, and record review, the facility failed to implement an infection prevention and control program in accordance with facility policies to prevent the potential transmission of communicable diseases and infections as evidenced by failure to: 1. Document signs and symptoms of infections. 2. Conduct departmental surveillance for adherence to infection control practices. 3. Handle meal trays for residents in transmission-based precautions in accordance with facility policy. 4. Provide barriers for insulin pens during medication administration. 5. Ensure urinary catheter drainage bag and tubing remained off the floor. This deficient practice resulted in the potential for the transmission of pathogens between residents and the spread of infectious organisms to all 63 residents in the facility. Findings include: The facility's Infection Prevention and Control Program was reviewed with the Infection Preventionist (IP) on 7/24/24 at 10:47 a.m. The IP explained the facility used a line list as part of a monthly infection surveillance to identify infections and determine if residents' symptoms met McGeer Criteria (a surveillance tool used to define types of infections). The IP explained each resident's signs and symptoms of infection were documented on a monthly line list to identify, track, trend, and correlate infections. The infection surveillance line list for May 2024 was reviewed. The line list contained the names of 13 residents. The column labeled symptoms was blank and did not document the symptoms of infections for any of the 13 listed residents. The IP was asked the location of the documentation of symptoms. The IP said the signs and symptoms of infection would be documented on the line list and said, I don't know how I missed that when shown the blank symptom column on the May 2024 line list. The IP was asked the process for conducting infection surveillance activities throughout the facility. The IP said departmental surveillance was conducted monthly by respective department managers. When asked if departmental surveillance had been completed for May, June, and July of 2024, the IP responded, Probably not. The IP presented a departmental surveillance form dated 7/17/24 by the dietary department. The IP confirmed no other department had conducted infection control and prevention rounds in their department during the quarter requested. When asked if the IP ever conducted surveillance rounds in the departments, the IP responded, No, but I need to. The policy Infection Surveillance dated 12/15/23 read, in part: .updated McGeer criteria or other nationally-recognized surveillance criteria will be used to define infections .Surveillance activities will be monitored facility-wide, and may be broken down by department .The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying: .signs and symptoms .Line charts will be used . On 7/24/24 at 8:30 AM, an observation was made of LPN H preparing medication pass for a Resident #14 (R14) and LPN H dropped a tablet of carvedilol on top of the medication cart. LPN H picked it up and threw it in the medication cart trash. LPN H proceeded to dispense medications for R14 and dropped a doxycycline on top of the medication cart and again picked it up and threw it in the medication cart trash. LPN H continued to dispense medications for R14 and dropped twice in a row spironolactone on top of the medication cart and after the second time he dropped the medication on top of the medication cart, he picked the second spironolactone up with his bare hands and placed it in the medication cup he was preparing for R14. LPN H was without explanation of why he used his bare hands, did not perform hand hygiene, or why he used the second dropped spironolactone and placed it in the medication cup for R14. On 7/24/24 at 1:55 PM, medication administration was observed with LPN H for R30. LPN H proceeded to R30's room to administer his medications. LPN H gave R30 his insulin and then placed the insulin pen on his bedside table without a barrier and then handed him his medication cup. LPN H returned the insulin pen back to the medication cart without wiping it off before returning it to the medication cart. On 7/24/24 at 9:45 AM, an interview was conducted with the Assistant Director of Nursing/Registered Nurse (ADON/RN) A and was asked what the proper destruction of medications was and replied, Nurses are required to take them to the medication room and use the drug buster container. RN A was asked if a barrier should be used on top of bedside tables if nurses need to set medications down that will be returned to the medication cart and replied, Yes, barriers are required in resident rooms if medical items are placed on bedside tables per policy. Resident #22 (R22) During a room visit on 7/22/24 at 2:55 PM, R22 was sitting in her wheelchair and her catheter tubing was observed extending from her pant leg and resting on the floor. During a dining room observation on 7/23/24 at 1:17 PM, R22 was sitting in her wheelchair and her catheter tubing was observed extending from her pant leg and resting on the floor. During a room visit on 7/25/24 at 10:00 AM, R22 was in bed and her catheter drainage bag was observed to be resting on the floor and not contained in a privacy bag. Licensed Practical Nurse (LPN) H was asked to observe the catheter drainage bag and said the drainage bag should not be touching the ground and proceeded to make corrections to prevent infection. The Electronic Medical Record (EMR) for R22 revealed a physician order dated 7/19/19 for an ongoing indwelling urinary catheter and diagnoses which included dysuria (difficult or painful urination). The care plan for R22 included, The resident has Indwelling Catheter. During an interview on 7/25/24 at 10:06 AM, when asked about the urinary catheter bag and tubing resting on the floor, RN A agreed the catheter tubing and drainage bag should be kept off the floor. The facility policy Catheter Care dated as reviewed 5/10/24 read in part, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use . Privacy bags will be available and catheter drainage bags will be covered at all times while in use . .

Based on interview and record review the facility failed to maintain a complete infection control program, including an outbreak line listing and surveillance mapping during an RSV (contageous respiratory illness) outbreak in the facility that had the potential to affect all 65 vulnerable residents in the facility. This deficient practice resulted in the potential for sustained spread of RSV within the facility resident population. Findings include: During an interview on 1/16/24 at 1:23 p.m., Infection Preventionist (IP) F and Registered Nurse (RN) Supervisor G were asked for the outbreak line listing and surveillance tracking map for the RSV outbreak in the facility. (IP) F said a line listing for the RSV had not been completed, nor had there been any surveillance mapping to identify RSV illness as it occurred in affected individuals. IP F stated, We did have an outbreak of RSV . [Resident R1] on 12/22/23 was suspected of having RSV. When asked for the name of the Resident with the first case of RSV in the facility, IP F stated, Give me just a second, as she looked through her emails to determine who she had first contacted at the local Public Health Department regarding an RSV infection. IP F and RN G verbally compiled a list of eight Residents, in the presence of this Surveyor, that had contracted RSV, with one resident who just tested positive this week. As mistakes were made in the order of resident infections, IP F and RN G would verbally correct each other, until they were satisfied the order was as accurate as they could recall. IP F stated, I do not have an outbreak listing for RSV (outbreak residents). I do not have time to do everything. IP F also confirmed surveillance mapping was not performed, to identify the location of the RSV infections within the building. During an interview on 1/16/24 at 1:59 p.m., when asked about staff education to reduce the risk of transmission of RSV within the facility, IP F stated, No, we did not do any staff education on RSV. Review of the Infection Outbreak Response and Investigation, with a reviewed date of 10/31/23, revealed the following, in part: Policy: The facility promptly responds to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections . e. Staff will be educated on the mode of transmission of the organism, symptoms of infection, and isolation or other special procedures. This includes special environmental infection control measures that are warranted based on the organism and current CDC (Centers for Disease Control) guidelines. f. Surveillance activities will increase to daily for the duration of the outbreak. 3. Outbreak investigation: a. When the existence of an outbreak has been established, an investigation will begin. b. The Infection Preventionist will be responsible for coordinating all investigation activities . c. A case definition will be developed in order to identify other staff and residents who may be affected. Criteria for developing a case definition include: i. Person - key characteristics the patients share in common. ii. Place - the location associated with the outbreak. iii. Time - period of time associated with illness onset for the cases under investigation. iv. Clinical features - objective signs and symptoms, such as sudden onset of fever and cough. d. A line list about each person affected by the outbreak will be maintained. e. The incubation period, period of contagiousness, and date of most recent case will be used in making the determination that the outbreak is resolved . During an interview on 1/16/24 at 4:32 p.m., the Nursing Home Administrator (NHA) confirmed an RSV outbreak line listing and surveillance mapping should have been completed to monitor the progression of infection within the building, and to attempt to prevent further RSV resident infections.

On 7/20/23 at 9:45 AM, during a breakfast observation, CNA LL was circulating through the first-floor dining room. CNA LL stood over a seated resident and gave this unidentified resident a bite of eggs and was moving toward another resident. CNA LL stated she did this on a regular basis (stand and give bites to residents). CNA LL said, There are not enough CNAs (to provide the needed care) . There is just too much to do. CNA LL explained, We are supposed to come to the dining room to assist but we cannot always make it. This happens often and I do the best I can but . CNA LL then shook her head. Review of the Right of Resident in Michigan Nursing Facilities pamphlet, dated 11/28/16, revealed the following, in part: .You have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. This deficiency pertains to Intakes MI00132367 and MI00134358. Based on observation, interview, and record review, the facility failed to provide respect and dignity during dining for three Residents (R9, R29, and R49) of 21 sample residents reviewed for dining. This deficient practice resulted in the potential for decreased meal consumption and dissatisfaction with dining assistance provided by facility staff. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident #29 (R29) During breakfast observation on 7/19/23 at 9:07 a.m., Resident (R29) took one fork full of eggs and had great difficulty getting the eggs from the plate to their mouth. R29 picked up a half slice of toast and took a bite and then picked up a bite of eggs with a fork, but dropped the eggs onto their lap. R29 attempted to pick up the egg from his lap, unsuccessfully. R29 balanced the half-slice of toast, held in the left hand with the fork held in their right hand, supporting the toast. R29 took another bite of toast. R29 continued to try and eat the toast with the left hand, balancing with his fork in his right hand. R29 appeared to have great difficulty biting off and chewing the piece of toast. R29's beverages were outside of their reach, and none were offered by any staff entering or exiting the dining room. Observation on 7/19/23 at 9:29 a.m., found R29 apparently sleeping with food dripping out of their mouth. R29 awoke with ½ a piece of toast in hands. R29 appeared to have eaten ½ of one piece of toast and one bite of egg during the observation. On 7/19/23 at 9:39 a.m., CNA W offered Resident (R29) the first drink of a beverage from the breakfast tray since the start of this breakfast observation on 7/13/23 at 8:58 a.m. CNA W stood next to the resident, as R29 consumed all the beverage offered. No assistance or encouragement to eat food on R29's breakfast tray was offered between 8:58 a.m. and 9:39 a.m., as R29 visibly struggled to eat. Review of R29's Breakfast Meal Tray Card revealed the following, in part: FEEDS SELF, cue and encouragement at meals - assist prn (as needed), open packages - offer me an egg salad sandwich if I do not eat: offer and encourage fluids with and between meals . Resident #49 (R49) During a dining observation on 7/19/23 at 9:13 a.m., Certified Nurse Aide (CNA) W assisted Resident (R49), while standing next to them, with the breakfast meal. CNA W used R49's silverware and offered repeated bites of food to R49 who was seated in their wheelchair. CNA W continued to walk around the dining room, assisting residents with their meal while standing next to them. CNA W did not sit next to R49 while meal assistance was being provided. Resident #9 (R9) During a dining room observation on 7/27/23 at 1:31 p.m., three residents, including R9, were sitting in a makeshift dining room with two square dining room tables in an empty resident room on the 600 Wing of the facility. R9's lunch tray had been delivered to the resident, and she was eating large pieces of broccoli upon initial observation. No staff were present in the room for resident supervision. CNA DD assisted another unidentified resident into the room, delivered three meal trays to the three residents waiting for their lunch, and then left the room with no staff supervision and no visible camera surveillance of the residents eating in the room. On 7/27/23 at 1:35 p.m., R9 told this Surveyor, I can't eat this (rest of food). I can't get it on my spoon. No dining assistance was offered to R9 by facility staff. On 7/27/23 at 1:42 p.m., this Surveyor informed CNA DD that R9 said she could not eat because she could not get it on her spoon. CNA DD sighed loudly, and said it must be R9, and returned to the makeshift dining room to assist R9 with her lunch. CNA DD stood while providing dining assistance by placing the food on the spoon and offering the spoon to R9. While R9 was chewing the food, CNA DD placed both hands on the dining room table, as she leaned over the table waiting. No chairs were present in the makeshift dining room for any staff member to sit and assist any resident. On 7/27/23 at 1:55 p.m., CNA DD exited the dining room. When asked if there were any additional lunch trays still waiting to be passed to resident rooms, CNA DD stated, I still have two feeders (in their rooms). During an interview on 7/20/23 at 10:46 a.m., the Nursing Home Administrator (NHA) acknowledged she had come into the first-floor dining room following the above observation of R29 and R49, and found no staff present in the dining room for resident supervision. The NHA confirmed staff should be seated while providing dining assistance to residents in the facility. The NHA stated, It was [CNA W] who was assigned to the (first floor) dining room yesterday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to obtain consent for psychoactive medication for one Resident (#51) of five residents reviewed for psychoactive medications. This deficient practice resulted in Resident #51 (R51)and their Responsible Party not being informed of potential medication side effects/adverse reactions. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. A review of R51's electronic medical records (EMR) indicated an admission into the facility on 8/31/21 with diagnoses including major depressive disorder, unspecified dementia, and congestive heart failure. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed R51 had severely impaired cognition with a score of 3/15 on the Brief Interview for Mental Status (BIMS) assessment. The medical record documented R51 had an appointed responsible party for health care and financial decisions. A review of R51's 'Physician Orders' for July 2023 indicated the antipsychotic medication Olanzapine 5 mg (milligrams) was prescribed by mouth once a day and was initiated on 10/10/22. A review of Resident #51's EMR revealed no evidence that R51's Responsible Party had given written or verbal consent for the administration of an antipsychotic nor were they informed of the potential side effects/adverse reactions. During an interview on 07/27/23 at 10:42 AM, Staff EE stated no consent was found for Olanzapine. Staff EE said the process was for the licensed nurses to put in the physician order for the medications, print the consent and pass it to Staff EE who mailed it. Staff EE concluded, The process got lost with the change of staffing. During an interview on 7/27/23 at 1:09 PM, Assistant Director of Nursing (ADON) A stated she was looking for a consent policy but could not find one. No consent policy was presented by the close of the annual survey. .

Based on observation, interview, and record review, the facility failed to facilitate resident self-determination related to dining location preference for one Resident (R3) of one resident reviewed for resident choices. This deficient practice resulted in frustration, anger, dissatisfaction with care, and feelings of helplessness when resident choices were not honored. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted. During an interview on 7/18/23 at approximately 1:10 p.m., R3 was asked about any concerns with nursing care. R3 stated, One nurse won't even talk to me. She will not say one word to me. [Staff AA] is the nurse. [Staff AA] makes me go to breakfast every day I am here (and she is here) - even if I don't want to. During an observation and interview on 7/21/23 at 8:35 a.m., when asked about the location of breakfast the previous day, R3 stated, [Staff AA] made me go to breakfast yesterday (in the dining room) and I did not want to go to breakfast. I want to watch TV while I am eating my breakfast. I never want to go to breakfast, but [Staff AA] tells me I am getting up, and it doesn't make any difference if I say that I am not going - she gets me up with the lift and makes me go to breakfast anyway. I should be able to go to breakfast if I want to go to breakfast. I should not have someone else telling me what I have to do when I don't want to do it. R3 was observed in bed, awaiting delivery of her breakfast tray, with the television on. Staff AA was not observed working on R3's hall on 7/21/23. Review of the daily staffing assignments confirmed Staff AA did work on 7/20/23. During an interview on 7/20/23 at 3:13 p.m., when asked where R3 ate breakfast that day, Staff AA confirmed R3 ate breakfast in the dining room that morning (7/20/23). During an interview on 7/26/23 at approximately 4:00 p.m., when asked about R29's choice to eat in her room or in the dining room, Social Services Designee CC stated, If she wants to eat in her room, she should be able to eat in her room. It is what the resident wants. It is not what the staff wants - their (Resident) wishes should be upheld. Review of the Rights of Residents in Michigan Nursing Facilities pamphlet, dated 11/18/16, revealed the following, in part: Self-Determination: You have the right to, and the facility must promote and facilitate, resident self-determination through support of resident choice, including but not limited to . b. The right to make choices about aspects of your life in the facility, that are significant to you .

This deficiency pertains to Intake MI00136498. Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse and neglect by Staff for one Resident (R9), out of eight residents reviewed for abuse. This deficient practice resulted in the potential for fear, humiliation, and feelings of helplessness when R9 was verbally disparaged following a fall from a chair. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Review of the Facility Reported Incident (FRI), dated 5/1/23, revealed the following, in part: On May 1, 2023, at approximately 5:15 p.m., it was reported to me [Director of Nursing (DON)], by the RN Supervisor, that an aide, [Certified Nurse Aide (CNA) Y], swore at a resident while trying to pick her (R9) up off the floor. A witness reported that while he was trying to get her back into her chair, she heard him (CNA Y) say, 'sh*t and G*d d*mn you' to the resident . Review of R9's Minimum Data Set (MDS) assessment, dated 6/20/23, revealed R9 had active diagnoses that included heart failure, diabetes mellitus, dementia, Parkinson's disease, anxiety disorder, depression, and schizophrenia. R9 scored 2 of 15 on the Brief Interview for Mental Status reflective of severe cognitive impairment and required extensive two-person assistance with transfers. R9 was documented in the MDS assessment at 65 inches (5 foot 5 inches) tall and weighing 153 pounds. Review of R3's 03/28/23 MDS assessment, revealed R9 required limited, two-person physical assistance with transfers prior to the 5/1/23 fall to the floor. R9 was documented as 65 inches tall and 151 pounds in weight. During an interview on 7/26/23 at 8:39 a.m., Housekeeper (Staff) FF said she recalled the May 1st 2023 incident. Staff FF said she heard a ruckus on the wing (hall), looked up and CNA Y had a resident on the floor. CNA Y told Staff FF that they needed to get R9 in the chair. CNA Y indicated to Staff FF R9 did not fall, but CNA Y had to lower (R9) to the floor. Staff FF said they did not know what the ruckus (loud commotion) was prior to seeing the Resident on the floor. When asked if R9 had a gait belt on for safe repositioning, Staff FF could not recall, but said they lifted R9 back into the chair by holding on underneath her arms. Review of hand-written witness statements for the incident dated 5/1/23, provided by facility staff included the following, in part: 1. Activity Aide (Staff) HH: On Monday May 1st at 9:30 a.m. I was writing on the boards (activity boards) when I heard a commotion behind me. I turned around and saw a resident had fallen when a CNA [CNA Y] tried to move her (R9) from the chair into her wheelchair . he (CNA Y) caught her by her arms. She was half lying on the ground. He tried to pick her back up and failed which was followed by 'Sh*t, G*d d*mn you.' He did not call for help and when I asked if he needed help his words were, 'I'm fine, she's fine.' I then watched as he tried to lift her again and strugled (sic). The resident cried out in pain as he was trying to lift her. Still not asking for help. He tried again lifting under her arms and got her back in the chair. She was whimpering and sounded in pain. Signed and dated 5/2/23 at 9:42 a.m. 2. Registered Nurse (RN)/Unit Manager Z: On May 1st at approximately 4:55 p.m., [Activity Aide II] reported to me that [Staff HH] from activities witnessed [CNA Y] at 9:30 a.m. lower a resident (R9) to the floor and then lifted her off the floor . her (R9's) entire body was on the floor except for her head . then [CNA Y] tried lifting the resident back into the recliner and was unable to lift her and set her back on the floor . while he was trying to lift (R9) into the chair [Staff HH] heard him saying sh*t and G*d damn you to the resident (R9) . 3. Activity Aide/Staff II: At 5:00 p.m. I was talking with [R9] and she was complaining of a sore arm and that she had fallen earlier. I went and told [Licensed Practical Nurse (LPN) L] (R9) was complaining of pain. He said he hadn't been told of anything (fall happening). [Staff HH] told me she seen/heard (R9) fall in the morning around 9:30 a.m. (Staff HH) said she was doing boards, heard a commotion behind her, turned around and heard/seen [CNA Y] trying to pick [R9] up and was holding/picking her up under her right arm . Signed and dated 5/3/23. No witness statement was provided by CNA Y in the investigation packet, and CNA Y was unavailable for interviews. During an interview on 7/27/23 at 8:44 a.m., the Nursing Home Administrator (NHA) was asked which Witness Statement she would give more credibility to: the hand-written statement completed by the eye witness to the incident, or a typed interview completed by ADON A. The NHA said the would consider the handwritten witness statement to have more validity. No evidence or witness statement supported the presence or use of a gait belt for safe transfers for R9 following the fall. When CNA Y neglected to use a gait belt, R9 was subjected to physical harm and pain. Review of R9's nursing progress notes revealed the following, in part: 5/1/23 - Transferred to emergency department . Reason for Transfer: Resident was lowered to the floor earlier in the day and is now complaining of right arm pain. Had a fall at 5:15 p.m. [Central Standard Time (CST)] which she slid from her wheelchair and has complained on and off about right hip and lower back pain. Resident then choked on a piece of hot dog and had to have the Heimlich performed to remove the hotdog . Date of Transfer: 5/1/23, Time: 06:22 [6:22 p.m. (CST)] .PRIMARY HOSPITAL DIAGNOSIS: fracture to one right rib . .5/2/23 . SKIN PROBLEMS: Res (Resident) complained of pain during cares under left arm and chest area . .5/3/23 . SKIN PROBLEMS: bruises, left deltoid small superficial scrape also noted on lower area of bruising. Area not noted yesterday at this time . Bruise is blue/purplish in color . resident continues to have some purple bruising on her left arm down the side of her bicep. Also has a slight laceration that is scabbed over at this time on the side of her left bicep . Review of Fall Procedure Training, provided to [CNA Y] 5/24/23, revealed the following: It is the policy of [Facility Name] to assess any resident by a licensed nurse prior to being moved. The definition of a fall is any unplanned change in a plane. This includes being lowered to the floor by a staff member. It is necessary to follow the fall procedure to prevent further injury to the resident. The typed document was signed by CNA Y and Assistant Director of Nursing (ADON) A. Review of a Resident Abuse Prevention and Reporting, Post Test with CNA Y's name at the top of the first page revealed CNA Y was required to complete an abuse refresher following the 5/1/23 incident of the fall with verbally disparaging comments reflective of verbal abuse. Review of an Attendance Record of Inservice, dated 5/4/23, with speaker (educator) MM on Abuse Policy and Reporting revealed Staff HH was re-educated on abuse and required reporting. Review of the Abuse, Neglect, and Exploitation policy, reviewed 5/2/23, revealed the following, in part: .Definitions: Verbal Abuse means the use of oral, written or gestured communication or wounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview, and record review, the facility failed to completely assess and establish a baseline care plan within 48 hours that included measurable goals and interventions for one Resident (#58) of two sampled residents reviewed for development of baseline care plans. This deficient practice resulted in the facility's failure to address priority risk factors and individual needs. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. The first plan of care for R58 was presented on 07/20/23 at 3:52 PM by Staff T who stated it was started on 1/2/23. A baseline care plan was not written within 48 hours of the admission on [DATE] and did not mention plans to keep R58 safe using the knowledge of R58's previous daily habits of leaving his home. According to the electronic medical record (EMR), Resident #58 (R58) was admitted to the facility on [DATE], with a primary diagnosis of Alzheimer's disease. A review of the Minimum Data Set (MDS) assessment for R58, with a reference date of 1/4/23 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated R58 had severe cognitive impairment. The EMR contained a home assessment dated [DATE] (prior to admission) which revealed information gained during discussion with the family included R58 would leave his house and go to watch the family work up the farm fields behind the house and to tend to his chickens at the light of day. The family had placed a safety device on R58 to be able to find him if he wandered from home and fell. A Facility Reported Incident dated as initially submitted 12/30/23, read in part: .Date of incident 12/30/22 Time of incident 255PM (2:55 PM) On 12/30/22 (R58) was seen talking to two male visitors at the nurse's station with his jacket and hat on. Review of our inside cameras confirmed that (R58) got onto the elevator with the two male visitors. Review of our outside cameras confirmed resident going out the door by the ambulance entrance and was outside for a total of 6 minutes when resident came back in the same door he exited on his own. The facility's policy titled: Comprehensive Care Plans dated as reviewed on 7/5/23 read in part, . A baseline care plan will be developed within 48 hours of admission and remain in place until the comprehensive care plan is completed . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an effective means of communication for one Resident (#50) of two residents reviewed for communication. This deficient practice resulted in Resident #50 struggling to communicate her basic needs, which resulted in feelings of frustration. Findings include: Resident #50 (R50) Review of the Minimum Data Set (MDS) assessment, dated 5/16/23, revealed R50 was admitted to the facility on [DATE], with diagnoses including fracture (unspecified), dementia, and urinary tract infection. The assessment revealed R50 required extensive two-person assistance for bed mobility, transfers, dressing, and toileting, and could feed herself with set-up only. The Brief Interview for Mental (BIMS) assessment revealed a score of 3/15, which indicated R50 had severe cognitive impairment. The sensory assessment revealed R50 had clear speech, and was usually understood, and was sometimes able to understand others, had no vision impairment and wore hearing aids. During an observation on 7/18/23 at 2:22 p.m., R50 demonstrated limited communication; she responded to yes/no questions but was unable to elaborate when attempting to explain her responses. During an interview on 7/19/23 at 3:28 p.m., Licensed Practical Nurse (LPN) AA was asked about R50's ability to communicate her needs. LPN AA reported R50 attended activities and enjoyed being around her peers and having socialization. LPN AA reported R50's Yes and No responses were accurate. LPN AA also indicated R50 needed to be given extra time to process, and she did occasionally give one-word responses. LPN AA reported R50 had no visual impairment and could understand well when wearing hearing aids. LPN AA reported when R50 needed to use the bathroom she would state, I gotta go, and could show pain by grimacing and non-verbal communication. LPN AA reported R50 used the call light, however sometimes staff could not determine what she wanted. LPN AA clarified sometimes a need was expressed and other times R50 was unable to communicate what was needed, but could say, Help. LPN AA was asked if R50 had received speech language therapy services to assist her with communication, such as working on improving her communication skills verbally or with using a communication board, or alternate means of communication. LPN AA reported there had been no referrals to speech therapy services to their awareness. During an interview on 7/21/23 at 2:00 p.m., the Rehabilitation Director, Physical Therapist Assistant (PTA) R, was asked about Resident #50's functional communication during therapy services. PTA R acknowledged they evaluated and treated R50 shortly after admission to the facility, however occupational therapy services had never seen R50 during her ongoing stay at the facility, and speech therapy services had only seen R50 after a choking episode in April (2023). PTA R reported they communicated with R50 through yes/no communication and clarified R50 could follow one-step directions when she participated in therapy. Upon review of R50's observed and reported attempts to communicate during the survey, PTA R concurred R50 had the potential to improve their communication to better convey their needs and would have benefitted from speech therapy services for communication. PTA R explained they (the facility) only requested PT and OT evaluations upon admission, and there were no speech screenings done, and speech therapy evaluations were done only when the resident was admitted with a stroke. PTA R was asked if they or the occupational therapist screened for speech therapy services routinely, for any needs or declines in speech (language), swallowing, or cognition. PTA R acknowledged they did not, as they did not routinely have speech therapy staff available, so they only screened for PT and OT services. PTA R confirmed post review they would have their speech language pathologist evaluate R50 as soon as possible for a communication board or to improve her speech communication to best convey her needs. PTA R clarified R50 often understood what was being communicated to follow basic directions during physical therapy and had the rehab potential to improve her communication. Review of R50's Care Plan, accessed 7/19/23, revealed, 01/28/23. [Need/Preference]: I have a communication deficit because I have impaired hearing . I show this by poor memory, difficulty finding words, difficulty expressing needs, slow or slurred speech, difficulty understanding others, disorientation and confusion I need everyone to reduce background noise when speaking with me, adjust tone appropriately, make eye contact with me, allow me time to respond, repeat self as needed, ask simple yes/no questions, use clear, direct, simple terms. My goal is to understand what is being communicated to me. Goal time: three months . During an interview on 07/26/23 at 12:22 p.m., Activities aides, Staff KKK and Staff II, were interviewed about R50's participation in the facility activity program, and R50's ability to communicate. Both replied R50 was able to communicate with yes/no responses accurately, given extra time, and conveyed she could understand to participate in some of the activities. Activity Aide KKK reported R50 could state, I need to go to the bathroom., and both reported she could read her BINGO card to target the number called with minimal assistance on occasion. Staff II reported R50 would do well with a picture means of communication, such as a communication board, as there were times she tried to communicate her needs but did not have the ability to do so. Both reported she could identify objects when they were named and she was given choices, and both agreed she could better communicate her needs, given choices in picture or other method. Both reported R50 could follow one-step directions, and reported they could say, Please sit here, and she would where indicated. Both reported R50 understood most of the directions for the activities and had the potential to communicate her needs more effectively. During an interview on 7/27/23 at 9:15 a.m., Staff PP reported they believed R50 could communicate her basic needs and would be able to communicate more effectively if she had another means to communicate, such as a communication board. During an observation on 7/27/23 at 9:28 a.m., R50 was observed up in their wheelchair in the resident hallway, wearing gripper socks; she was clean and smiling. R50 responded to yes/no questions accurately, and attempted to say more, but was difficult to understand, but tried to communicate to Surveyor how she was doing. R50 was not provided a Speech Therapy Evaluation and Plan of Treatment until 7/26/23, during the second week of the annual recertification survey. This evaluation and plan of treatment revealed the following: Short term goals: Patient will understand yes/no questions with 90% accuracy and 50% verbal cues in order to communicate medical needs and in order to participate in activities of choice: Baseline (7/26/23) = 75%. Patient will complete picture description tasks with 85% accuracy .and cues .to increase ability to communicate complex thoughts, ideas, opinions and/or feeling and improve expressive communication. Baseline (7/26/23) = 60%. Patient will articulate simple/short sentences with 85% intelligibility using over articulation and pacing in order to communicate complete thoughts, ideas, opinions and /or feelings and in order to participate in meaningful interactions. Baseline (7/26/23) = 60% .Reason for referral: Patient [Resident #50] referred to ST [Speech Therapy] due to exacerbation of decreased socialization and decreased speech intelligibility indicating the need for ST [Speech Therapy] to analyze communication abilities and improve language function. Hx [history]/complexities: Metabolic encephalopathy [brain dysfunction from disease or toxin] .Comments: Subjective/Objective: Patient is able to express her basic wants and needs verbally when provide [sic] extra time for processing of verbal output and repetitions from communication partner to improve comprehension. However, SLP did provided [sic] a communication book to assist with expression of basic needs and wants . During a phone interview on 7/27/23 at 3:27 p.m., Speech Language Pathologist (SLP) LLL, reviewed their 7/26/23 evaluation of R50 with Surveyor. The evaluation showed R50 scored well above 50% by demonstrating she understood yes/no questions, articulated short sentences, understood conversations, followed one step directions, demonstrated verbal expression and comprehension, named objects, demonstrated reading comprehension, and presented with motor speech, with the potential for improvement. A standardized assessment was given for aphasis (loss of ability to understand or express speech) which showed moderate speech and language deficits. SLP LLL confirmed a communication book with pictures (communication board) was not provided to staff until following the assessment. R50's daughter was present and her primary goal for R50 was to maximize verbal communication. SLP LLL conveyed R50 was a good candidate for SLP services for both verbal and adaptive communication. SLP LLL stated, I do think [R50] has the potential to improve where she is at right now. I think she needs five days of [speech] therapy that you could get with a full-time therapist. I'm not sure how much I can improve a patient with a cognitive deficit in two days. [R50] has signs and symptoms of moderate dementia .you [the clinician] want to be there every day to employ the strategies. I do think we can improve the basic things w a yes/no answer, and there could be more potential if there is more therapeutic intervention. SLP LLL acknowledged R50 would benefit from more training. During an interview on 7/27/23 at 4:28 p.m., the concerns were reviewed with the Nursing Home Administrator (NHA), who reported they understood the concerns identified. Review of the policy, Effective Communication, copyrighted 2022, received 7/26/23, revealed, Effective Communication - Residents with impaired communication. Policy: It is the policy of this facility to accommodate needs when communicating with residents who have impaired communication to promote dignity, understanding, and safety. Definition: Effective Communication describes a process of dialogue between individuals. The skills include speaking to others in a way they can understand and active listening and observation of verbal and non-verbal cues. Understanding what the resident is trying to communicate is essential to giving a response. Additionally, effective communication ensures that information provided to the resident is provided in a form and manner that the resident can access and understand, including in a language that the resident can understand. Policy Explanation and Compliance Guidelines: 1. During the pre-screening and admission process, as much information as possible will be obtained regarding the resident's current processes for communication .The IDT [Interdisciplinary Team] will assess the need to any alternate forms of communication along with a therapy screen. Staff will communicate with the resident, using techniques identified in their plan of care, and in accordance with his/her established routine for communication, as possible. Adaptive techniques include but are not limited to: a. Looking at the resident and speak face to face when speaking to them to promote dignity and to faciltiy resident's ability to speech read/lip read (if capable). b. Standing or sitting under or near a light source and keeping hands and objects away from mouth when speaking. c. Written captioning of audio communications (i.e., closed captioning on TV .). d. Using communication boards or writing materials (i.e., write legibly, in plain terms)

Based on observation, interview, and record review, the facility failed to ensure appropriate catheter care to prevent urinary tract infections for one Resident (R4) of one resident reviewed for catheter care. This deficient practice resulted in the potential for cross-contamination of feces and increased risk of urinary tract infection. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. During a catheter care observation for R4 on 7/21/23 at 10:36 a.m., CNA LL began catheter care with cleansing of the catheter tubing. CNA LL held the tubing, approximately one inch from the urethral opening, and cleansed downward four times. The tubing near the urethra was never cleansed. The tubing was rinsed, and CNA LL took the towel that was draped over R4's body to dry the catheter tubing with the same dirty gloves. CNA LL then used a new, wet washcloth to cleanse the right and left creases between the pubic area and the inner thigh. CNA LL wiped downward three times in the left and right thigh crease, finding brown feces on the white washcloth with each of the swipes. CNA LL then used a clean rinse cloth which again was left with brown feces after passing down the right and left thigh crease. CNA LL separated the labia and used a clean, wet washcloth to cleanse over the urethral meatus, over the dirty tubing that was not properly cleanse, and down past the vagina. Three swipes downward were completed by CNA LL who then said, Am I done? When asked if there was still feces on the rinse cloth, CNA LL confirmed there was stool present after cleaning the resident. CNA LL said R3's bowel movement should have been cleaned up prior to completion of catheter care. CNA LL said R4 would have to be rolled over to thoroughly clean the feces from between the legs and off the buttocks. CNA LL said R4 was a one-person assist with bed mobility, and stated, I am scared to do her because she says ouch all the time. Review of R4's Minimum Data Set (MDS) assessment, dated 6/14/23, revealed R4 required extensive two-person assistance with bed mobility and transfers. R4 scored 6 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment. Active diagnoses included the following, in part: neurogenic bladder, UTI (urinary tract infection in the last 30 days), other fracture, non-Alzheimer's dementia, multiple sclerosis and paraplegia (paralysis of the legs and lower body). Review of R4's Care Plans revealed the following, in part: (6/22/23) I REPOSITION IN BED: with the help of 1 person extensively, bearing my weight to dependent 100% of the effort depending on my ability . I USE THE BATHROOM: extensively, bearing my weight to dependent 100% of the effort with the help of 1 person depending on my ability. I have a foley catheter . I do not use the toilet. I am prone to UTIs. Let my nurse know if any changes are noted . R4's left leg was observed to be physically deformed or broken, and positioned in a bent, unnatural position. The left leg flopped just below the hip, like a rag doll leg, as CNA LL rolled R4 onto her left side. R4 continued to roll, past the left side position, with her face down half on the mattress and half on top of a stuffed animal. R4 was positioned on the left leg and abdomen. R4 cried out softy, It hurts, it hurts hard. CNA LL used two wet washcloths to remove feces from buttocks and up near the catheter tubing. The washcloth removing feces from the resident was observed coming into contact with the catheter tubing. CNA LL removed the dirty gloves and donned new gloves without hand hygiene. R4 was rolled from her face being on the mattress to her back and a clean brief applied, as she cried out It hurts, it hurts. As CNA LL untangled the catheter tubing from between and around R4's leg, CNA LL raised the urinary drainage bag over the resident's bladder and the backflow of urine was observed. Following the observation on 7/21/23 at approximately 10:50 a.m., CNA LL asked if she had performed the catheter care ok. When asked about failure to cleanse the catheter tubing from the urinary meatus to approximately one inch out from the body, CNA LL confirmed she had not cleaned the urinary catheter tubing from her fingers on the tubing to the urinary meatus, and sighed loudly as she looked down and walked away. During an interview on 7/21/23 at 11:13 a.m., Assistant Director of Nursing (ADON) A said the Registered Nurse (RN) Unit Managers would be the supervisory staff for the CNAs, per their job description. When asked about observation of peri care and catheter care for CNA LL, RN/Unit Manager Z said CNA LL was contract (agency) staff. RN Z stated, We do not do competencies (to ensure staff are able to properly perform tasks) on agency staff. ADON A confirmed R4 had an unhealable broken, left leg, and stated, If I were the one doing it (catheter care) I would have a two-person assist. I would have someone holding the (left) leg while I cleaned . During an interview on 7/21/23 at 11:24 a.m., RN Z agreed she would have had a second person present to support the broken left leg during catheter care. Review of the Catheter Care policy, reviewed 3/7/2023, revealed the following, in part: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use . Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. Female: Gently separate the labia to expose the urinary meatus. Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). Use a new part of the cloth or different cloth for each side. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Dry area with towel . Review of the Perineal Care policy, reviewed 3/6/23, revealed the following, in part: Policy: It is the practice of this facility to provide perineal care to all incontinent residents during bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown . If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard .

Based on interview and record review the facility failed to ensure the provision of trauma-informed care to mitigate triggers that may cause re-traumatization for one Resident (R3) of one resident reviewed for trauma-informed care. This deficient practice resulted in increased anxiety, flashbacks, and feelings of re-traumatization. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted. During an interview on 7/18/23 at approximately 1:10 p.m., R3 stated, This morning and all this week so far, and I have told them, and told them, and told them - I don't like men washing me up. The man put me on the bedpan, he gave me my bath this morning. Back when I was sixteen, I was [sexually assaulted], and it brings the anxiety back up. I know he won't [sexually assault] me but there is always the chance that he would. I have told them several times that I don't want a man. I have asked them to get someone else, and they say - 'He is the only one we got. It is him or nobody.' I can't do it myself. Review of R3's Minimum Data Set (MDS) assessment, dated 5/31/23, revealed no diagnoses of mood disorder, history of trauma or PTSD, but it was reflected in her Care Plan. R3 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition and was able to make her needs known. Review of R3's Care Plans revealed the following 10/13/22 Need/Preference: I have the potential to feel anxious, scared, angry, sad, alone/isolated. I have a history of trauma that affects me negatively and triggers that have the potential to re-traumatize me. Once I have experienced a trigger, I may display these signs/symptoms: anxiety, overwhelming fear, and changes in mood. BECAUSE I have a diagnosed mood disorder, have episodes of depression, am a victim of physical and sexual assault . WHEN I FEEL THIS WAY I: don't feel like doing anything, feel down or depressed .feel bad about myself . may want to be left alone, fear that my abuser may come here to harm me, get anxious around male care givers and become anxious when man walk past my room . APPROACH (Interventions): 5/4/22, I need everyone to . know what my triggers are (male care givers, when men walk past me room) . During an interview on 7/26/23 at approximately 4:00 p.m., when asked about R3's expressed preference to have female care providers, Social Services Designee CC stated, If they (R3) do not want a male caregiver, and there is a male caregiver assigned to that hallway, the person on the other hallway would have to come over and do the care . If they say they don't want a male care giver they should not have a male caregiver. At no time should anyone say you are not going to get your cares if you don't have him (male care giver) for the night. That is not acceptable. Review of the Trauma Informed Care policy, copyright 2023, revealed the following, in part: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Common sources of trauma may include, but are not limited to . d. Physical, sexual, metal, and/or emotional abuse (past or present), e. Rape, f. Violent crime . I. Traumatic life events (death of a loved one, personal illness, etc.) The facility will work to facilitate the principles of trauma informed care which include: . Empowerment, voice, and choice - Ensuring that resident's choice and preferences are honored and that residents are empowered to be active participants in their care and decision-making, including recognition of, and building on resident's strengths . The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions . The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan . The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included in this evaluation to ensure clear and open discussion and better understand if interventions must be modified.

Based on interview, and record review, the facility failed to evaluate the use of antipsychotic medication for potential adverse consequences at least quarterly, if not more often for three Residents (#9, #36 and #51) of five sampled residents reviewed for unnecessary medications. This deficient practice resulted in the facility's failure to determine the potential for reducing or discontinuing psychoactive medications based on therapeutic goals and any adverse effects or functional impairment. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. Resident #9 (R9) The facility electronic medical records (EMR) for R9 revealed the most recent admission date of 12/29/20 with current diagnoses which included anxiety disorder, major depressive disorder, recurrent, schizophrenia, unspecified, and drug induced subacute dyskinesia (unusual movements that a person cannot control). Current Physician ordered psychotropic medications included Seroquel, Lexapro, Trazadone, and Lorazepam. The EMR contained Abnormal Involuntary Movement Scale (AIMS) evaluations dated 2/22/21, 5/18/21, 9/14/21, 11/14/21, 2/14/22, 7/19/22, 1/4/23, 3/28/23 and 6/22/23. Resident #36 (R36) The facility EMR for R36 revealed an admission date of 6/16/21 with current diagnoses which included major depressive disorder, recurrent, and paranoid personality disorder. The current Physician ordered psychotropic medications included Seroquel, Cymbalta, and Lexapro. The EMR only contained AIMS evaluations in 2022 for 2/4/22, 11/4/22, and 12/26/22. No AIMs evaluations were completed in 2023. Resident #51 (R51) A review of R51's EMR indicated an admission into the facility on 8/31/21 with diagnoses including major depressive disorder, and unspecified dementia. The current Physician ordered psychotropic medications included Olanzapine, and Fluvoxamine Maleate. The EMR contained AIMS evaluations dated 2/8/22 and 12/8/22. No AIMs evaluations were completed in 2023. During an interview on 7/26/23 at 2:32 PM, Assistant Director of Nursing (ADON) A stated AIMS should be done quarterly, annually and with significant changes. ADON A said, I possibly missed it (doing the AIMS evaluations) as I was acting DON (Director of Nursing) and MDS (Minimum Data Set) nurse. I was putting out fires at the time. The undated facility policy titled Use of Psychotropic Medication read in part, Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, PRN (as needed) or as per facility policy. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure timely radiology services in a timely manner and professional standards of practice after an unwitnessed fall for one Resident (R15) out of one resident reviewed for radiology services. This deficient practice resulted in the delay of medical treatment, diagnosis, and pain control for two fractures. Finding include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. According to the Facility Reported Incident (FRI), dated 8/30/22, read in part, .Registered Nurse [RN S] was called into the locked unit to assess [R15's] leg, left lower extremity swollen (which she does have 2+ edema to that extremity) and bruising noted to ankle, resident was unable to move foot/toes and foot drop noted. RN called physician and order to send out to hospital for evaluation . Review of R15's face sheet, dated 8/30/22, reveal R15 was a [AGE] year-old female resident admitted to the facility on [DATE] with medical diagnoses including anxiety, severe intellectual disability, schizophrenia, and diabetes mellitus. Review of handwritten notes from a communication notebook between facility staff, dated 8/28/22 and timed 11p [11:00 PM] author unknown, read in part, [R15's] yelled out on and off all night long. Slapped herself a few times. Left foot is hanging weird - she can't put pressure on it. Review of handwritten notes from communication notebook between facility staff, dated 8/28/22 and timed 3-7 [3:00 PM - 7:00 PM] author staff C, read in part, .tried to transfer self to bed and was sit (sic) on floor next to w/c [wheelchair]. Looked like she [R15] looked like she may attempted to transfer into bed but didn't make it. 2-person pivot with gait belt, no grimacing - stood up without issue and pivoted into bed. Note: Indicating RN D and RN E were aware and present at the time. Another note with the same date, read in part, Sitting on w/c and floor. Signed by RN E. R15's nursing notes were reviewed, dated 8/13/22, and 8/30/22, lacked any documentation of a fall, injury, bruising, pain, mood changes or behaviors, or change in ROM. Review of R15's progress note, dated 8/30/22, read in part, .Left ankle swollen and bruised .[physician name] notified. R15's progress note, date 8/31/23, read in part, Transferred to: acute care hospital . Reason for transfer: Non-fall related in jury: major injury, possible broken left leg . Review of R15's hospital radiology report, dated 8/30/22, read in part, . CT [computerized tomography] LWR [lower] extremity . left . Findings: . Acute mildly comminuted (a bone that is broken in at least two places) fracture of the mid shaft fibula with main butterfly fragment measuring 5.8 cm [centimeters]. Additional comminuted fracture involving the distal fibular shaft with medial displacement of a thin 1.2 cm fragment. Comminuted fracture involving the distal third tibial shaft extending to the metaphysis (lower distal part of the tibia) without intra-articular extension .Impression: 1. Left lower extremity fractures . Review of R15's discharge summary, date printed 9/1/22, revealed, R15 had been admitted to the hospital on [DATE] and was discharged on 9/1/22, and further review revealed, discharge diagnosis: left ankle fracture, requiring operative fixation at some point . Hospital Course: . 09/01/2022: Patient did well postoperatively, She's been able to eat. She is now completely nonweightbearing status post surgery. Orthopedics comments that the patient could lose her leg and her entirety if she tries to walk on this and damages it further . On 7/26/23 at 3:55 PM, an interview was conducted with facility staff C. Staff C was asked about her witness statement in the facility reported investigation summary and confirmed that R15 was on the floor next to her bed and R15's fall was unwitnessed. Note: No official witness statement was found for staff C. On 7/26/23 at 4:00 PM, an interview was conducted with the Nursing Home Administrator (NHA), and the NHA confirmed that an incident and accident report should have been filled out on 8/28/22 when R15 fell in her room unwitnessed, an assessment should have been completed by the nurse(s) on shift, that the State Agency (SA) should have been reported to when the bruise was discovered on 8/29/22 by staff, and R15 should have received medical treatment sooner for an x-ray, a full investigation should have been properly completed with witness statements for all working with R15 during that time frame, and did not receive sooner medical treatment most likely related to the lack of an incident and did not most likely related to the lack of an incident and accident report being completed and physician should have been notified. Review of facility reported incident summary, dated 4/5/23, read in part, .Resident has been noticed hitting self in the face, right arm and right hand. She has severe intellectual disabilities and has a long history of self-abusive behaviors .MD was in house on 4/4/23 and saw resident. New orders were received to have x-ray done. Report was phoned to the facility at 5pm this evening that resident does have a right wrist nondisplaced fracture. Continual investigation will proceed. Review of handwritten witness statement, dated 3/30/23 author Staff Q, read in part, (Before Lunch). I started to do [R15's] ROM on her arms when I seen that her right hand was black and blue. She opened and closed her fingers for me two times. Upon leaving room LPN [unknown] was notified. Review of handwritten witness statement, dated 4/2/23 author PTA R, read in part, .I entered Resident's room, [R15], to check mobility bars and perform an assessment. She was lying in bed, I began talking to her and she was holding her right arm up saying ouch. I noticed her right hand was black and blue and swollen. Upon exiting room LPN [unknown]was notified. Review of R15's radiology report, dated 4/5/23, read in part, .Impression: Suspected nondisplaced distal radius or ulna fracture. Facility incident and accident reports were reviewed between March 2023 and April 2023 for R15 and revealed, no evidence of a report being completed during that time frame. On 7/26/23 at 4:10 PM, an interview was conducted with the NHA, and the NHA confirmed that an incident and accident report should have been filled out on 3/30/23 when staff Q discovered a bruise on R15's right hand, an assessment should have been completed by the nurse on shift, that the SA should have been reported to when the bruise was discovered on 3/30/23 by staff, and R15 should have received medical treatment sooner for an x-ray, a full investigation should have been properly completed with witness statements for all working with R15 during that time frame, and did not receive sooner medical treatment most likely related to the lack of an incident and accident report being completed and physician should have been notified immediately.

This deficiency pertains to Intake MI00132367. Based on interview and record review, the facility failed to implement their abuse policy to screen potential employees for a history of abuse by completion of reference checks for four recent hires ( Staff BB, JJ, OO, and PP) out of five staff reviewed for reference checks. This deficient practice resulted in the potential for individuals with a history of abuse to be employeed by the facility which had the potential to affect all 68 facility residents. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of Staff OO's Employment Application on 7/25/23 at 2:27 p.m., revealed no reference checks were completed prior to starting employment with the facility. When asked if reference checks were available for Staff OO, Administrative (Staff) Z said no reference checks were performed. Staff Z said the reference checks were not being completed by the Director of Nursing (DON) who was responsible for the decision to hire the nursing staff employees. Staff Z said her job description did not include responsibility for reference checks, and she noted she was not party to the nursing department hiring process. The DON would decide if the applicant was going to be hired. Staff Z stated, It has always been the managers that have done the reference checks. The Manager is offering this individual employment - I wonder how you can hire someone if you don't know about their prior work ethic. On 7/25/23 at 2:33 p.m., review of Staff PP's employment application found no attempted or completed references. Staff PP had been a prior employee three years previous. Staff Z stated, If it was my responsibility to do reference checks, I would follow up with references if they had been a previous employee. On 7/25/23 at 2:36 p.m., the employment applications for Staff BB (4/17/23) and Staff JJ (6/1/23) were also reviewed and found without attempted or completed reference checks. Staff BB had a previous employment application, dated 8/5/22, with no reference checks attempted or completed. Staff JJ also had a previous employment application, dated 5/10/22, with no reference checks attempted or completed. During a telephone interview on 7/26/23 at 11:10 a.m., the DON was contacted while working from home. The DON confirmed that she had worked almost exclusively from home since being out for medical procedure beginning March 29, 2023. The DON said when Staff OO was hired, the process was to send the references out via mail to the references listed and wait for them to be returned prior to hiring the new staff member. The DON stated, When I became aware of that issue, I told [Human Resources (HR)] that we could not wait for those papers (references) to come in (the mail). I told [HR] we had to call and get those references. At that time that was an HR responsibility. It (reference check) was something that got overlooked. During an interview on 7/25/23 at 2:53 p.m., the Nursing Home Administrator (NHA) was asked who was responsible for completion of employee reference checks. The NHA stated, If nursing hires someone the DON is responsible for performing reference checks. When asked if she was aware the DON had not completed reference checks for most of the newly hired nursing employees, the NHA stated, I did not know that. We know we have lots of things to fix. Review of the Abuse, Neglect and Exploitation policy, reviewed 5/2/23, revealed the following, in part: 1. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants .3. The facility will maintain documentation of proof that the screening occurred .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15 (R15) Injury of unknown origin facility reported incident dated 8/30/22: Review of R15's face sheet, dated 8/30/22, reveal R15 was a [AGE] year-old female resident admitted to the facility on [DATE] with medical diagnoses including anxiety, severe intellectual disability, schizophrenia, and diabetes mellitus. Review of handwritten notes from a communication notebook between facility staff, dated 8/28/22 and timed 11p [11:00 PM] author unknown, read in part, [R15] yelled out on and off all night long. Slapped herself a few times. Left foot is hanging weird - she can't put pressure on it. Review of handwritten notes from communication notebook between facility staff, dated 8/28/22 and timed 3-7 [3:00 PM - 7:00 PM] author LPN C, read in part, .tried to transfer self to bed and was sit (sic) on floor next to w/c [wheelchair]. Looked like [R15] may attempted to transfer into bed but didn't make it. 2-person pivot with gait belt, no grimacing - stood up without issue and pivoted into bed. Note: Indicating RN D and RN E were aware and present at the time. Another note with the same date, read in part, Sitting on w/c and floor. Signed by RN E. Review of handwritten notes from communication notebook between facility staff, dated 8/29/22 and timed 0700-1900 [7:00 AM - 7:00 PM] author unknown, read in part, . [R15] - noted decline in function, asked PT [physical therapy] to eval. (evaluate)., used . lift today d/t [due to] resident unable to assist up to standing position. Note an increase in edema to LLE [left lower extremity] this am. Review of handwritten notes from communication notebook between facility staff, dated 8/29/22 and timed 3-11[3:00 PM - 11:00 PM] authors RN I and CNA H, read in part, [R15] slight bruise to L [left] ankle, almost feels broken. Limited to no mobility try to keep her off of it and elevated. Very swollen. Did she fall?? Review of facility reported incident summary, dated 8/30/22, read in part, .RN S was called into the locked unit to assess [R15's] leg, left lower extremity swollen (which she does have 2+ edema to that extremity) and bruising noted to ankle, resident was unable to move foot/toes and foot drop noted. RN called physician and order to send out to hospital for evaluation . Review of facility investigation summary, dated 9/7/22, read in part, .CNA [B] - I worked from 3 p.m. to 7 p.m. in the unit on Sunday August 28th. When I came on at 3 p.m. [R15] was in bed. Approximately 4 p.m. I got her out of bed and brought her to the dining room for dinner, per usual. After supper she wheeled herself around in the w/c [wheelchair]. When I left at 7 p.m. she was up sitting in her w/c in the common area. LPN [C] - I was working Sunday August 28th, 3p-7p with the RN [D]. RN [E] was coming in to work 7p-11p. As [RN E] walked past [R15's] room she hollered for some help. It looked like [R15] tried to transfer herself to bed and was sitting on the floor next to her w/c. She was checked over and then she was a 2-person pivot transfer with a gait belt .CNA [F] - I helped resident Monday August 29th with am cares. I did not see any bruises, but she would not put any weight on her legs. She complained of lower leg pain. I notified the LPN [G]. CNA [H] - I worked on Thursday August 25th and [R15] was transferring as normal. I was off Friday, Saturday, and Sunday. I came in on Monday August 29th and saw [R15] sitting in her wheelchair by her room, in the hallway. I asked her to lift her legs so I could move her down to the living room area. She didn't lift them, and I noticed she had a foot pedal on only the left side. I moved her leg onto the foot pedal and wheeled her down. I thought it might have been her blood clots hurting her, as she usually complains of leg pain from that. During supper, she seemed very tired and slumped over. After supper, I asked my nurse [RN I] to check her sugar to see if it was low. It was within normal range. I figured maybe they didn't lay her down after lunch and she was just super tired. I kept her up after supper for an hour, per her care plan. I wheeled her back down to go to bed at about 6:45 p.m. I asked [R15] to stand up to transfer her into bed, but she didn't budge. Usually [R15] will help, at least try to stand up to help pivot transfer into bed. I remember seeing something in the communication book about a previous shift having to use the sit to stand lift on her. CNA [J] - On Tuesday, August 30, 22, I went to 400 wing and clocked in at 2:53 am. [CNA H] was giving me report and said [R15's] ankle was swollen and bruised. I told her I'm going to look at it now, so I'll know if it gets worse. I went and looked at her (L) [left] ankle and it was very bruised, swollen and with deformities in the shape. I got back to the nursing office and told [CNA H], yeah, that looks broke, and [CNA H] agreed. [RN K] was in the office also and I said, [RN K] have you seen that, and [RN K] said Yeah, she'll need an x-ray later when they get in. I kept checking on [R15's]. [RN K] had given her Tylenol around 3 a.m. because I asked [R15] what happened, and she said it hurts. I applied an ice pack around 4 a.m. and that seemed to make her more comfortable. At 7 a.m. I called the Rn, [RN S] to address her ankle first thing. I didn't feel she should stay to wait for an x-ray. Rn came up right away and agreed she should go to hospital . Conclusion: .The fracture did happen, and abuse can be ruled out at this time. There were no other residents in the vicinity of her room at the time. Review of injury of unknown origin witness statement, dated 8/31/22 author RN D, read in part, Date of injury: unknown .Resident was in w/c [wheelchair] sitting next to bed attempting to self-transfer. Was sliding out of w/c so [RN E] asked for assistance and LPN [C] and this writer assisted resident into bed using gait belt and pivot transfer . Review of injury of unknown origin witness statement, dated 8/31/22 author RN E, read in part, Date of injury: unknown .When writer came on shift at 7 P.M., resident was sitting next to bed and was crying in her wheelchair .Writer walked to her office to put lunch and drink in office. When I walked back resident was sliding out of her wheelchair. I called [RN D] and [LPN C] for assistance. We all assisted resident into bed with gait belt and pivot transfer . Note: On the side of this form there was a date that had an arrow and dated 8/28/22 at the beginning of the first sentence. Review of witness statement, dated 8/31/22 author RN I, read in part, On Monday, August 29th, 2022, I was working on the special care unit doing med pass from 3 p.m. to 7 p.m As I was leaving the unit at the end of my shift I was stopped by the CNA, [H] and asked to look at [R15] left leg and foot. I do not care for [R15] regularly and I am unaware of what her baseline ROM [range of motion] and edema levels are. The CNA [H] noted that her foot was droopy and stated she had been dragging it. Some bruising was noted to her mid shin area .I am not overly familiar with orthopedic issues, and I had observed [R15] not using that foot the same as her right in prior passing observations .I was not confident in my assessment skills as I was unfamiliar with [R15] .and asked the CNA [H] to have the oncoming RN [unknown]please assess her . Review of fall witness statement, dated 9/2/22 author CNA F, read in part, Date of fall: 8/29/23 .I helped resident Monday with am cares. I did not see any bruises, but she would not put any weight on her legs. She also complained of lower leg pain. I notified LPN [G]. Facility incident and accident reports for R15 were reviewed for date range 8/1/22 through 9/1/22 and revealed no evidence of a report being completed during that time frame. R15's nursing notes were reviewed for date range 8/13/22 through 8/30/22. There was no documentation of a fall, injury, bruising, pain, mood changes or behaviors, or change in ROM. Review of R15's progress note, dated 8/30/22, read in part, .Left ankle swollen and bruised .[Nurse Practitioner (NP) RR] notified. Review of R15's progress note, date 8/31/23, read in part, Transferred to: acute care hospital .Reason for transfer: Non-fall related in jury: major injury, possible broken left leg . Review of R15's hospital radiology report, dated 8/30/22, read in part, .CT [computerized tomography] LWR [lower] extremity .left .Findings: .Acute mildly comminuted (a bone that is broken in at least two places) fracture of the mid shaft fibula with main butterfly fragment measuring 5.8 cm [centimeters]. Additional comminuted fracture involving the distal fibular shaft with medial displacement of a thin 1.2 cm fragment. Comminuted fracture involving the distal third tibial shaft extending to the metaphysis (lower distal part of the tibia) .Impression: 1. Left lower extremity fractures . Review of R15's discharge summary, date printed 9/1/22, revealed, R15 had been admitted to the hospital on [DATE] and was discharged on 9/1/22, and further review revealed, discharge diagnosis: left ankle fracture, requiring operative fixation at some point .Hospital Course: .09/01/2022: Patient did well postoperatively, She's been able to eat. She is now completely nonweightbearing status post surgery. Orthopedics comments that the patient could lose her leg and her entirety if she tries to walk on this and damages it further . On 7/26/23 at 3:55 PM, an interview was conducted with facility LPN C. LPN C was asked about her witness statement in the facility reported investigation summary and confirmed that R15 was on the floor next to her bed and R15's fall was unwitnessed. Note: No official witness statement was found for LPN C. On 7/26/23 at 4:00 PM, an interview was conducted with the NHA, who confirmed that an incident and accident report should have been filled out on 8/28/22 when R15 fell in her room unwitnessed. The NHA also indicated an assessment should have been completed by the nurse(s) on shift, the incident should have been reported to the State Agency (SA) when the bruise was discovered on 8/29/22 by staff, and R15 should have received medical treatment sooner for an x-ray. The NHA acknowledged a full investigation should have been properly completed with witness statements for all staff working with R15 during that time frame. The NHA confirmed R15 likely did not receive sooner medical treatment related to staff not following the policy for accident and incident facility reporting and the physician should have been notified immediately. Injury of unknown origin facility reported incident dated 4/4/23: Review of facility reported incident summary, dated 4/5/23, read in part, .Resident has been noticed hitting self in the face, right arm and right hand. She has severe intellectual disabilities and has a long history of self-abusive behaviors .MD was in house on 4/4/23 and saw resident. New orders were received to have x-ray done. Report was phoned to the facility at 5 p.m. this evening that resident does have a right wrist nondisplaced fracture. Continual investigation will proceed. Review of facility investigation summary, dated 4/13/23, read in part, .[R15] was noticed to have a large bruise on the top of her right hand/wrist area. This area was noted by the therapy department during treatment. Physician Assistant [PA TT ], .saw the resident and ordered an x-ray of her hand. She was brought to [local hospital name] for x-ray of her hand and wrist. According to the x-ray impression she has a suspected nondisplaced distal radius or ulna fracture. [Staff Q] therapy aide I started to do [R15] ROM on her arms when I seen that her right hand was black and blue. She opened and closed her fingers for me two times. Upon leaving the room I notified the LPN [unknown]. PTA (physical therapy assistant) R On Sunday, April 2, I entered Resident, [R15] room to check mobility bars and perform an assessment. She was lying in bed. I began talking to her and she was holding her right arm up saying ouch. I noticed her right hand was black and blue and swollen. Upon exiting room, the LPN was notified . Conclusion: Fracture did happen; however, it was self-inflicted. We can r/o abuse at this time. Review of handwritten witness statement, dated 3/30/23 author Staff Q, read in part, (Before Lunch). I started to do [R15] ROM on her arms when I seen that her right hand was black and blue. She opened and closed her fingers for me two times. Upon leaving room LPN [unknown] was notified. Review of handwritten witness statement, dated 4/2/23 author PTA R, read in part, .I entered Resident's room, [R15], to check mobility bars and perform an assessment. She was lying in bed, I began talking to her and she was holding her right arm up saying ouch. I noticed her right hand was black and blue and swollen. Upon exiting room LPN [unknown] was notified. Review of R15's radiology report, dated 4/5/23, read in part, .Impression: Suspected nondisplaced distal radius or ulna fracture. Facility incident and accident reports for R15 were reviewed for the date range 3/1/23 through 5/1/23 and revealed no evidence of a report being completed during that time frame. On 7/26/23 at 4:10 PM, an interview was conducted with the NHA, and the NHA confirmed an incident and accident report should have been filled out on 3/30/23 when staff Q discovered a bruise on R15's right hand, an assessment should have been completed by the nurse on shift, and the incident should have been reported to the SA when the bruise was discovered on 3/30/23 by staff. The NHA acknowledged R15 should have received medical treatment sooner for an x-ray and a full investigation should have been properly completed with witness statements for all staff working with R15 during that time frame. The NHA indicated R15 likely did not receive medical treatment sooner related to the lack of an incident and accident report being completed and the physician should have been notified immediately. Review of the Abuse, Neglect and Exploitation policy, reviewed 5/2/23, revealed the following, in part: VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies . within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the policy, Incident/Falls, revised 4/18/22, revealed, Policy: To ensure all required documentation is completed on an incident/fall. Procedure: Incident report completed by nurse at time of fall, bruise, new or worsening behaviors, skin tears, allegations of abuse, and etc Be sure to document Cause, and call Administrator if suspected abuse or imminent threat Notify physician .Incident given to Director of Nursing . Resident #50 (R50) An anonymous complaint was received by the SA on 2/16/23, which revealed R50 sustained a large bruise down her whole leg. There was no explanation [regarding] what happened .[R50] reported 'the big guy picked her up.' The complainant further explained there was no reason for the cause of the bruise provided. Review of R50's MDS assessment, dated 5/16/23, revealed R50 was admitted to the facility on [DATE], with diagnoses including fracture (unspecified), dementia, and urinary tract infection. The assessment revealed R50 required extensive two-person assistance for bed mobility, transfers, dressing, and toileting, and could feed herself with set-up only. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 3/15, which showed R50 had severe cognitive impairment. The sensory assessment revealed R50 had clear speech, was usually understood, was sometimes able to understand others, had no vision impairment and wore hearing aids. Review of R50's nursing note, dated 10/10/22, revealed, .Incident type: Skin tear. Location: Resident's room.Position: Sitting. Mental State: Normal for resident. Activity at the time: in chair. Equipment involved: wheelchair. Injury: skin tear right hand. Body part.: right hand area. 1 cm [centimeters] x 1.2 and .5 x .5. Did resident hit head? No. Pupils: n/a .First aid: Steri strips [applied] after cleansing .cause: bumped on handle. Staff involved: none. Physician notification. Family notification Resident statement: .I don't know, hit on there; I think [it] was in kitchen . Review of R50's nursing note, dated 10/11/22, revealed, .Incident type: Bruise. Location: Resident's room. Wing Location: Wing 500. Resident position other: found while daughter was getting [R50] ready for bed. Mental state: Normal for resident. Activity at the time: In bed. Equipment involved: None. Injury: Moves all extremities. Body part: right hip areas. Length [cm - centimeters]: 6. Width [cm]: 4. Did resident hit head? No. Pupils: n/a. First aid: None needed. Cause other : Undetermined. Staff involved: none. Family member was present. Notification: physician notified. Family notification: family notified. [name of family member]. Actions: continue to observe. Resident: Unable to give a statement. Interventions: n/a. Shift: PM shift. Day of week. Tuesday. Date of incident: Unknown. Time of incident: unknown. During an interview on 7/20/23 at 2:40 p.m., Licensed Practical Nurse (LPN) L was asked about the reported incident on 10/11/22, when R50 sustained a bruise to their right hip. LPN L confirmed they were the nurse working at the time the bruise was initially discovered. LPN L reported it was difficult to recall so many months ago, however recalled there was an allegation a big man picked (R50) up off the floor. LPN L recalled being interviewed as well as three other male staff. None of which observed R50 on the floor, nor had they picked her up off the floor. LPN L recalled R50 said someone picked her up off the kitchen floor, and she had been on a home visit the two days prior to sustaining a skin tear to her right hand, and the bruise being discovered, so there was no way for them to ascertain when the injuries occurred, or how they occurred. When asked if R50 was an accurate reporter, LPN L responded, Sometimes, as she had dementia and sometimes pressed the call light for no apparent reason, and had some confusion, walked without assistance (despite unsafe), took her gripper socks off, etc . LPN L reported abuse was ruled out, and not substantiated. Review of R50's nursing notes dated 10/12/22, 10/13/22, 10/14/22, 10/15/22, 10/17/22, 10/18/22, and 10/19/22 showed no mention of the bruise. Review of R50's 10/16/22 nursing note showed, .bruise to right hip apparent, no swelling . Review of R50's nursing note, dated 10/20/22, at 1:01 a.m., revealed, .General skin condition: Bruise to right hip is very apparent and has increased in size now traveling below the right knee to the middle of her calf, is starting to yellow with no swelling noted at this time. [R50] should possibly have an x-ray performed the next time x-ray is in the facility. Left message with Administrator [initials] and DON [Director of Nursing - initials] regarding this topic to please follow up on. 8:24 a.m.: Action: Physician notified. Orders received, for x-ray of (R - right) hip . Review of R50's nursing noted, dated 10/20/22 at 12:45 p.m., revealed, Writer has been communicating back and forth with DPOA [Durable Power of Attorney] regarding where to get resident's right hip x-ray d/t [due to] worsening bruise. DPOA yelled and accused RN [Registered Nurse] Supervisor [unnamed] of failing to report incident to provider [physician]. DPOA insist resident fell and bruise came from that fall on 10/10/22. Per nurse charting, resident did get skin tear to right hand but there's no evidence that the bruise resulted from the fall. Writer asked DPOA if she or any of our staff saw resident on the floor. DPOA denied it. DPOA accused LPN [initials] of failure to report fall and tried to cover Writer asked DPOA how she was so sure LPN [initials] witnessed the fall. DPOA stated, My mom [R50] told me she fell and [a] big male doctor picked her up. Writer asked DPOA if she has a statement of LPN [initials] admitting he witnessed the fall. DPOA stated, I assume that is [initials] LPN. Who else could it be? Writer attempted to educate DPOA that resident has dementia and for that reason because she cannot make her own medical decision. And nurses cannot take a statement from a dementia patient and write a fall report. DPOA yelled, My mom is not dumb. Writer also notified DPOA that we found the bruise on the 11th and the nurse wrote unknown source of skin injury form, and the reason why we are getting an x-ray today is resident's bruise is spreading to her calf and we just noticed it. Writer tried to reassure DPOA that nurses have been monitoring bruises. DPOA stated, When my mom was hospitalized , they did bone work and she did not have a fracture anywhere. If she has one, she got that from [facility], and hung up [the phone]. Resident was LOA [on a leave of absence] the weekend of 10/8/22 to 10/9/22 with DPOA per staff . Review of R50's right hip x-ray, dated 10/20/22, 2-3 views, with pelvis unilateral right. Dx: Acute pain of hip .possible fall no acute fracture present . Degenerative changes in both hips. Review of notes handwritten and provided by NHA, revealed on 10/20/22 at 3:15 p.m., they became aware of a bruise to R50's right hip/leg. Nurse [unnamed] stated [R50] out with family the weekend prior [on 10/08/22 and 10/09/22] and reported they were never notified of any bruises, only a skin tear. NHA noted family had resident up walking in hallway, with no complaints of pain with walking. It was observed as yellow bruising which continued to weep down leg, which started as a fist size when noticed as 6 [cm] x 4 [cm] on hip, found by daughter. Resident was walking without difficulty. Their notes questioned if when R50 was out with family, she hit her hip on car door, while closing door or possibly getting in vehicle, or the skin tear happening at home in the kitchen .NHA interviewed three male staff and found no falls or incidents of picking up R50 off the floor; resident denied pain. Investigation (internal only) concluded skin tear right hand and bruise right hip likely happened on LOA home two days prior to initial discovery with DPOA. The NHA reported they had no incident report for 10/20/22 large bruise, only their soft file notes, and acknowledged there should have been an incident report and investigation earlier. During an interview on 7/21/23 at 12:55 p.m., Assistant Director of Nursing (ADON) A reported they discovered the incident with the bruise occurred on 10/20/22, and there was no incident report for the event. ADON A confirmed an incident report should have been completed, and they were not working at the facility at the time of the incident. ADON A reported they would have expected to see some blood work done at the time of the incident and confirmed Resident #50 was not on a blood thinner (medication). During an interview on 7/21/23 at 1:33 p.m., the NHA confirmed R50 was not sent out to the hospital for a bruise, no fall was confirmed, and the incident was not reported to the State Agency (SA). The NHA reported there was no investigation and they had not learned of a concern until well after the incident. The NHA was asked for an ER (Emergency Room) report, or any skin assessments of the bruise. The NHA confirmed none were found, as R50 had an internal (in house) x-ray and was not sent to the hospital. The NHA reported they spoke to R50's nurse and interviewed male staff, and no abuse was suspected or found. The NHA confirmed they understood the concern of the incident not being reported. During a phone interview on 7/26/23 at 4:30 p.m., Physician MMM verified they were not made aware of the bruise to R50's hip until 10/20/22, by R50's DPOA, and did not visually observe the bruise until their scheduled visit with R50 on 10/27/22. Physician MMM reported R50 had some hip pain when the incident was reported to them on 10/20/22, and the x-ray was negative. Physician MMM reported by the time of their visit on 10/27/22, the bruise was resolving, the hip pain was resolved, and the bruise was on the right posterior hip, the size of a large orange, and green and yellow in appearance. Physician MMM reported they spoke to the nurse involved, and could not confirm or deny a fall occurred, as none was reported. Physician MMM reported typically the facility would have notified them of a new bruise or injury of unknown origin, and this must have been an oversight. During an interview on 7/26/23 at approximately 3:34 p.m., RN GG confirmed there was no incident report or skin assessment related to the large bruise on R50's right hip described on 10/20/22 in their nursing note. Review of photographs of R50s' bruise, shown to the SA by the anonymous complainant on 7/27/23 at 10:28 a.m., revealed photographs of bruising to R50's right hip and elbow, from the dates 10/12/22 to 10/14/22. On 10/14/22, a large purple bruise was observed covering R50's back of thigh (below the buttocks), which appeared to extend just below the right buttocks crease, down to the back of the knee crease. The large dark purple bruise rounded the thigh on the lateral side. An earlier photograph on 10/12/22 showed it was a diffuse bruise with purple blue speckling on the back of the thigh, the size of a large deck of cards. There was a bruise to the right elbow just above the olecranon (elbow bone), the size of a baseball. The elbow bruise was not earlier reported. The complainant reported they believed R50 had sustained the injuries from a fall, and the incident should have been reported. This deficient practice pertains to Intakes: MI00132367, MI00134358, MI00136498, MI00134726, MI136473 and MI00137019. Based on observation, interview, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the timely reporting of allegations of abuse and injuries of unknown origin for four Residents (R9, R29, R15, and R50) out of 21 residents reviewed for abuse. This deficient practice resulted in the potential for continued abuse for facility residents. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Resident R9 Review of the Facility Reported Incident (FRI), dated 5/1/23, revealed the following, in part: On May 1, 2023, at approximately 5:15 p.m., it was reported to me [Director of Nursing (DON)], by the RN (Registered Nurse) Supervisor, that an aide, [Certified Nurse Aide (CNA) Y], swore at a resident (R9) while trying to pick her up off the floor. A witness reported that while he was trying to get her back into her chair, she heard him (CNA Y) say, 'sh*t and G*d d*mn you' to the resident . Review of R9's Minimum Data Set (MDS) assessment, dated 6/20/23, revealed R9 had active diagnoses that included dementia, Parkinson's disease, anxiety disorder, depression, and schizophrenia. R9 scored 2 of 15 on the Brief Interview for Mental Status reflective of severe cognitive impairment and required extensive two-person assistance with transfers. R9 was documented in the MDS assessment at 65 inches (5 foot 5 inches) tall and weighing 153 pounds. Review of hand-written witness statements provided by facility staff included the following, in part: 1. Activity Aide (Staff) HH: On Monday May 1st at 9:30 a.m. I was writing on the boards (activity boards) when I heard a commotion behind me. I turned around and saw a resident had fallen when a CNA [Y] tried to move her (R9) from the chair into her wheelchair . (CNA Y) caught her by her arms. She was half lying on the ground. He tried to pick her back up and failed which was followed by 'Sh*t, G*d d*mn you.' He did not call for help and when I asked if he needed help his words were, 'I'm fine, she's fine.' I then watched as he tried to lift her again and strugled (sic). The resident cried out in pain as he was trying to lift her. Still not asking for help. He tried again lifting under her arms and got her back in the chair. She was whimpering and sounded in pain. Signed and dated 5/2/23 at 9:42 a.m. Review of Intake MI00136498 revealed the alleged incident was witnessed on 5/1/23 at 9:30 a.m., with the Facility incident report received via online submission on: 5/1/23, 7:25 PM. During an interview on 7/26/23 at 4:30 p.m., the Nursing Home Administrator (NHA) confirmed no facility incident report was completed related to the alleged verbal abuse by CNA Y toward R9. The NHA acknowledged timely reporting of the event to the State Agency (SA) was delayed due to the failure of facility staff to report the alleged abuse. Resident (R29) During an interview on 7/18/23 at 12:07 p.m., Family Member (FM) QQ stated, (R29) hurt his foot about three months ago to the point that they took him to the hospital for an x-ray on it . This was on a Saturday morning, and there are no x-ray people here . On Monday morning they sent him to the hospital for an x-ray . Review of R29's MDS assessment, dated, 4/11/23, revealed R29 had the following active diagnoses, in part: Alzheimer's disease, dementia, anxiety disorder, psychotic disorder and depression. Resident #29 was documented as having severely impaired cognitive skills for daily decision making. R29 required extensive, one-person assistance for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Observation of a photo of R29's bruised, left foot, received via email from FM QQ on 7/18/23, showed nearly the entirety of the top left foot was bruised and swollen. FM included the following in the email: Attached is the photo of [R29's] left foot. The incident happened the morning of March 18, 2023. Not sure how it happened. Review of R29's Progress Notes revealed the following in part: 3/18/23, 11:32 a.m., .Location: resident's room .Injury: Bruise to top of right foot . Cause: other: Unwitnessed . Witnesses: none . Resident Statement: unable to give a statement, Interventions: Staff education, Date of Incident: 03/18/23, Time of Incident: 01:09 PM unknown . 3/18/23 1:37 p.m., left foot not right 3/18/23 1:57 p.m., Party Contact: responsible party [FM QQ] found bruise to left dorsal foot this AM. Writer advised resident to be assessed today at the ED (Emergency Department) since it is highly likely a fracture as evidenced by resident having unilateral +3 edema to left foot, the size of bruise, a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15 (R15) Injury of unknown origin facility reported incident dated 8/30/22: Review of R15's face sheet, dated 8/30/22, reveal R15 was a [AGE] year-old female resident admitted to the facility on [DATE] with medical diagnoses including anxiety, severe intellectual disability, schizophrenia, and diabetes mellitus. Review of handwritten notes from a communication notebook between facility staff, dated 8/28/22 and timed 11p [11:00 PM] author unknown, read in part, [R15] yelled out on and off all night long. Slapped herself a few times. Left foot is hanging weird - she can't put pressure on it. Review of handwritten notes from communication notebook between facility staff, dated 8/28/22 and timed 3-7 [3:00 PM - 7:00 PM] author LPN C, read in part, .tried to transfer self to bed and was sit (sic) on floor next to w/c [wheelchair]. Looked like she [R15] may attempted to transfer into bed but didn't make it. 2-person pivot with gait belt, no grimacing - stood up without issue and pivoted into bed. Note: Indicating RN D and RN E were aware and present at the time. Another note with the same date, read in part, Sitting on w/c and floor. Signed by RN E. Review of handwritten notes from communication notebook between facility staff, dated 8/29/22 and timed 0700-1900 [7:00 AM - 7:00 PM] author unknown, read in part, .[R15] - noted decline in function, asked PT [physical therapy] to eval., used .lift today d/t [due to] resident unable to assist up to standing position. Note an increase in edema to LLE [left lower extremity] this am. Review of handwritten notes from communication notebook between facility staff, dated 8/29/22 and timed 3-11[3:00 PM - 11:00 PM] authors RN I and CNA H, read in part, [R15] slight bruise to L [left] ankle, almost feels broken. Limited to no mobility try to keep her off of it and elevated. Very swollen. Did she fall?? Review of facility reported incident summary, dated 8/30/22, read in part, .RN S was called into the locked unit to assess [R15] leg, left lower extremity swollen (which she does have 2+ edema to that extremity) and bruising noted to ankle, resident was unable to move foot/toes and foot drop noted. RN called physician and order to send out to hospital for evaluation . Review of injury of unknown origin witness statement, dated 8/31/22 author RN D, read in part, Date of injury: unknown .Resident was in w/c [wheelchair] sitting next to bed attempting to self-transfer. Was sliding out of w/c so [RN E] asked for assistance and LPN [C] and this writer assisted resident into bed using gait belt and pivot transfer . Review of injury of unknown origin witness statement, dated 8/31/22 author RN E, read in part, Date of injury: unknown .When writer came on shift at 7PM, resident was sitting next to bed and was crying in her wheelchair .Writer walked to her office to put lunch and drink in office. When I walked back resident was sliding out of her wheelchair. I called [RN D] and [staff C] for assistance. We all assisted resident into bed with gait belt and pivot transfer . Note: On the side of this form there was a date that had an arrow and dated 8/28/22 at the beginning of the first sentence. Review of witness statement, dated 8/31/22 author RN I, read in part, On Monday, August 29th, 2022, I was working on the special care unit doing med pass from 3pm to 7pm. As I was leaving the unit at the end of my shift I was stopped by the CNA, [H] and asked to look at [R15] left leg and foot. I do not care for [R15] regularly and I am unaware of what her baseline ROM [range of motion] and edema levels are. The CNA [H] noted that her foot was droopy and stated she had been dragging it. Some bruising was noted to her mid shin area .I am not overly familiar with orthopedic issues, and I had observed [R15] not using that foot the same as her right in prior passing observations .I was not confident in my assessment skills as I was unfamiliar with [R15] .and asked the CNA [H] to have the oncoming RN [unknown]please assess her . Review of fall witness statement, dated 9/2/22 author CNA F, read in part, Date of fall: 8/29/23 .I helped resident Monday with am cares. I did not see any bruises, but she would not put any weight on her legs. She also complained of lower leg pain. I notified LPN [G]. Facility incident and accident reports were reviewed, the date range 8/1/22 through 9/1/22, for R15 and revealed, no evidence of a report being completed during that time frame. R15's nursing notes were reviewed, the date range 8/13/22 through 8/30/22. There was no documentation of a fall, injury, bruising, pain, mood changes or behaviors, or change in ROM. Review of R15's progress note, dated 8/30/22, read in part, .Left ankle swollen and bruised .[Nurse Practitioner (NP) RR] notified. Review of R15's progress note, date 8/31/23, read in part, Transferred to: acute care hospital .Reason for transfer: Non-fall related in jury: major injury, possible broken left leg . Review of R15's hospital radiology report, dated 8/30/22, read in part, .CT [computerized tomography] LWR [lower] extremity .left .Findings: .Acute mildly comminuted (a bone that is broken in at least two places) fracture of the mid shaft fibula with main butterfly fragment measuring 5.8 cm [centimeters]. Additional comminuted fracture involving the distal fibular shaft with medial displacement of a thin 1.2 cm fragment. Comminuted fracture involving the distal third tibial shaft extending to the metaphysis (lower distal part of the tibia) .Impression: 1. Left lower extremity fractures . Review of R15's discharge summary, date printed 9/1/22, revealed, R15 had been admitted to the hospital on [DATE] and was discharged on 9/1/22, and further review revealed, discharge diagnosis: left ankle fracture, requiring operative fixation at some point .Hospital Course: .09/01/2022: Patient did well postoperatively, She's been able to eat. She is now completely nonweightbearing status post surgery. Orthopedics comments that the patient could lose her leg and her entirety if she tries to walk on this and damages it further . On 7/26/23 at 3:55 PM, an interview was conducted with facility LPN C. LPN C was asked about her witness statement in the facility reported investigation summary and confirmed that R15 was on the floor next to her bed and R15's fall was unwitnessed. Note: No official witness statement was found for LPN C. Injury of unknown origin facility reported incident dated 4/4/23: Review of facility reported incident summary, dated 4/5/23, read in part, .Resident has been noticed hitting self in the face, right arm and right hand. She has severe intellectual disabilities and has a long history of self-abusive behaviors .MD was in house on 4/4/23 and saw resident. New orders were received to have x-ray done. Report was phoned to the facility at 5pm this evening that resident does have a right wrist nondisplaced fracture. Continual investigation will proceed. Review of handwritten witness statement, dated 3/30/23 author Staff Q, read in part, (Before Lunch). I started to do [R15] ROM on her arms when I seen that her right hand was black and blue. She opened and closed her fingers for me two times. Upon leaving room LPN [unknown] was notified. Review of handwritten witness statement, dated 4/2/23 author PTA R, read in part, .I entered Resident's room, [R15], to check mobility bars and perform an assessment. She was lying in bed, I began talking to her and she was holding her right arm up saying ouch. I noticed her right hand was black and blue and swollen. Upon exiting room LPN [unknown] was notified. Review of R15's radiology report, dated 4/5/23, read in part, .Impression: Suspected nondisplaced distal radius or ulna fracture. Facility incident and accident reports were reviewed, the date range 3/1/23 through 5/1/23, for R15 and revealed, no evidence of a report being completed during that time frame. On 7/26/23 at 4:10 PM, an interview was conducted with the NHA, and the NHA confirmed that an incident and accident report should have been filled out on 3/30/23 when staff Q discovered a bruise on R15's right hand, an assessment should have been completed by the nurse on shift, and the incident should have been reported to the SA when the bruise was discovered on 3/30/23 by staff. The NHA acknowledged and R15 should have received medical treatment sooner for an x-ray and a full investigation should have been properly completed with witness statements for all staff working with R15 during that time frame. The NHA indicated R15 likely did not receive medical treatment sooner related to the lack of an incident and accident report being completed and the physician should have been notified immediately. Review of the Abuse, Neglect and Exploitation policy, reviewed 5/2/23, revealed the following, in part: V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation . 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation . Review of the policy, Abuse Prevention and Procedure, reviewed 08/12/2020, revealed, It is the policy of [facility] to maintain an environment free of abuse and neglect .Injury of Unknown Source: an injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person, or the source of the injury could not be explained by the residents, and the injury is suspicious because of the extent of the injury or the location of the injury (i.e . the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time .Identification: Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse, and to determine the direction of the investigation .The facility will identify and investigate all suspicions of allegations of abuse such as suspicious bruising of residents, unusual occurrences . Resident #50 (R50) An anonymous complaint was received by the State Agency (SA) on 2/16/23, which revealed R50 sustained a large bruise down her whole leg. There was no explanation [regarding] what happened .[R50] reported 'the big guy picked her up.' The complainant further explained there was no reason for the cause of the bruise provided. Review of the Minimum Data Set (MDS) assessment, dated 5/16/23, revealed R50 was admitted to the facility on [DATE], with diagnoses including fracture (unspecified), dementia, and urinary tract infection. The assessment revealed R50 required extensive two-person assistance for bed mobility, transfers, dressing, and toileting, and could feed herself with set-up only. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 3/15, which showed R50 had severe cognitive impairment. The sensory assessment revealed R50 had clear speech, was usually understood, was sometimes able to understand others, had no vision impairment and wore hearing aids. Review of R50's nursing note, dated 10/10/22, revealed, .Incident type: Skin tear. Location: (R50's) room.Position: Sitting. Mental State: Normal for resident. Activity at the time: in chair. Equipment involved: wheelchair. Injury: skin tear right hand. Body part.: right hand area. 1 cm [centimeters] x 1.2 and .5 x .5. Did resident hit head? No. Pupils: n/a (not applicable) . First aid: Steri strips [applied] after cleansing .cause: bumped on handle. Staff involved: none. Physician notification. Family notification Resident statement: .I don't know, hit on there; I think [it] was in kitchen . Review of R50's nursing note, dated 10/11/22, revealed, .Incident type: Bruise. Location: Resident's room. Wing Location: Wing 500. Resident position other: found while daughter was getting [R50] ready for bed. Mental state: Normal for resident. Activity at the time: In bed. Equipment involved: None. Injury: Moves all extremities. Body part: right hip areas. Length [cm]: 6. Width [cm]: 4. Did resident hit head? No. Pupils: n/a. First aid: None needed. Cause other : Undetermined. Staff involved: none. Family member was present. Notification: physician notified. Family notification: family notified. [name of family member]. Actions: continue to observe. Resident: Unable to give a statement. Interventions: n/a. Shift: PM (afternoon) shift. Day of week. Tuesday. Date of incident: Unknown. Time of incident: unknown. During an interview on 7/20/23 at 2:40 p.m., Licensed Practical Nurse (LPN) L was asked about the reported incident on 10/11/22, when Resident #50 sustained a bruise to their right hip. LPN L confirmed they were the nurse working at the time the bruise was initially discovered. LPN L reported it was difficult to recall so many months ago, however recalled there was an allegation a big man picked (R50) up off the floor. LPN L recalled being interviewed as well as three other male staff. None of which observed R50 on the floor, nor had they picked her up off the floor. LPN L recalled R50 said someone picked her up off the kitchen floor, and she had been on a home visit the two days prior to sustaining a skin tear to her right hand, and the bruise being discovered, so there was no way for them to ascertain when the injuries occurred, or how they occurred. When asked if R50 was an accurate reporter, LPN L responded, Sometimes, as she had dementia and sometimes pressed the call light for no apparent reason, and had some confusion, walked without assistance (despite unsafe), took her gripper socks off, etc . LPN L reported abuse was ruled out, and not substantiated. Review of R50's nursing notes dated 10/12/22, 10/13/22, 10/14/22, 10/15/22, 10/17/22, 10/18/22, and 10/19/22 showed no mention of the bruise. Review of R50's 10/16/22 nursing note showed, .bruise to right hip apparent, no swelling . Review of R50's nursing note, dated 10/20/22, at 1:01 a.m., revealed, .General skin condition: Bruise to right hip is very apparent and has increased in size now traveling below the right knee to the middle of her calf, is starting to yellow with no swelling noted at this time. [R50] should possibly have an x-ray performed the next time x-ray is in the facility. Left message with Administrator . and DON . regarding this topic to please follow up on. 8:24 a.m.: Action: Physician notified. Orders received, for x-ray of (R - right) hip . Review of R50's nursing noted, dated 10/20/22 at 12:45 p.m., revealed, Writer has been communicating back and forth with DPOA [Durable Power of Attorney] regarding where to get resident's right hip x-ray d/t [due to] worsening bruise. DPOA yelled and accused RN [Registered Nurse] Supervisor [unnamed] of failing to report incident to provider [physician]. DPOA insist resident fell and bruise came from that fall on 10/10/22. Per nurse charting, resident did get skin tear to right hand but there's no evidence that the bruise resulted from the fall. Writer asked DPOA if she or any of our staff saw resident on the floor. DPOA denied it. DPOA accused LPN [initials] of failure to report fall and tried to cover Writer asked DPOA how she was so sure LPN [initials] witnessed the fall. DPOA stated, My mom [R50] told me she fell and [a] bit male doctor picked her up. Writer asked DPOA if she has a statement of LPN [initials] admitting he witnessed the fall. DPOA stated, I assume that is [initials] LPN. Who else could it be? Writer attempted to educate DPOA that resident has dementia and for that reason because she cannot make her own medical decision. And nurses cannot take a statement form a dementia patient and write a fall report. DPOA yelled, My mom is not dumb. Writer also notified DPOA that we found the bruise on the 11th and the nurse wrote unknown source of skin injury form, and the reason why we are getting an x-ray today is resident's bruise is spreading to her calf and we just noticed it. Writer tried to reassure DPOA that nurses have been monitoring bruises. DPOA stated, When my mom was hospitalized , they did bone work and she did not have a fracture anywhere. If she has one, she got that from [facility], and hung up [the phone]. Resident was LOA [on a leave of absence] the weekend of 10/8/22 to 10/9/22 with DPOA per staff . Review of R50's right hip x-ray, dated 10/20/22, 2-3 views, with pelvis unilateral right. Dx: Acute pain of hip .possible fall no acute fracture present . Degenerative changes in both hips. Review of notes handwritten and provided by the NHA, revealed on 10/20/22 at 3:15 p.m., they became aware of a bruise to R50's right hip/leg. Nurse [unnamed] stated [R50] out with family the weekend prior [on 10/08/22 and 10/09/22] and reported they were never notified of any bruises, only a skin tear. NHA noted family had resident up walking in hallway, with no complaints of pain with walking. It was observed as yellow bruising which continued to weep down leg, which started as a fist size when noticed as 6 [cm] x 4 [cm] on hip, found by daughter. Resident was walking without difficulty. Their notes questioned if when R50 was out with family, she hit her hip on car door, while closing door or possibly getting in vehicle, or the skin tear happening at home in the kitchen .NHA interviewed three male staff and found no falls or incidents of picking up R50 off the floor; resident denied pain. Investigation (internal only) concluded skin tear right hand and bruise right hip likely happened on LOA home two days prior to initial discovery with DPOA. The NHA reported they had no incident report for 10/20/22 large bruise, only their soft file notes, and acknowledged there should have been an incident report and investigation earlier. During an interview on 7/21/23 at 12:55 p.m., Assistant Director of Nursing (ADON) A reported they discovered the incident with the bruise for R50 occurred on 10/20/22, and there was no incident report for the event. ADON A confirmed an incident report should have been completed, and they were not working at the facility at the time of the incident. ADON A reported they would have expected to see some bloodwork done at that time of the incident. During an interview on 7/21/23 at 1:33 p.m., the NHA confirmed R50 was not sent out to the hospital for a bruise, no fall was confirmed, and the incident was not reported to the SA. The NHA reported there was no investigation and they had not learned of a concern until well after the incident. The NHA was asked for an ER (Emergency Room) report, or any skin assessments of the bruise. The NHA confirmed none were found, as R50 had an internal (in house) x-ray and was not sent to the hospital. The NHA reported they spoke to R50's nurse and interviewed male staff, and no abuse was suspected or found. The NHA confirmed they understood the concern regarding the incident not being investigated timely. During a phone interview on 07/26/23 at 4:30 p.m., Physician MMM verified they were not made aware of the bruise to R50's hip until 10/20/22, by R50's DPOA, and did not visually observe the bruise until their scheduled visit with R50 on 10/27/22. Physician MMM reported R50 had some hip pain when the incident was reported to them on 10/20/22, and the x-ray was negative. Physician MMM reported by the time of their visit on 10/27/22, the bruise was resolving, the hip pain was resolved, and the bruise was on the right posterior hip, the size of a large orange, and green and yellow in appearance. Physician MMM reported they spoke to the nurse involved, and could not confirm or deny a fall occurred, as none was reported. Physician MMM reported typically the facility would have notified them of a new bruise or injury of unknown origin, and this must have been an oversight. Physician MMM clarified by the time they saw the bruise it was resolving. During an interview on 7/26/23 at approximately 3:34 p.m., RN GG confirmed there was no incident report or skin assessment related to the large bruise on R50's right hip described on 10/20/22 in their nursing note. Review of photographs of R50s' bruise, shown to the Surveyor by the anonymous complainant on 7/27/23 at 10:28 a.m., revealed photographs of bruising to R50's right hip and elbow, from the dates 10/12/22 to 10/14/22. On 10/14/22, a large purple bruise was observed covering R50's back of thigh (below the buttocks), which appeared to extend just below the right buttocks crease, down to the back of the knee crease. The large dark purple bruise rounded the thigh on the lateral side. An earlier photograph on 10/12/22 showed it was a diffuse bruise with purple blue speckling on the back of the thigh, the size of a large deck of cards. There was a bruise to the right elbow just above the olecranon (elbow bone), the size of a baseball. The elbow bruise was not earlier reported. The complainant reported they believed R50 had sustained the injuries from a fall, and the incident should have been fully investigated.This deficient practice pertains to Intakes: MI00132367, MI00134358, MI00136498, MI00134726, MI136473 and MI00137019. Based on observation, interview, and record review, the facility failed to ensure thorough investigations were completed for allegations of abuse including injuries of unknown origin for four Residents (R9, R29, R15, and R50) out of 21 residents reviewed for abuse. This deficient practice resulted in the potential for continuation of abuse. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Resident R9 Review of the Facility Reported Incident (FRI), dated 5/1/23, revealed the following, in part: On May 1, 2023, at approximately 5:15pm, it was reported to me [Director of Nursing (DON)], by the RN (Registered Nurse) Supervisor, that an aide, [Certified Nurse Aide (CNA) Y], swore at a resident while trying to pick (R9) up off the floor. A witness reported that while (CNA Y) was trying to get (R9) back into her chair, she heard (CNA Y) say, 'sh*t and G*d d*mn you' to the resident . Review of the facility investigation file for the above incident found no witness statement from the alleged perpetrator, CNA Y. During an interview on 7/26/23 at 4:30 p.m., the Nursing Home Administrator (NHA) confirmed no facility incident report was completed related to the alleged verbal abuse by CNA Y toward R9, and acknowledged a complete, and thorough investigation was not completed. Resident (R29) During an interview on 7/18/23 at 12:07 p.m., Family Member (FM) QQ stated, (R29) hurt his foot about three months ago to the point that they took him to the hospital for an x-ray on it . Observation of a photo of R29's bruised, left foot, received via email from FM QQ on 7/18/23, showed nearly the entirety of the top left foot was bruised and swollen. FM included the following in the email: Attached is the photo of [R29's] left foot. The incident happened the morning of March 18, 2023. Not sure how it happened. Review of R29's Progress Notes revealed the following in part: 3/18/23, 11:32 a.m., .Location: resident's room .Injury: Bruise to top of right foot . Cause: other: Unwitnessed . Witnesses: none . Resident Statement: unable to give a statement, Interventions: Staff education, Date of Incident: 03/18/23, Time of Incident: 01:09 PM unknown . 3/18/23 1:37 p.m., left foot not right During an interview on 7/26/23 at 4:30 p.m., the NHA confirmed the facility had not completed a thorough investigation related to R29's injury of unknown origin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency pertains to Intake MI00132367. Based on observation, interview, and record review, the facility failed to ensure facility staff were trained and knowledgeable of the location of Cardiopulmonary Resuscitation (CPR) equipment for basic life support for residents with a full-code status. This deficient practice resulted in the potential for the delay or inability to perform CPR as a life-saving measure for facility residents. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. During a telephone interview on [DATE] at approximately 8:00 p.m., Confidential Staff CCC was asked about CPR equipment in the facility. Staff CCC stated, We don't have emergency crash carts, but I am pretty sure they bought some and they have been sitting in the basement for some time. We don't have any crash carts on the floor. All of our (CPR and emergency supply) stuff is really spread out about the building. I don't even know if we have a code policy. We have our oxygen tanks; they are at the end of the 300 and 600 halls at the very furthest point of the hall. In our Supply room we have our (non) rebreathers (oxygen masks for emergency use), and our back plates (back boards) on the second floor. Get off the elevator and you head to the unit there is a door right next to the unit door - the back board, rebreather, and (bag valve mask) are in that room, and . in the supply room behind the fish tank . Then if you are doing a code - the AED (automated external defibrillator) machine is in the front entranceway - so then you have to run down and get the AED machine. During an interview on [DATE] at 10:00 a.m., Assistant Director of Nursing (ADON) A was asked where the emergency CPR supplies were in the facility. ADON A said the facility had ordered and received crash carts which were now in the sub-basement which was inaccessible due to a remodel. ADON A stated, We have the crash carts, but we have not set them up because we did not have the AED's. When asked where the oxygen rooms were, ADON A stated, Off the top of my head I don't know where they (oxygen supplies) are. I know there is one on each floor . When asked for the location of the rebreathers ADON A said they were downstairs in the basements supply room . ADON A stated, I don't know where the supply room is. I was given a tour and I haven't had to use it. Back boards are attached to the crash carts in the basement that are not assembled but there is a backboard and oxygen tank on each one, and a suction and an AED - there are two carts one for each floor. ADON A said there was one (AED) on this (first) floor - I believe it is down by the [Name] entrance. I believe it is ours that we got a grant for . During an interview on [DATE] 10:11 a.m., Registered Nurse (RN)/Minimum Data Set (MDS) assessment Coordinator BB was asked where the AED machine was located. RN BB stated, At the nurses station? When asked where at the nurse's station the AED was located RN BB stated, I don't know to be honest with you. To be honest with you I didn't think we have them in the building yet. I know they were on order. Our crash carts they were downstairs in the subbasement . They were waiting until all the supplies came. RN BB did not know the location of the oxygen room on either floor, and said she thought the rebreathers were in Central Supply in the basement, but she would have to go and look in central supply to be sure. RN BB confirmed if the rebreathers were in central supply, they would not be accessible on night shift . RN BB said They (AED's) are on backorder. When asked about the backboard RN BB stated, Not knowing that, I would have to find out and let you know later. Nursing staff are not allowed in the subbasement (where the newly acquired crash carts were being set up). They are doing the flooring and we did not know that the flooring was being done. During an interview with RN/Unit Manager Z and the Nursing Home Administrator (NHA) on [DATE] at 10:26 a.m., both were asked for the location and accessibility of emergency CPR supplies. RN Z stated, . The crash carts are in the sub-basement getting set up. There is stuff on back order right now . The NHA confirmed not all Certified Nurse Aides (CNAs) were CPR certified . Observation of the first-floor oxygen room with RN C on [DATE] at 1:59 p.m., found a sign reading: This 15-liter (L) tank (with 15 L regulator) is for Full Code CPR Use Only - Not for Regular Use. RN C confirmed there was no 15 L tank in the oxygen room for emergency use. Observation of the first-floor clean utility room found a backboard and a bag valve mask (emergency breathing assistance device) with instructions that included the following: Send someone to grab 15 L portable O2 (oxygen) from the oxygen storage room at the end of 300 hall covered with a red bag. Send someone to Get AED/Defibrillator from ambulance entrance. RN C confirmed the AED could be taken by community first responders, paramedics, and ambulance service; whoever needed it, (AED) and it was not always available for facility use. RN C also agreed the instructions would have not been able to be followed as the previous observation found the oxygen room without a 15 L oxygen tank. During an interview on [DATE] at 2:03 p.m., ADON A confirmed she was aware that the Transport Driver and the Transport Attendant were not CPR certified as required by their facility policy. ADON A stated, That is why I said I think we are going to certify everyone (all staff). We are going to have our one driver, who is CPR certified . and a CPR certified CNA . helping with transport. One of our maintenance guys will also be helping with transports. We are going to work to ensure that somebody that is CPR certified is on those (transport) runs. During an interview on [DATE] at 9:25 a.m., nursing (Confidential Nurse) PP confirmed they did not know where the AED or rebreather was located, did not know what to do if they had a code or where to get emergency supplies. Review of the [Facility] Cardiopulmonary Resuscitation (CPR) policy, reviewed [DATE], revealed the following, in part: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR) . CPR certified staff will be available at all times. Staff will maintain current CPR certification for healthcare providers through a CPR provide who evaluates proper technique through in-person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable. Review of the Van Attendant Job Description, dated [DATE], revealed the following, in part: Qualifications: Must be at least [AGE] years of age, current Michigan Certified Nursing Assistant and CPR certified ([Facility] will certify) . Review of the Van Driver Job Description, dated [DATE], revealed the following, in part: Qualifications: Must be at least [AGE] years of age, current CPR-certified ([Facility will certify) . Review of the CPR certification status for two Van Drivers and two Van Attendants revealed that only Van Driver GGG was CPR certified. Neither of the two Van Attendants were current on their CPR certification. When Van Driver NNN, who was not CPR certified, was driving the van, no facility staff on the van were CPR certified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #9 (R9) On 7/20/23 at 8:20 AM, an observation was made on the 600 hall of Certified Nurse Aide (CNA) VV assisting R9 in her wheelchair. CNA VV was pushing R9 down the 600 hall from room [ROOM NUMBER] down to the nursing station area (approximately 50 feet in distance). R9's feet were dragging on the floor below her as she sat in her wheelchair. CNA seen Surveyor witness R9 being pushed without foot pedals and immediately went to R9's room [room [ROOM NUMBER]] retrieved the foot pedals and placed them on R9's wheelchair. Review of R9's care plan, date printed 7/21/23, read in part, .I can't complete my cares on my own and need assistance of one to two staff to help me with my activities of daily living .I need my aides to .Whenever needed, use a regular wheelchair (one with a cushion, slip pads and foot pedals) . Resident #268 (R268) On 7/20/23 at 9:38 AM, an observation was made of the 600 hall of CNA VV assisting R268 in her wheelchair. CNA VV was observed pushing R268 on the 600 hall from room [ROOM NUMBER] to room [ROOM NUMBER] (approximately 40 feet in distance). R268's feet were dangling just above the floor surface. CNA seen this Surveyor witness R268 being pushed without foot pedals and immediately put the foot pedals on R268's wheelchair after she got into room [ROOM NUMBER]. Review of R268's care plan, date printed 7/21/23, read in part, .I need help minimizing safety risks .I need my aides to .use safety devices . On 7/22/23 at 10:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON confirmed that anytime a resident is not self-propelling on their own and staff are assisting them with propelling foot pedals are to be used during that time. This citation pertains to intakes: MI00132367, MI00136124, and MI00137175. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance devices to prevent elopement and potential accidents for four Residents (R9, R45, R58 and R268) of 17 residents reviewed for accidents and supervision. This deficient practice resulted in: 1. Resident #58 (R58) exiting the building, falling, and re-entering without facility knowledge, 2. A potential for falls from a transport vehicle for Resident #45 (R45) and 3. A potential for injury while being pushed in a wheelchair without foot pedals for Resident #9 (R9) and Resident #268 (R268). Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. R58 According to the electronic medical record (EMR), R58 was admitted to the facility on [DATE], with a primary diagnosis of Alzheimer's disease. A review of the Minimum Data Set (MDS) assessment for R58, with a reference date of 1/4/23 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated R58 had severe cognitive impairment. The EMR contained a home assessment dated [DATE] (prior to admission). The information on this assessment was taken from discussion with the family and included R58 would leave his house to watch the family work the farm fields behind the house and to tend to his chickens at the light of day. The family had placed a safety device on R58 to be able to find him if he wandered from home and fell. The EMR contained an outpatient medical Pre-admittance physical for long-term care placement assessment dated [DATE] which read in part: Chief complaint: Worsening dementia. Pt (patient) attempting to wonder (sic) during the night. Plan: Patient will be admitted to [Facility name/location] on 12/29/22. He is here today with son [name]. (Son) tells me that his father's dementia has been getting worse. (R58) has been attempting to leave his home at different hours during the night. His son tells me that they have alarms on all the doors and his father wears a wandering bracelet. (Son) feels that caring for his dad at home is getting to be 'too much'. The EMR included an ELOPEMENT RISK ASSESSMENT dated 12/29/22 at 4:18 PM for R58. This assessment revealed R58 had a total score of 12 with a conclusion Resident is at risk of elopement. A Facility Reported Incident dated as initially submitted 12/30/23, read in part: .Date of incident 12/30/22 Time of incident 255PM On 12/30/22 (R58) was seen talking to two male visitors at the nurse's station with his jacket and hat on. Review of our inside cameras confirmed that (R58) got onto the elevator with the two male visitors. Review of our outside cameras confirmed resident going out the door by the ambulance entrance and was outside for a total of 6 minutes when resident came back in the same door he exited on his own. During an interview and review of still shots of the video footage with facility Maintenance department leadership on 07/20/23 at 3:10 PM, Staff SS and Staff X confirmed R58 entered the elevator and exited out the door at 3:01:02 PM on 12/30/22. They also confirmed R58 re-entered the building after walking on the grounds for 6 minutes. Evidence showed R58 left on his own accord and walked along the building unsupervised. Evidence showed R58 on the sidewalk on the ground and then he got up and returned to the door he exited from. He pushed the door open and entered. The outside cameras were able to capture the entire event. During an interview, review of still shots of the video footage and timeline of the event on 07/20/23 at 03:26 PM, the Nursing Home Administrator (NHA) stated the facility . didn't know (R58) was gone. A review of the elopement investigation dated 1/10/23 for R58 included a summary of the incident which read in part: Resident did exit the facility unsupervised as evidenced by the pictures from our cameras with time stamps. Resident was dressed in a flannel shirt with a t-shirt under it, [brand name] work pants, socks, shoes a coat and a hat. The temperature outside was 36 degrees with no precipitation, no wind and cloudy. Resident had a temp of 96.8 upon reentry which is his baseline. He was outside for 6 minutes on initial report it was thought to be less than 14 minutes. Resident was seen on camera exiting the door at 1501 (3:01 PM) and re-entering at 1507 (3:07 PM), never leaving the premises, did fall as he had reported with his only injury being an abrasion to his right knee, and resident returned into the facility using the door he exited out of on his own . The nursing assessment of R58 after the incident dated 12/30/22 at 5:26 PM, included RESIDENT STATEMENT: Resident states, I was just going to check the trailers, then I fell on the ice. INJURY: no complaints of pain moves all extremities small scrape to right knee. The incident investigation witness statements included staff members reporting a visitor brought R58 back into the building. However, video footage shots reveal R58 pushing the entrance door open unaccompanied, and pictured is a visitor on the telephone at the building entrance with his back to the door and to R58. The investigation included a Visitor statement in which the visitor reported he asked R58 who he was, and he questioned if R58 should be outside. (No audio was available to confirm.) No Care Plan was developed to include the risks, goals, and approaches to prevent R58 elopement behavior until 1/2/23. During a phone interview on 07/21/23 at 9:18 AM, Family Member (FM) UU stated the family was informed of R58's elopement. FM UU said He (R58) had been in the facility a very short time and watched out the window and figured out how to get out of there. He watched others and stood by visitors. After putting on his hat and coat, he got in the elevator with the visitors. When asked if the facility should have put his dad on the dementia unit upon admission, FM UU replied, Oh no. We wanted him in the room he was admitted to. We did not want him on the dementia/locked unit as we had heard stories of other bad nursing homes .They (the facility staff) did move him after he got out and we like the dementia unit and feel it is fine, but we did not want him there at first . The facility Elopement Policy dated 6/30/2019 read in part: Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans . Definitions: for the purpose of this policy, 'missing resident' shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility . Resident (R45) Review of Complaint Intake MI00137175 revealed the following, in part: I was in the facility visiting a resident on [Specific Date and Time in April 2023]. I just happened to stand up and take a walk to look out the window and the images above are what I saw. I don't know what standard procedures are for things like this, but I do know that this must not be the proper way to be doing this as that is a handicap ramp for a wheelchair. The man holding her has one hand holding a folder and looks like a coffee mug, so he isn't even holding onto this woman well. A staff member walked by as this was happening . The staff member stated that this resident's name shown in these pictures is [Resident (R45)] . I cannot imagine them hauling anyone like this, let alone this poor woman who is visibly scared in these photos that she could fall . Observation of three photographs provided by an anonymous complainant related to Complaint Intake #MI00137175, Picture 1 showed Certified Nurse Aide (CNA)/Van Attendant (Staff) Y's exit from the back wheelchair lift with an unidentified Resident, standing without a walker, wheelchair, or gait belt visible in the photo. Staff Y had a folder and a cup both held in his left hand with his right arm not visible, but presumptively behind the resident. The wheelchair lift was elevated to the height of the van floor. The resident appeared to be grabbing the hands of the van driver for stability, and both Staff Y and the resident were standing on the wheelchair lift. Observation of Picture 2 showed a similar photo, with the resident only being supported by the unidentified van driver with one hand. Observation of Picture 3 showed the van wheelchair lift in a slightly lower position (apparently lowered while the resident and van attendant were standing on the lift). The resident was turned right, facing the van driver with both hands on the driver. The resident's body was hunched over, as she appeared unstable and at risk of falling, holding on to the van driver who was positioned on the ground. Staff Y continued to stand with his right arm now positioned around the right side of the resident as she is turned sideways on the wheelchair lift. Staff Y had the cup and folder still in his left hand, and no gait belt was visible on the resident. Staff Y appeared slightly bent at the waist as if trying to support the resident with his right arm around her waist. Review of R45's MDS assessment, dated 4/23/23, revealed R45 was admitted to the facility with the following active diagnoses: stroke, non-Alzheimer's dementia, and hemiplegia (paralysis of one side of the body). R45 scored 5 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment, and required one-person supervision for ambulation in the corridor, and extensive one-person assistance with transfers. Review of R45's Care Plans revealed the following, in part: 4/19/23 . use safety devices . I walk with the help of 1 person limited to extensive staff assistance depending on my ability. I use a front-wheeled walker . On 7/18/23 at 12:25 p.m., the transportation van was observed as it backed up to the facility entrance doors on the basement level of the facility. Observation was from a resident room window, with full view of back (wheelchair) entrance and exit of the van. The back doors opened, and the wheelchair lift was at the level of the van floor. Staff Y pushed a woman in a wheelchair out of the van onto the raised lift but pushing on the wheelchair armrests. Staff Y then stood on the wheelchair lift and accompanied the resident sitting in the wheelchair to the ground. Staff Y stepped off the wheelchair lift and went to the side of the wheelchair lift closest to the building, and used the wheelchair handles to pull the resident off the wheelchair lift onto the ground. During an interview on 7/18/23 at 12:31 p.m., Staff Y confirmed the person to his right in the three photos was R45. When asked how ambulatory residents are transported in the van, Staff Y stated, If they (residents) walk, they used to take a step stool and they would step on a stool and they would walk up (on the passenger side of the van). I would rather not have them do that. I would rather have them go up on the (wheelchair) lift. I would agree the lift in the back of the van is a wheelchair lift. If they are ambulatory using the side of the van for residents is like walking up stairs. When asked how residents that could not walk upstairs were transported, Staff Y said they should be put in a wheelchair. Staff Y stated, I would never hold on to something different like a cup of coffee and a paper when assisting an ambulatory resident out of the van by standing on the wheelchair lift. I do not use a gait belt. They should be in a wheelchair if they can't walk up the steps. Staff Y continued to repeat his way was the best way. Staff Y appeared agitated and spoke quickly. During an interview on 7/18/23 at 2:44 p.m., Maintenance Director (Staff) X reviewed the photos and confirmed Staff GGG was the van driver, Staff Y was the van attendant, and R45 was the resident being assisted on the transport van in the photos. When asked about use of the wheelchair lift for resident transport, Staff X said the Activity department staff were trained, as well as the Transporters. When asked how an ambulatory resident would enter and/or exit the transportation van, Staff X stated, An ambulatory resident; they have a gait belt and there is a bar in the van and the helper or CNA person helps, and the Residents walk up the steps on the side (passenger side of the van). An ambulatory (resident) should not be coming off the wheelchair lift. The wheelchair lift is not designed for that . There should always be a gait belt going (placed) on ambulatory residents. That is a nursing policy. There would be some trouble if they were riding the lift. The CNA (or transport attendant) will never ride with the resident (on the wheelchair lift). When asked if he would be surprised if staff were riding the wheelchair lift, Staff X stated, I would be, if that was happening, because they are not trained to operate the lifts like that. They push them from the inside of the van (to exit), the handles are towards the door on the back of the van - otherwise the resident would be riding backwards and who would want to be riding backward in the van. One person is pushed in, pushed out. No staff ride the van (wheelchair) lift . Review of the [Name Brand] Public Use Wheelchair Lifts Operator's Manual, dated March 2010, revealed the following instructions, in part: . Lift Operation Safety: WARNING: Whenever a wheelchair passenger (or standee is on the platform, the: . Passenger should grip both handrails (if able) . Operation Notes and Details . Standees should stand in the center of the platform . The lift attendant (operator) should not ride on the platform with the passenger . Review of the Safe Resident Handling/Transfers policy, copyright 2022, revealed the following, in part: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines . Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure expired medications were removed from one medication cart out of four medication carts and one medication storage room out of three medication storage rooms reviewed for medication storage. This deficient practice resulted in the administration of expired insulin, the potential for decrease in potency of insulin, and medication errors. Finding include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. On 7/20/23 at 7:45 AM, an observation was made of the 500/600 hall medication cart. The 500/600 medication cart was found to have the following expired medications: a. Insulin lispro 100u (unit)/ml (milliliters), date opened 6/28/23 and expired date 7/19/23, and belonged to Resident #5 (R5); b. Insulin lispro 100u /ml, date opened 6/17/23 and expired date 7/15/23, and belonged to Resident 15 (R15); c. Insulin glargine 100u /ml, date opened 6/29/23 and expired date 7/20/23, and belonged to Resident #64 (R64) and Insulin lispro 100u (unit)/ml (milliliters), date opened 6/29/23 and expired date 7/20/23, and belonged to Resident #64 (R64); d. One loose pink round pill was observed in the base of the second draw on the left side of the medication cart and identified as clopidogrel bisulfate (blood thinner) 75 mg (milligrams). An observation was made on 7/20/23 at 8:25 AM, of the second-floor medication storage room. The second-floor medication storage room was found to have the following expired medications and biologicals: a. One vial of tuberculin purified protein derivative solution 5 TU (tuberculin units)/1 ml [ten tests], undated and opened, expiration date 09/24 and lots number 61471; On 7/20/23 at 8:35AM, and interview was conducted with LPN L. LPN L verified expired medications and biologicals from the medication storage room on the second floor. Review of the medication administration records (MAR), printed on 7/20/23 at 10:30 AM, for R5, R15 and R64, revealed that the expired insulin in the 500/600 hall medications carts was administered as follows: a. R5 received expired insulin on 7/19/23 at 12:15 PM and at 9:33 PM, and on 7/20/23 at 8:10 AM; b. R15 received expired insulin on 7/15/23 at 2:15 PM and at 3:51 PM, on 7/16/23 at 1:14 PM and at 3:57 PM, on 7/17/23 at 11:30 AM and at 5:03 PM, om 7/18/23 at 1:00 PM and at 4:16 PM, and on 7/19/23 at 12:13 PM and at 4:38 PM; c. R64 received expired insulin on 7/20/23 at 10:02 AM. On 7/20/23 at 11:15 AM, an interview was conducted with Licensed Practical Nurse (LPN) L. LPN L confirmed R5, R15, and R64 all had expired insulin and there was one loose pink round pill in the 500/600 hall medication cart. LPN L was asked if the insulin should have been used if it was expired for medication administration and replied, No. I should have not used it. It should have been discarded and a new vial should have been opened and dated. On 7/21/23 at 10:00 AM, an interview was conducted with Assistant Director of Nursing (ADON). The ADON verified insulins should not be used past the expiration date on the vial after it has been opened per pharmacy and manufacturer's recommendations and all [NAME] use vials should be dated when opened. The ADON also confirmed that no loose pills should be left in the medication carts. Review of facility policy titled, Medication Storage, undated, read in part, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . Review of facility Medication Storage Guidance, provide by facility pharmacy, dated 3/20, read in part, .Tuberculin tests .date when opened and discard unused portion after 30 days .[Brand Name] Insulin glargine, discard after 28 days of being opened .insulin lispro, discard after 28 days of being opened .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #61 (R61) Review of R61's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview Mental Status (BIMS) of 15/15 which indicated she was cognitively intact. R61's MDS also revealed, an activities of daily living assistance functioning for toileting indicated she was total dependance of two-person physical assist. On 7/21/23 at 2:00 PM, and interview was conducted with R61 in her room. R61 voiced concerns with extended periods of time to wait for call light to be answered. R61 stated this occurred mostly in the morning upon rising and needing to use the bathroom. R61 was asked if she had any specific dates and time that this occurred and responded, Yes. Do you see that notebook over there. That is where I have been writing dated and times down. Go ahead and take a look at it if you want. Surveyor picked up the notebook and verified the entries made by R61 as follows: 6/14/23 - Call light on at 5:38 AM and not assisted until 9:07 AM and noted call-in (a staff member who was to work called in and did not work); 6/18/23 - Call light on at 6:14 AM and not assisted until 9:00 AM and documented no staff on hall (R61 stated no CNA was working to care for residents in her 600 hall); 6/26/23 - Call light on at 6:50 AM and not assisted until 7:30 AM and call light on at 9:30 AM and not assisted until 1:48 PM; 6/27/23 - Call light on at 8:10 AM and not assisted until 9:00 AM and CNA WW made a rude remark stating, Good luck with that one! (referring to the R61) and left her hanging in the lift in her room; 6/28/23 - Call light on at 3:10 AM and not assisted until 6:29 AM, call light on again at 8:30 AM and got told by staff [unknown] she had to wait and then staff [unknown] sat at the desk and turned her light off and never returned until change of shift; 6/30/23 - Call light on at 3:57 AM and not assisted until 6:17 AM; 7/3/23 - Call light on at 4:53 AM and not assisted until 8:27 AM; 7/9/23 - Call light on at 5:59 AM and not assisted until 11:25 AM and documented that only one CNA for the entire wing and nurse trying to get someone to come in; 7/12/23 - Call light on at 4:56 AM and not assisted until 7:23 AM; 7/13/23 - Call light on at 4:50 AM and not assisted until 7:48 AM; 7/16/23 - Call light on at 4:38 AM and not assisted until 6:29 AM; 7/19/23 - Call light on at 5:48 AM and not assisted until 6:28 AM and documented only one CNA; 7/20/23 - Call light on at 3:15 Am and not assisted until 4:08 AM, then CNA [unknown] told her she would have to wait as they were doing computer work and did not get assistance until 9:28 AM (R61 stated that during these times she needed to use the bathroom and had to wait an extended period of time for assistance and voiced frustration). On 7/26/23 at 9:00 AM, an interview was conducted with staff XX. Staff XX was asked if she could verify the day that R61 reported her light was turned off by CNA [unknown] and replied, Yes. I remember and that did happen. On 7/26/23 at 1:00 PM, a follow up interview was conducted with R61 in her room. R61 was upset and said that the current CNA (DD) had work all by herself this past Saturday for both the 500 and the 600 halls. R61 was asked when she experienced extended periods of time for call light response how that made her feel and replied, Like sh*t. I can't imagine what the other residents go through. You know the ones that can not speak up for themselves or advocate that something happened or went wrong or did not have their needs met. On 7/26/23 at 1:05 PM, an interview was conducted with CNA DD. CNA DD was asked about working over this past weekend and replied, I was the only CNA on the schedule for both 500 and 600 halls (The 500 hall had 12 residents and the 600 hall had 12 residents and most of them were dependent on staff for some type of activities of daily living and most were two person assist). The LPN [L] on shift told me to do the best I could. I worked from 7:00 AM until 3:00 PM and the night shift CNA [unknown] left at 7:00 AM. Most of these residents are a two person assist and the nurse has their own stuff to do and are usually busy passing meds. On 7/26/23 at 1:30 PM, an interview was conducted with staff YY. Staff YY was asked how staffing was for this past weekend and replied, I was off Thursday and Friday. I heard it was a bit messy. Staff YY was asked why staffing was a bit messy and replied, A CNA [AAA] calling in sick. There was a Registered Nurse (RN) [C] on call and I think she came in, but you would have to ask her. Review of posted staffing schedules, dated 7/22/23, for shifts days/afternoons/nights, confirmed that only one CNA [DD] was listed and worked the day shift on 7/22/23 during 7:00 AM - 3:00 PM. Review of posted staffing schedules, dated 7/22/23, for shifts days/afternoons/midnights, had markings where white out had been used to alter the schedule. Staff YY was asked why white out had been used and not a line drawn through and then a correction and replied, I am not sure. Staff YY was asked if it was appropriate to use white out of the original posted schedules and replied, I guess not. It may look like we are trying to hide or falsify something. On 7/26/23 at 2:40 PM, an interview was conducted with RN C (formerly an LPN). RN C was asked why she did not work as a CNA up on the second floor and help CNA DD out and replied, I had not worked as a CNA before, but I did offer to help her a couple of times. RN C was asked what the proper policy and procedure was if there was a call-in when she was the on-call nurse. RN C replied, I guess I should have bumped the lowest seniority LPN [JJ] to work as a CNA and taken over her cart. RN C was asked why she did not bump lowest seniority staff and responded, I guess I did not think about doing that. During a lunch meal observation on 7/18/23 at 1:37 PM, the 1st floor dining room had no nursing personnel present to assist residents or assure safety. The residents were on their own and encouraging one another. One resident who wished to remain anonymous, stated, I help him (a resident at her table) as I am afraid he will eat his blanket. At another table, a resident was encouraging her tablemate to pick up the silverware and take a bite, remarking, She doesn't eat very well. Dietary Staff V and Dietary Staff U were present in the 1st floor kitchen which was separated from the dining room with a half wall. Staff V said a nurse should be present as they were busy making trays and were not watching the residents. On 7/18/23 at 1:45 PM, an interview with LPN (Staff JJ) was conducted near the 1st floor nursing station. Staff JJ was asked if she was the LPN who should be in the 1st floor dining room. Staff JJ replied, although she was an LPN, she had been pulled to work as a CNA and was not assigned to the dining room. Staff JJ stated, RN (KK) was assigned to the dining room. When asked where RN KK was, Staff JJ stated, She is on break. Fourteen Residents were observed to be in the 1st floor dining room at that time. During a breakfast meal observation on 7/20/23 at 9:21 AM, the 1st floor dining room contained 10 residents eating breakfast. No CNAs or licensed nurses were present. At 9:45 AM, the final tray was being prepared and CNA LL was circulating through the first-floor dining room. CNA LL stood over a seated resident (unidentified), gave this resident a bite of eggs, and then proceeded to move toward another resident. CNA LL stated she did this on a regular basis (stood and gave bites to residents). CNA LL said, There are not enough CNAs (to provide the needed care) . There is just too much to do. CNA LL explained, We are supposed to come to the dining room to assist, but we cannot always make it. This happens often and I do the best I can but . CNA LL then shook her head. In a confidential group meeting on 7/19/23 at approximately 11:00 AM, the six residents in attendance agreed they would like to speak anonymously. They stated the staffing levels did not meet their care needs. Resident C2 said the facility needed more help. Others in attendance gave examples of problems that arose due to low staffing levels. C4 stated she had to wait upwards a couple hours after using her call light at night. She stated after waiting so long she ended up peeing my bed. She went on to say, I try not to go and not to go. I hate to make a mess. It makes you feel like sh*t. C3 stated, They are so short you have to be patient. C4 then added the night is the worst explaining, I feel like I am going to explode at 1:00 AM and they (nursing staff) would not come (to assist) until 9:00 AM. C4 then said, They (nursing staff) peek in and say we will be with you but they do not come in and help. C6 added she must be assisted to get into bed. C6 said, They do come, but I have to wait a long time every night. The minutes from previous monthly Resident Council meetings were reviewed. - The minutes of 3/30/23 included a resident statement regarding the CNAs (Certified Nurse Aides) working short on the floors. Two other named residents also brought up concerns of having to ask to have their mouth and teeth care done and felt they should not have to ask. - The minutes of 1/17/23 listed concerns that one resident wished the CNAs would set up her tray and cut up her meat. Other concerns revealed call lights were on, but no one answered, and there was no assistance available on the halls during mealtimes. A specific complaint was recorded regarding long wait times while on the toilet. This deficiency pertains to Intakes MI00134358, MI00132367, and MI00131319. Based on observation, interview, and record review, the facility failed to ensure sufficient staff to provide nursing related services, assure resident safety, and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, based on resident acuity and diagnoses of the resident population. This deficient practice resulted in unmet resident care needs and inadequate supervision to prevent and respond to resident needs. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Observation during breakfast on 7/19/23 at 8:58 a.m., found 10 residents seated in the dining room without nursing supervision while the meal trays were consumed. Two Dietary Aides (Staff); U and V, were present in the kitchen who prepared and delivered the individual meal trays to each resident. During an interview on 7/19/23 at 9:00 a.m., Staff U and V were asked if any licensed nursing staff was present to provide dining supervision when residents were eating breakfast. Staff U and V both turned their heads from side-to-side, and stated, No. When asked if Staff U and V were CPR (cardiopulmonary resuscitation) or Emergency First Aide certified, both said they were not. When asked if there was any concern for resident safety in the first-floor dining room during breakfast, Staff V stated Every day. Staff V continued, Aides [Certified Nurse Aides (CNAs)] will come in to bring residents in, but they do not stay in the dining room on the first floor to assist the residents (with their breakfast meal) . There is one nurse on each wing, and one CNA on each wing . Staff V said there was often not enough staff to cover the halls and the dining room. Continued observation on 7/19/23 at 9:09 a.m., showed CNA W entered the dining room with Resident (R54), placed a clothing protector around the Residents neck and left the dining room. During an interview on 7/19/23 at 9:33 Staff V approached this Surveyor in the first- floor dining room and stated, Just so you know, that (staff offering any assistance, or wheeling residents back to room) does not happen. Five residents remained in the dining room, with breakfast trays in front of them and/or eating, with no staff present. All CNAs left the dining room, and both dietary staff left the kitchen area where the food was served. During the dining observation on 7/19/23 at 9:57 a.m., CNA B removed Resident (R29's) clothing protector and left the first-floor dining room. All CNAs left the dining room, and both dietary staff left the kitchen area where the food was served. Residents remained in the dining room with breakfast meal trays. During a telephone interview on 7/19/23 at 8:31 p.m., Confidential Staff CCC was asked about the adequacy of facility staffing to meet resident needs. Staff CCC stated, Because our facility is not on one floor, I would say the staffing is not good. Staffing is supposed to be 1 to 8 (1 staff member to 8 residents) in the (memory care) unit. During the day the there is one RN (Registered Nurse) on the med (medication) cart, and one CNA is left on the floor by themselves. That happens a lot . I would say that we are understaffed based on the acuity of the residents. When asked about resident supervision in the dining rooms, Staff CCC stated, For the second floor, none of the residents eat in the dining room. On the 600 wing there is an empty resident room that they turned into a dining room . There is no dining supervision in the room. During an interview on 7/20/23 at 2:47 p.m., when asked about staffing, Staff FFF burst into tears and said a lot of people had left (employment at the facility), and it was very difficult have a Director of Nursing (DON) who was not in the building. Staff FFF stated, We are tired, and the ones (employees) that have been here are getting tired and they are leaving. There needs to be more staff. During an interview on 7/20/23 at 3:13 p.m., when asked about staffing levels, Staff AA stated, I have never seen us work so short as I have in the past year. One aide to 15 residents (during day shift). For my first hour - hour and a half, I just do aide work. There is no way that one aid can do one wing alone. They (CNAs) should not have that many residents . we have one aide (CNA) and 1 LPN (licensed practical nurse) to each wing. During an interview on 7/27/23 at 9:25 a.m., when asked about staffing in the facility, Staff PP stated [CNA B] is my aide today . There is always just one aide on the wing. They do the Hoyers (mechanical full-body lifts) by themselves all the time. I have never seen them do the (full-body mechanical) lifts with anyone (assisting them) . They (CNAs) don't have the staff to do anything with two staff . During a second-floor dining observation on 7/27/23 at 1:31 p.m., three Residents, including R9, were seated in the dining room (former Resident room). Two square dining room tables with five chairs were provided for a group dining experience on the second floor. R9 was observed eating broccoli from her plate, with several large pieces on her plate and lap. R9 was able to eat all the broccoli small enough to fit on their spoon without drinking any liquids for swallowing safety. R9 stated, I can't eat this (additional food on plate including ground meat with gravy, tater tots, and orange creamsicle dessert). I can't get it on my spoon. R9 picked up the chocolate supplement beverage and consumed it all. R9 coughed after the chocolate beverage was finished. No staff were in the small resident room converted to a small dining room. R9 picked up, what appeared to be juice, and drank that with a straw. No dining assistance was offered to the resident between 1:31 p.m. and 1:42 p.m., and no licensed staff were present for dining supervision. On 7/27/23 at 1:42 p.m., this Surveyor found LPN L and CNA DD in the hallway and told them R9 could not eat anything additional because she could not get it on her spoon. CNA DD said, I know who it is, as she returned to the 600-hall congregate dining area. CNA DD chopped up the large pieces of broccoli R9 could not eat independently. Review of R9's progress notes revealed the following, in part: 5/1/2023 . TRANSFERRED TO: emergency department .REASON FOR TRANSFER . Resident (R9) was lowered to the floor earlier in the day (fell) and is now complaining of right arm pain. Had a fall at 5:15 pm which she slid from her wheelchair and has complained on and off about right hip and lower back pain. Resident then choked on a piece of hot dog and had to have the Heimlich performed to remove the hotdog . Review of R9's lunch meal tray card, dated 7/27/23, revealed the following, in part: .SUPERVISION: close supervision, use/prompt swallowing strategies for slow rate - prompt with 2 sips - Stop, liquid wash after several bites and second dry swallow prior to consuming more food. Encourage at meals to eat . During an interview on 7/27/23 at 1:49 p.m., when asked about valid CPR certification or First Aide, CNA DD said their CPR (cardiopulmonary resuscitation certification) was not up to date, and they had not completed a current First Aide course. CNA DD was the only CNA for both the 500 and 600 Wings at the time of these dining observations and interview and was the only staff member who entered the congregate dining room where R9 was eating lunch. During an interview on 7/27/23 at 1:55 p.m., when asked if there were still additional lunch trays to be passed, CNA DD stated, I still have two feeders (in their room). During an observation on 7/27/23 at 1:57 p.m., an unidentified Resident was heard yelling, Ow, Ow, Ow, Ow, Ow for approximately five minutes on the 500 Hall. No staff were visible or present on the 500 Hall. As this Surveyor walked down the 500 Hall, Resident (R42) was heard crying out, Ow, ow. When asked what hurt, R42 stated, My foot hurts. R42 was observed with his heels in direct contact with the mattress, without protection of blue protective boots to prevent pressure injuries as specified in his care plan. Observation on 7/27/23 at 2:00 p.m., found Resident R5's call light on. No staff were on the 500 Hall to respond to the resident at the far end of the hall. This Surveyor found R5 with visible difficulty breathing. R5 stated I need a breathing treatment. LPN L and CNA DD were notified of the resident concerns by this Surveyor. Review of payroll documentation for 7/27/23, to show the number of direct care staff and administrative staff revealed the following; - 11 CNAs were working the day shift between 6, 100 foot halls. Two CNAs were on the Memory Care Unit, leaving nine CNAs to handle all resident cares, and dining assistance for breakfast and lunch as well as take their own breaks and lunches. - Two LPNs were on the floor providing direct care. - Six Registered Nurses (RN's) were working, but only three were providing direct care to the residents observed during lunch. The MDS RN, Staff Development RN, and Wound Care RN were not observed providing direct care to facility residents. - Three Activity Aides were working, but were not providing direct care or dining assistance or supervision to the facility residents. - 14 Administrative/Managers, including two nurses and one licensed CNA, were not providing direct resident care, nor were they on the floor assisting staff where there was no staff on the Wing, or only one CNA on the Wing due to breaks, lunches, baths, etc. On 7/27/23 at approximately 2:05 p.m., CNA DD entered R42's room and placed the blue protective boots on both of R42's feet. CNA DD also found R42's incontinence brief appeared wet with urine. CNA DD opened R42's incontinence brief, and reached her gloved hand in, and slightly under his scrotum, and she pulled a secondary brief liner out of the incontinence brief and secured the same brief with the adhesive tabs. When asked where R42's call light was positioned, it was found between the sheets in the two bottom layers of covers and the two top layers of blankets. The call light was not accessible for R42 to call for staff assistance. During an interview on 7/27/23 at 2:11 p.m., when asked about staffing, Staff HHH stated, (The) day has been tough. I just came back from lunch. When asked about the incontinence brief liner found in R42's incontinence brief, Staff HHH stated, Most of the guys have extra pads for urine absorption in their brief . basically all my guys . I took his (R42's) boots off for a break from them. I took them off - the blue boots . I move him on my own with the maxi lift. I have to (use the lift alone) because there is not enough staff . I was in with my bath lady [R5] today for an hour . when I came out (of their room) I had two call lights on, and it was mainly because I had to basically clean up incontinent BM (bowel movement) twice. While I was doing the bed bath, I was not watching the residents. The other aide is assigned to the other hall. In all honesty something terrible could happen here and we would not even know because we don't have enough staff. During an interview on 7/21/23 at 8:45 a.m., the Nursing Home Administrator (NHA) was asked about staff using the mechanical lift (Hoyer) without a second staff member present for Resident safety. The NHA said the full body lift (Hoyer) required two staff members for use, and she has been preaching to the CNA's that they are to get a nurse to assist if they need to use the lift. When asked if nurses could use the lift independently with residents, the NHA said they could not, and appeared as if in disbelief with an open mouth, that a nurse would be using the full-body lift without a second support person. During a telephone interview on 7/27/23 at 2:36 p.m., when asked by the facility NHA to specify the length of all resident occupied Halls, Maintenance Director X said the Wings (Halls) were all 100 feet long from the fire door to the end of the Hall. This distance pertained to the first and second floor Wings; each with three halls. During an interview on 7/27/23 at 2:55 p.m., Family Member (FM) QQ said they were aware facility staff were double-briefing R49 and R50. During a telephone interview on 7/27/23 at 3:37 p.m., Confidential FM III of a facility Resident (identity not revealed to protect confidentiality of FM) stated, They (facility staff) double brief my mom all the time. I would prefer they just be a single brief on her and put her in the bathroom. On Saturday when I came (to the facility) she was wet through the diaper liner, the diaper, her pants - she was soaked . This is not helping her condition - she does not go to the bathroom, and I get the excuse We are doing the best we can. We have limited help. They double diaper her - I wouldn't want that in my crotch all day . She is not being changed often enough . this is (an) every weekend occurrence. During an interview on 7/27/23 at 4:17 PM Confidential FM JJJ stated, I have been calling the State of Michigan and it is all answering machines . The concern that I had and want you to know about so it can be documented . happened back in June (2023) . I had come to visit my mom who is (resides) on the 200 Hall. I got in the building at 4:10 p.m. I was trying to see where she was at - and she was still sitting there (in the first-floor dining room) from lunch. Her tray was gone - she had her silverware, and empty glass in front of her, and her placemat in front of her (on the dining room table). The staff didn't know where she was. Staff was busy and there is really nobody on the floors to ask in the first place. This place is so big that there is not enough staff . Review of Rights of Residents in Michigan Nursing Facilities, dated 11/28/2016, revealed the following, in part: . You have the right to be informed of, and participate in, your treatment, including: . The right to receive the services and/or items included in the plan of care . You have a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely . You are entitled to receive adequate and appropriate care .

This deficiency pertains to Intakes: MI00134358, MI00132367, MI00131319. Based on observation, interview, and record review, the facility failed to perform annual licensed nurse and nurse aide competency evaluations and ensure licensed nursing staff and certified nurse aides (CNAs) had the specific competencies, skill sets, and techniques necessary to care for two Residents (R4 and R42] of four residents reviewed for pressure ulcer and catheter care. This deficient practice resulted in improper catheter and wound care technique and the potential for worsening of condition for both residents and had the potential to affect all facility residents. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Resident R4 During a catheter care observation for R4 on 7/21/23 at 10:36 a.m., CNA LL began catheter care with cleansing of the catheter tubing. CNA LL held the tubing, approximately one inch from the urethral opening, and cleansed downward four times. The tubing near the urethra was never cleansed. The tubing was rinsed, and CNA LL took the towel that was draped over R4's body to dry the catheter tubing. CNA LL then used a new, wet washcloth to cleanse the right and left creases between the pubic area and the inner thigh. CNA LL wiped downward three times in the left and right thigh crease, finding brown feces on the white washcloth with each of the swipes. CNA LL then used a clean rinse cloth which again was left with brown feces after passing down the right and left thigh crease. CNA LL separated the labia and used a clean, wet washcloth to cleanse over the clitoris, over the dirty tubing that was not properly cleanse, and down past the vagina. Three swipes downward were completed by CNA LL who then said, Am I done? When asked if there was still feces on the rinse cloth, CNA LL confirmed there was stool present after cleaning the resident. CNA LL said R4's bowel movement should have been cleaned up prior to completion of catheter care. During an interview on 7/21/23 at 11:13 a.m., Assistant Director of Nursing (ADON) A said Registered Nurse (RN) Unit Managers would be the supervisory staff for the CNAs, per their job description. When asked about observation of peri care and catheter care for CNA LL, RN/Unit Manager Z said CNA LL was contract staff. RN Z stated, We do not do competencies on agency staff. Resident R42 During a wound care observation on 7/26/23 at 8:17 a.m., Registered Nurse (RN) GG emptied the contents of a clear plastic bag on the prepared over bed table in R42's room. Small pieces of wound packing were previous cut and tossed into the bag filled with open gauze pads that had been saturated with normal saline. This contaminated the wound packing prior to placement into and on the Stage 3 pressure injury. RN GG did not bring any normal saline vials or bottles into the room with the dressing supplies. This Surveyor indicated she wanted to see the entire wound care process and RN GG said she thought the Surveyor only wanted to see the wound dressing change, not the process of preparing the supplies for wound care. RN Supervisor (RN) C was also present in the room. RN GG uncovered the coccyx wound, and no dressing was present at the time of observation. RN GG began by using a 4x4 gauze pad she had previously moistened in her office and wiped the surface of R42's coccyx wound. No internal cleansing or irrigation of the Stage 3 pressure injury was performed. RN GG was asked how she cleansed the interior of the Stage 3 pressure injury. RN GG used a previously moistened 4x4 gauze pad, bunched it up in the middle of the gauze pad and attempted to stick it inside the small diameter Stage 3 pressure injury. When asked about the same process being used to cleanse the wound over that last several weeks, RN GG confirmed that was .how I always do it . Review of the physician orders for R42's pressure injury dressing revealed the following, in part: 5/23/2023 TREATMENT: Skin: Document coccyx wound measurement, drainage and peri wound conditions two times per week AM, Thursday and Monday. 6/16/2023 TREATMENT: Cleanse coccyx open area with NS (normal saline), pack with moistened [collagen-based wound packing material], [sodium chloride dressing that stimulate debridement of heavily discharging wounds] and apply [foam dressing]. OK to use dry [collagen-based wound packing] if maceration occurs, every other day AM FIRST DATE: 06/15/2023. During an interview on 7/26/23 at 2:32 p.m., when asked who was responsible for transcribing and entering the wound orders from the specialty wound clinic for R42, RN GG stated, That would be me. During an interview on 7/27/23 at 2:00 p.m., when asked about consistent completion of wound measurements for R42, RN GG acknowledge she had not always measured and documented the weekly skin assessments. During an interview on 7/26/23 at 3:13 p.m., the Nursing Home Administrator (NHA) was asked about the wound care provided by LPN GG. The NHA stated, You bring your supplies into your room, and you cut what you need at the time, you don't cut it up and put it into a bag . we have the vials of NS . they should be using that to irrigate the interior of the wound . by opening the wound and cleaning it out after the measurements are done . I would take two of the little vials (of NS) in to make sure it is irrigated well. No, I would not put a 4x4 into the wound. I would agree that was not an appropriate cleansing of the wound. During a telephone interview on 7/26/23 at 9:11 a.m., the Specialty Wound Clinic Practice Manager/LPN BBB was asked about R42's continuity of care between the Wound Clinic and the facility. LPN BBB stated, They (facility) were not using the correct product . usually we irrigate those (Stage 3 pressure injuries) with normal saline (but squirting the normal saline directly into the wound with a vial or syringe) - especially given the area it is in (coccyx) . We have had to be pretty specific with our orders due to them not being followed. We have had to be specific because they were not doing what we said. LPN BBB agreed by using a NS moistened 4x4 inside the wound, mechanical abrasion of the wound could occur and result in delayed or absence of wound healing. Annual Competency Documentation During an interview on 7/21/23 at 11:45 a.m., RN/Unit Manager Z was asked, and provided all documentation for licensed nurse and CNA annual competency completion. Review of the documentation revealed the following: Licensed Practical Nurse Skill Checklist - 20 forms (six were duplicated names), none completed, 18 partially completed, 2 absent any completed task (only name on the form). Certified Nursing Assistant Skills Checklist - 28 CNA forms, none completed, 25 partially complete, 3 absent any completed task. Registered Nurse Skill Checklist - no forms received. Review of the Facility Assessment, reviewed 3/15/23, revealed the following, in part: .We perform the following competency checks (this is not an inclusive list): - Person-centered care - This should include but not be limited to person-centered care planning, education of resident and family/resident representative about treatments and medications, documentation of resident treatment preferences, end-of-life care, and advance care planning . - Infection control-hand hygiene, isolation, standard universal precautions including use of personal protective equipment . - Medication administration - injectable, oral, subcutaneous, topical . - Resident assessment and examination - admission assessment, skin assessment, pressure injury assessment . - Specialized care - catheterization insertion/care . wound care/dressings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency pertains to MI00134358, MI00132367, MI00131319. Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was designated and served as the Director of Nursing (DON) on a full-time basis. This deficient practice resulted in the inability to provide in-person supervision over the activities of the Nursing Department. This deficiency had the ability to affect all 68 facility residents. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. During a telephone interview on 7/19/23 at 8:31 p.m., Staff CCC was asked about the absence of the DON in the building. Staff CCC stated, Our DON has been working from home, but I know she is getting paid, because she calls in to the morning meeting. She has been working from home since March. You can't expect the survey to succeed when she has been working from home since March . [The DON] has the DON (work) cell phone and we have to call her and notify her if someone falls or goes to the hospital. We are still expected to call or text our Director of Nursing on her (work) cell phone sitting home. During an interview on 7/20/23 at 7:45 a.m., RN/Unit Manager Z was asked who the facility DON was. RN Z stated, [DON working from home's name]. On 7/20/23 at 8:33 a.m., Executive Assistant (Staff) DDD was asked for payroll documentation for the DON from 3/1/23 through to the present. Staff DDD confirmed [Name] had continued in the DON roll, and provided physical timecards for when she was off (not working from home). On 7/20/23 at 8:45 a.m., Administrative Staff T was asked about the DON's job description and extended absence from the building. Staff T said the DON had been out of the building since March 29th, 2023, and started working from home on 4/27/23. During an interview on 7/20/23 at 9:00 a.m. Confidential (Staff) EEE was asked about the ability of the DON to perform job functions while being at home. Staff EEE stated, I don't believe she is doing her job. She cannot do any of her job functions working from home . [DON] keeps saying I am coming back . then more working from home. [The DON] was in a meeting (telephone), and she was supposed to be doing PASSARS (resident screenings), and she said she had two done, so Assistant Director of Nursing (ADON) A and Minimum Data Set (MDS) assessment RN started doing the PASSARS. During an interview on 7/20/23 at 1045 a.m., the Nursing Home Administrator (NHA) said she had a telephone conversation with the DON on Tuesday 7/18/23 and was expecting her to come back to work. The DON requested another six to eight weeks working from home. The NHA said she told her that the facility could not continue to function properly without a present, in-house DON. On 7/20/23 at 1:53 p.m., a sign on the 1st floor Nurses Office door stated, Important Contact Information All Staff - Any potential Abuse of a resident needs to be reported to the Administrator IMMEDIATELY. Office: [Phone Number], Cell Phone: [Phone Number] *DON - [first and last name], Office [Phone Number], Cell: [Phone Number] *ONLY CALL DON IF UNABLE TO REACH ADMINISTRATOR AFTER MULTIPLE ATTEMPTS. During an interview on 7/20/23 at 2:47 p.m., when asked about the DON's absence in the facility while she was working from home, Staff FFF burst into tears and stated, It has been very difficult having a DON who is not in the building. When asked when the last time was, that she had seen the DON in the building, Staff FFF stated, I can't remember. During an interview on 7/26/23 at 7:52 a.m., Staff T was asked for performance reviews for five staff members. Staff T stated, We don't have any (performance reviews). The managers of the department are responsible for the department - such as the DON for nurses. All the changes and the instability in the nursing level, there is nobody to perform them, because the DON is working from home. Staff T said it would not matter what performance reviews were requested because they had not been completed since 2020. During a telephone interview on 7/26/23 at 11:10 a.m., when asked who was responsible for ensuring nursing staff competencies, the DON stated, Competency evaluation is in my job description . I would oversee it. The DON noted her job description was last updated 1/30/23. During the same interview on 7/26/23 beginning at 11:10 a.m., when asked how the DON maintained the facility nursing program from home, the DON stated, My ADON (ADON A] should be stepping up. She should be monitoring the activities in house . Because I am not in the building . There is thing I cannot do. I cannot see the staff from here . being that the ADON (A) was in the building and the Clinical Manager, (they) would take over those (DON) responsibilities until I returned. Had I known it was going to be this long of a process I would have done things differently. The DON confirmed the ADON (A) had never been appointed as the Interim DON, nor had she accepted those job responsibilities, or maintained possession of the DON. The DON also acknowledged that she continued to be paid the DON wage while working from home and confirmed that she could not fulfill all the job duties delineated in the Director of Nursing job description, revised 1/30/23. Observation of the facility between 7/18/23 and 7/27/23 showed the DON was not present in the facility during the recertification survey. Review of the Director of Nursing job description, revised 1/30/23 by the DON, revealed the following, in part: Characteristic Duties and Responsibilities of the DON: Develop and maintain nursing service objectives and standards of nursing practice, assist in developing nursing service policies and procedures, and assist in writing job descriptions for nursing personnel. Antibiotic stewardship duties. Organize, develop, and direct nursing administration and resident care. Orient, instruct, and supervise personnel and functions. Assist in in-service education and training programs. Complete nursing service with other departments. Regularly inspect Facility and nursing practices for compliance with federal, state, and local standards and regulations. Develop and maintain nursing objective and standards for the Facility. Establish and write policies and procedures and review job descriptions for nursing service; interpret those to personnel and interested parties. Plan, organize, and direct effective administration of each nursing unit, based on the above-mentioned objectives, standards, policies, and procedures and assure residents of a comfortable, clean, orderly, and safe environment; evaluate nursing service needs and determine staffing requirements; and coordinate nursing department with other departments in a cooperative, facility minded manner. Interview applicants sent by the Human Resource Director and evaluate and interpret principles of management to nursing supervisory as to abilities. Assist in in-service education and training programs personnel. Schedule hours for 24-hour coverage to comply with state codes, and assign duties assisted by unit personnel. Supervise and evaluate work performance of personnel in all units, assisted by unit personnel. Discharge or discipline personnel who are not qualified, violate polices, or when staffing requirements warrant it. Assist charge nurses in developing nursing care plans for individual residents including rehabilitative and restorative activities, instruction in self-help, and cooperation with therapeutic policies such as occupational therapy, physical therapy, speech therapy, etc. Establish administration, procedure, and control of medications under direction of the pharmacist and the Pharmacy committee. Assist in providing for the spiritual, psychological, and social needs of residents and families. Serve as consultant on admitting and discharge policies and procedures. Identify and solve departmental and personnel problems. Be responsible for execution of resident care policies in the absence of the physician. Participate in Antibiotic Stewardship Program. Perform duties of Staff Nurse whenever and wherever required. Be on call for emergencies that supervisory personnel cannot handle. Establish employee health program. Assist in the establishment of a disaster, fire, and safety program in cooperation with administration. Assure proper handling and emergency care of residents, personnel and visitors involved in accidents while on the job or in the building. Maintain required records; review, update and revise policies procedures, job descriptions and to meet current objectives and standards. Advise and consult with administration on nursing administration and resident care. Prepare and submit required reports, and maintain statistics as directed. Attend department head meetings. Promote public relations and maintain liaison with other nursing service directors. Keep current in the field of nursing through attendance at meetings, conferences, conventions, and workshops; reading current literature pertaining to all aspects of resident care and restoration/rehabilitation; maintaining membership in professional organization. Provide nursing input on Medicare and Medicaid forms. Assist in preparing and administering budget for nursing department. Maintain state regulations as related to nursing be knowledgeable of state requirements for other services and departments in the Facility. Perform other related tasks as assigned. During an interview on 7/25/23 at 2:58 p.m., when asked to review the DON job description and highlight the job responsibilities the DON was able to perform while working from home, the NHA reviewed the DON job description and stated, In the last four months she has not done any of these things.

. This deficiency pertains to Intakes MI000134358, MI00132367, and MI00131319. Based on interview and record review, the facility failed to complete performance reviews of all nurse aide at least once every 12 months. This deficient practice resulted in the potential for quality-of-care concerns related to lack of training to meet the Certified Nurse Aide (CNA's) performance-based education needs. This deficient practice has the potential to affect all 68 vulnerable residents in the facility. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. During an interview on 7/26/23 at 7:52 a.m., Administrative Staff T was asked for performance reviews for five staff members pulled yesterday for review. Staff T stated, We don't have any (performance reviews). The managers of the department are responsible for the department performance reviews - such as the DON (Director of Nursing) for nurses. (With) all the changes and the instability in the nursing level, there is nobody to perform them because the DON is working from home. Administrative staff T indicated the DON had completely neglected performance reviews for CNAs since 2020. Review of the Facility Assessment, reviewed 3/15/23, revealed the following, in part: .Required in-service training for nurse aides. This is done through [Online Training] and face-to-face at mandatory meetings. In-service training must . Address areas of weakness as determined in nurse aide performance reviews and facility assessment and may address the special needs of residents as determined by facility staff . .

. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by failing to label, date, and store food to ensure it was kept free from contamination and failed to properly clean areas with a potential to contaminate food during preparation. This deficient practice had the potential to result in food borne illness among any or all 39 residents in the facility. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. During the initial tour of the kitchen with Certified Dietary Manager (CDM) N and CDM O on 07/18/23 at 11:45 AM, the walk-in freezer was observed with partially used, re-sealed, bags of broccoli, breaded fish, mixed vegetables, spinach, and asparagus, which were not dated when opened and had no use by date. CDM N stated these partially used frozen food items should be dated. CDM O agreed each item should be dated after opening. The satellite kitchens were observed with CDM O. The refrigerator in the first-floor satellite kitchen had an outdated chocolate syrup container marked as Best by 3/2023. The brown sugar tub contained a scoop embedded in the product which had the potential to contaminate the contents as product contacted the scoop handle. The hood over the cooking equipment providing the ventilation was observed with a thick grease build up. This hood area contained pipes running the length of the grill and directly over the grill area. The pipes were heavily laden with a thick brown colored residue. [NAME] trails from the upper portion to the edge of the metal suggested evidence of drippage over the cooking area. CDM O said these white trails were possibly lime deposits from the hard water generated by the steam system. He was able to chip the residue away with his fingernail. Above the grill long strands of dust up to 2 inches long were observed dangling from the pipes and were directly over the grilling area. CDM O stated the maintenance department cleaned the hood areas and was not certain when they had been cleaned last. The drip pans under the cooking area were observed with food debris which had dropped through the stove top to rest on the catch pans. CDM O did not believe the debris had been from the last meal prepared. The industrial [name brand] mixer had a thick brown residue on the undercarriage of the mixer arm which hung directly over the bowl. This residue had the potential to be incorporated into any mixed food product. CDM O stated it needed a good scrubbing. The FDA Food Code 2017 States: - 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . - 4-601.11 states: (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 directs that: NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The facility policy titled Food Safety/Sanitation dated as last revised 3/2023 read in part, LABELING 3. Label food with date it is opened or prepared and use by date.