**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #46: On 5/13/2025 at 12:15, Resident #46 was observed watching television in bed. He provided permission to look at the wound dressing on his right foot (enclosed in soft heel boot), the dressing which was dated 5/11/2025. Nurse Manager N was asked if his treatment was a daily order and after review of his physician orders, she stated it was. Manager N was asked to observe his right foot dressing and upon return she stated it was dated 5/11/25. The manager expressed understanding but offered only one treatment had possibly been missed not two. Manager N stated she would contact the nurse and follow up. On 5/13/2025 at approximately 12:45 PM, a review was conducted of Resident #46 medical records, and it indicated the resident readmitted to the facility on [DATE] with diagnoses that included, Sepsis, Diabetes, Atrial Fibrillation, Guillain-Barre Syndrome, Bell's Palsy and Borderline Personality Disorder. Further review of Resident #46's records yielded the following: Physician Orders: Cleanse right food vascular area with wound cleanser, apply Santyl over wound bed, cover with an abd and secure with kerlix daily and prn. On 5/13/2025 at 1:45 PM, Nurse N stated after speaking with the nurse she believed the dressing was dated incorrectly as the nurse thought yesterday was the 5/11/25. Based on observation, interview and record review, the facility failed to assess, monitor and document wound care timely for two residents (Resident #46, Resident #337) of three residents reviewed for wound care, resulting in missed treatments with the likelihood of worsening wounds. Findings include: Resident #337: On 5/13/25, at 9:30 AM, Resident #337 was in their room. They had an occlusive dressing over their left elbow that was dated 5-8. CNA S entered the room and was asked what date they read on the elbow dressing and CNA S stated, it says 5/8. On 5/13/25, at 11:35 AM, a record review of Resident #337 electronic medical record revealed an admission on [DATE] with diagnoses that included Aphasia, Hypertension and Stroke. Resident #337 required assistance with Activities of Daily Living. A review of Treatment Administration Record 5/1/2025 - 5/31/2025 revealed cleanse left antecubital skin tear with wound cleanser pat dry apply nonstick dressing wrap with kerlix daily and prn until healed one time a day for skin tears -Start Date-05/09/2025 1100 -D/C Date- 05/13/2025 1215. For the days of Fri 9 Sat 10 Sun 11 there was nurse initials with check marks which revealed the treatments were completed. On 5/14/25, at 11:56 AM, Nurse D was interviewed regarding Resident #337's left elbow skin tear and treatment. Nurse D was asked if they removed the old dressing and Nurse D offered, yes. Nurse D was asked if they saw the date of 5/8 on the old dressing and Nurse D shook their head yes but did not answer the question. On 5/14/25, at 12:46 PM, an observation of Resident #337's left elbow along with Nurse D was conducted. There were two small skin tears. On 5/15/25, at 9:47 AM, the Director of Nursing was interviewed regarding Resident #337 treatment record. The DON was asked why the nurses signed out that they completed the treatment when in fact the old dressing remained and the DON stated, the nurses that signed out the treatment were not the nurses that were doing the treatments for those days. The nurses were educated not to sign treatment records if they are not the nurse who completed the treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17: Review of the Face Sheet, care plans dated 11/24, and orders dated 2/23/25 through 5/14/25, revealed Resident #17 was [AGE] years old, admitted to the facility on [DATE], alert with a Guardian in place, and dependent on staff for Activities of Daily Living (ADL). The residents' diagnoses included diabetes, opioid dependence, depression, post-traumatic stress disorder, chronic pain, stroke with hemiplegia and hemiparesis, and muscle weakness. The resident used a ecteronic lift for transfers. During observations made on 5/13/25 at 11:30 a.m., and on 5/14/25 at 10:38 a.m., the resident was in her bed and her air mattress was not plugged in, it was inflated, however it was not working (alternative air flow). Observation of the plug revealed a prong was completely bent and unable to be plugged in. Review of the residents' facility Physician orders dated 2/23/25 through 5/13/25, revealed no documentation of any orders to check the air mattress for functionality and to be sure it was set on alternative pressure. Review of the Physician orders dated 5/14/25, stated Adaptive Device: low air mattress check that settings are on and static is off and weight to be 250 DEN, every day, every shift. Nurse Manager N had put in an order for staff to check functionality and settings of the mattress every shift after this surveyor brought it to her attention there was no order to check the air mattress and the residents' air mattress was not functional (per observation done on 5/13/25). During an interview on 5/14/25 at 10:40 a.m., Nurse, LPN G looked at the plug with the bent prong and stated, I am not sure why the mattress is not on. Nurse G reviewed the resident's MAR (medication administration record) and TAR (treatment administration record), and neither had documentation of confirming the air mattress was on. The nurse was unable to locate where nursing was to document they checked the resident's air mattress to make sure it was on. During an interview on 5/14/25 at 11:00 a.m., Director of Maintenance O observed the bent prong, he fixed the prong and plugged the air mattress in. Director of Maintenance O stated on 5/14/25 at 11:05 a.m., I usually leave it (air mattress) on static, and it cycles. Per the guidelines for use of this air mattress, it is not put on static for this mattress to use alternative pressure. During an interview done on 5/14/25 at 11:18 a.m., Nurse Manager, RN N stated it's on the Kardex, I can't find where it is documented that it was checked by nursing to ensure it's on alternative pressure. It needs to be on alternative pressure; it needs to be put on the tasks list. Nurse Manager N said she was putting instructions to check the residents' air mattress every shift on the residents' tasks so staff documented checking it. Review of the resident's Kardex revealed that prior to 5/14/25, instructions to check the air mattress were not on it. Review of the residents' Kardex dated 5/14/25, stated Low air loss mattress; check setting are set to alternative pressure and is functioning properly. The residents' air mattress was not to be put on static function. During an interview on 5/14/25 at 11:37 a.m., Nursing Assistant/CNA P stated We are all supposed to look at it (air mattress), we don't document it. Yes, I did look at it earlier today (the resident's air mattress that was not turned on). Based on observation, interview and record review, the facility failed to 1) Implement one resident's (Resident #17) preventive pressure ulcer measure (air mattress), and 2) Prevent an erosion to the penis area for one resident (Resident #74) of 4 residents reviewed for pressure ulcers, resulting in the potential for pressure ulcer development, increased discomfort and pain with hospitalization. Findings include: Resident #74: During an observation and interview on 05/15/25 at 09:11 AM, Licensed Practical Nurse (LPN) B went to Resident #74's room with the state surveyor for a penal erosion observation and measurements. In catheter observations the Resident #74 had on a regular catheter bag today left over from last night. Urinary catheter with secure device noted to be taunt from penis head to left thigh. Resident #74 had the large overnight catheter bag run down the left leg and it crossed to the right pant leg at the bottom of the pants. LPN B walked into the room and applied gown and gloves; no hand sanitizer was used. Resident #74 pulled down his pants and sat at the edge of the bed. LPN B held the penis to observe the penis head with left sided erosion noted to penis. The state surveyor observed left side penal erosion with measurement of 3 cm to 3.5 cm in length from the penis tip downward. LPN B then grabbed the leg bag container and opened the kit and attempted to pull the large overnight catheter bag from the urinary catheter, but the tubing stuck. LPN B asked the surveyor to get someone to help her separate the catheter bag from the catheter. In an observation on 05/15/25 09:25 AM, LPN B attempted to change the catheter bag over to a leg bag. LPN B had artificial nails estimated to be 3/4 to 1 inch in length with jewelry attachments noted on the fingernails. In an interview on 05/15/25 at 09:39 AM with Resident #74 stated that it does hurt the penis sore. also, the leg bag will get full and it gets heavy slides down my leg and pulls the tubing. A record review of the National Institute of Health (NIH) website revealed the following:, https://pmc.ncbi.nlm.nih.gov/articles/PMC10891379 Catheter-Associate Meatal pressure injuries ([NAME]) . Mucosal membrane pressure injuries refer to injuries caused by prolonged pressure and shear forces on the moist membranes that line the respiratory, gastrointestinal, and genitourinary tracts and are typically iatrogenic-caused by medical devices (7). [NAME] occur when an ICD (Indwelling catheter) erodes the urethra and surrounding soft tissue, leading to complete cleavage of the penis in the most severe cases. This therefore represents significant morbidity and loss of quality of life. A phone interview and record review was conducted via computer on 05/15/25 at 10:02 AM with Registered Nurse/Wound care RN A about Resident #74 penal erosion- it is in-house acquired. He does a lot of his own care, but yes, it was in-house acquired. The treatment is Bacitracin ointment. The treatment is limited to what we can do. We did a urology referral; they looked at it and took the urinary catheter out and he had issues with being able to urinate and the catheter had to be put back in. The facility inquired about a supra pubic catheter. When Resident #74 was first admitted he did have a large gauge catheter tubing upon admission. We recommend continuing with urology. The surveyor had the wound care nurse review the wound photos and measurements for the penal erosion in the electronic medical record. Wound nurse A stated that Measurement is difficult. The photograph only measures the skin that it picks up as reddened and it does not pick up the full tear from the penis tip to the tear opening on the penis. I use an IPAD and have to hold the penis/wound in position and still take quality photos. In an interview on 05/15/25 at 11:33 AM, the Director of Nursing (DON) acknowledged that Resident #74's penal erosion came from the urinary catheter and was facility acquired. The DON stated that Resident #74 messes with his catheter. The erosion/tear was caused by the catheter, and we are treating it. He is seen by wound care nurse A, and the facility made a urology referral. But so far, we are just watching and treating the penal erosion/tear.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one resident's (Resident #24) trapeze (bed mobility device) was within reach out of five residents reviewed for assistive devices. Findings Include: Resident #24: On 5/13/2025 at approximately 2:20 PM, Resident #24 was laying in bed and her trapeze was not hanging in a place that was accessible to her as it was flipped over the stabilization bar its connected too. Resident #24 was asked if she was able to reach the trapeze and she stated she was unable to and attempted to reach for it but was unable to access it. On 5/14/2025 at 10:55 AM, Resident #24 was observed sleeping peacefully in bed. Her trapeze was not accessible to the resident as it was flipped over the bar. On 5/14/2025 at approximately 11:30 AM, a review was conducted of Resident#24's records and it revealed she admitted to the facility on [DATE] with diagnoses the included, Diabetes, Dementia, Atrial Fibrillation and Hypertension. Further review yielded the following: Care Plan I prefer a trapeze for bed mobility. Initiated on 8/15/2023 On 5/14/2025 at 3:27 PM, Resident #24 was observed with the DON (Director of Nursing) sleeping. Her trapeze was still not accessible to her. The DON reported she is not certain if staff flipped it up when they were providing care and did not place it back down. The DON stated she would follow up regarding the concern. On 5/14/2025 at 4:05 PM, Nurse Manager N reported Resident #24 does utilize the trapeze for mobility in bed and she was assessed as being safe to utilize the trapeze. She expressed understanding with concern. On 5/15/2025 at 8:50 AM, Therapy Director R reported she spoke with the resident yesterday who stated she recently stopped using the trapeze. Resident #24 was asked if they could remove it and she agreed with it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that one resident (Resident #25) of 2 residents observed had their dry nebulizer mask stored in a storage bag when not in use, resulting in the potential for cross contamination with respiratory infection, and increased antibiotic usage. Findings Include: Resident #25: Review of the Face Sheet, care plans dated 2/25 through 4/25, orders and electronic medication admission record/EMAR dated 4/25 and 5/25, revealed Resident #25 was [AGE] years old, admitted to the facility on [DATE], alert with a Guardian in place, and required staff assistance with all Activities of Daily Living. The residents' diagnosis included, chronic heart and lung disease, Alzheimer's Disease, weakness, acute on chronic respiratory failure with hypoxia, Myocardial Infarction, Anxiety Disorder, Adjustment Disorder, Depression, and cerebral aneurysm. Review of the residents' Physician orders dated 2/25, stated Albuterol Sulfate Inhalation Nebulization Solution 0.083% 3 ml inhale orally via nebulizer four times a day for COPD (chronic heart and lung disease). Review of the facility Nebulizer Process policy dated 1/25, stated Once completely dried (nebulizer mask), place in storage bag. Observation was made on 5/13/25 at 9:21 a.m., of the residents' nebulizer mask attached to oxygen tubing sitting on top of a plastic bag next to the nebulizer treatment machine. The mask was completely dry and not found in a storage bag. During an interview done on 5/13/25 at 9:21 a.m., Resident #25 stated I got my last treatment about 2 hours ago. Review of the residents' EMAR dated 5/13/25, revealed she had received her last breathing treatment at 0600 (6 a.m.). The mask had ample time to dry and be put in a storage bag. During a second observation made on 5/14/25 at 12:18 p.m., the residents' nebulizer mask attached to oxygen tubing was found sitting inside the closed top drawer of her nightstand next to the top of her bed. The oxygen tubing was hanging out of the drawer. During an interview done on 5/14/25 at 12:20 a.m., Clinical Nurse Manager, RN J stated They (nebulizer treatment masks) should be in a bag

Based on observation, interview and record review, the facility failed to store and discard medications for 4 of 4 medication carts reviewed, resulting in a lack of dating of multi-dose medications, opened and undated medications, and the potential for residents to receive medications with altered efficiency. Findings include: Record review of the facility 'Storage of Medications' policy dated 8/2024, revealed medications and biological's are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Section III: Expiration dating- 3. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic . blood sugar testing solutions and strips require an expiration date shorter than the manufacture's expiration date once opened to ensure medication purity and potency. Observation and interview on 05/13/25 at 09:22 AM with Registered Nurse (RN) D of the 300-unit medication cart revealed: Resident #59- Ventolin HFA 90mcq/ACT multi-dose inhaler. RN D stated that the resident no longer resided at the facility, but the medications were still in cart although not a resident. Resident #76- Albuterol HFA 90mcq/ACT multi-dose inhaler with no open date. RN D stated that the resident no longer resided at the facility, but the medications were still in cart although not a resident. Resident #80- Novolin Flex pen opened with on open date or expiration date noted. RN D stated that Insulin pens have a shorter use life of 28 days. Accu check 50 stick container opened and not dated. 2 white loose tablets in the second drawer of the med cart. Observation and interview on 05/13/25 at 09:33 AM with licensed Practical Nurse (LPN) B of the 200-unit medication cart revealed: Resident #57- latanoprost 0.005% Ophthalmic drops multi-dose bottle were opened and not dated with open date or expiration date. Accu check 50 strips container opened with no opening date. Resident #51- fluticasone 50mcq multi-dose bottle nasal spray opened with no date. Resident #6- fluticasone 50mcq multi-dose bottle nasal spray open dated 5/12/2025 no expiration date. Resident #6 also had Lantus Solostar multi-dose insulin pen with no open date on the insulin pen. loose white tablet located in the third drawer of medication cart. Resident #9- Albuterol sulfate multi-dose inhaler with no open dated noted. Resident #8- Lantus insulin multi-dose insulin pen- no open date noted on pen or expiration date. LPN B acknowledged that insulin pens do have a shortened expiration date once opened. Observation and interview on 05/13/25 at 10:21 AM with Licensed Practical Nurse (LPN) E of the 1A hall medication cart revealed: Three loose tablets in the second drawer of the medication cart: one oval yellow, one round tan and one round pink tablet. Resident #41 - Brimonidine 0.2% ophthalmic multi-dose eye drops with no open date on bottle one or the box. Dorzol/timolol 22.3mg/6.8 ophthalmic multi-dose eye drops with no open date noted. Resident #1 - Tresiba FlexTouch multi-dose pen with open date or expiration date. (Only good for 8 weeks after opening) Resident #22- fluticasone 50mcq multi-dose nasal spray opened with no dates. Acular 0.5% ophthalmic multi-dose eye drops container was opened with no date. Resident #25- Combivent Respimat 20/100 mcg/ACT multi-dose inhaler opened and used with no open date on device or box, pharmacy label noted to discard after 3 months. Oxymetazoline 0.05% multi-dose nasal spray opened with no open date or expiration date noted. Resident #5- Combigan 0.2-0.5% ophthalmic solution (Brimonidine Tartrate-Timolol) multi-dose eye drops opened with no open date or expiration date. discharged resident that no longer resided within the facility- Breztri aerosphere multi-dose inhaler opened and used with no open dates, left in the medication cart after resident discharged . Resident #69- ipratropium bromide solution 0.03% multi-dose nasal spray opened and used with no open date or expiration date noted on container. Resident #44- Abilify (aripiprazole) liquid 1mg/ml antipsychotic medication multi-dose bottle opened and not dated with open date. LPN E stated that she was not sure if dates needed to be added to the containers, or what the policy was. Observation and interview on 05/13/25 at 10:45ish AM with Licensed Practical Nurse (LPN) F of the 1B hall (front of hall) medication cart revealed: Accu checks sticks opened and not dated 6 left in bottle. Resident #7- Advair HFA 115-21 mcg/ACT aerosol multi-dose inhaler opened and used with no date, also Fluticasone propionates 50 mcg/ACT multi-dose nasal spray open and used with no open date on bottle or box. Resident #52- ipratropium-albuterol solution 0.5-2.5 (3) mg/ml nebulizer ampules/vials foil packet opened with no date on foil packet or box. Resident #17- Lantus insulin 10ml multi-dose bottle opened with vial top off with no open date, also, Fluticasone propionates 50mcq/ACT multi-dose nasal opened/used and not dated. Resident #54- Fluticasone propionates 50mcq/ACT multi-dose nasal opened/used and not dated. Resident #30- Fluticasone propionates 50mcq/ACT multi-dose nasal opened and not dated. one loose table peach colored in bottom drawer of cart with punch card medications. Record review of the facility 'Medication Administration' policy dated 1/2025 revealed implementation #12.) The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 1) Ensure that one resident's (Resident #38), who was on isolation precautions, room was free of soiled linen, 2) Ensure two residents (Residents #15, Resident #64) of 2 residents observed for wound care were free of cross-contamination, and 3) Ensure that kitchen staff wore hair nets properly (covering all hair) and that no artificial finger nails were allowed on kitchen staff while preparing foods, resulting in the potential for cross contamination, resident illness, and increased risk for infection during wound care. Findings Include: During the initial tour of the facility kitchen, Dietary Manager Q was had a hair net on, however on the right and left side of her face were long tendrils of hair that were not covered by the hair net. Dietary Manger Q also had long artificial nails at the time. During an interview done on 5/13/25 at 10:00 a.m., Dietary Manager Q stated I just got my hair done; no we are not supposed to have fake nails. During an interview done on 5/13/25 at 2:54 p.m., Infection Control Nurse, RN I stated she (Dietary Manager Q) should of had her hair in the hair net, and no artificial nails. During an interview done on 5/14/25 at 2:35 PM, the Director of Nursing/DON stated The CDC recommends clean cut own nails Review of the facility Preventing Forborne Illness-Employee Hygiene and Sanitary Practices policy dated 2001, stated Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. Resident #15: Observation and interview on 05/13/25 at 08:54 AM with Licensed Practical Nurse (LPN) B of Resident #15's peg tube site at abdomen. LPN entered the resident's room and did not apply enhanced barrier precautions (gown, or gloves). LPN B proceeded to lift Resident #15's shirt as she was laying on the bed. LPN B and surveyor observation of peg tube site was a double lumen access peg tube. Resident #15 was observed with scratch marks on her belly, with no dressing in place. Licensed practical Nurse B had to lift Resident #15's left breast to get the tube out from under the breast. Resident #64: Observation and interview on 05/14/25 at 07:29 AM with Licensed Practical Nurse (LPN) B of resident #64's skin. LPN B Checked the physician orders, due to the wound nurse was in the previous day, looking for updated orders. LPN B gathered wound care supplies of wound cleanser, alginate/Demarginate Ag, / gauze sponges/ Comfort foam border dressing. LPN B gathered a clean towel from the utility room and proceeded to Resident #64's room. upon entering Resident #64's room LPN B put on gown and gloves. Certified Nurse Assistant C and LPN B both proceeded to move the bed away from the wall and position Resident #64 on to her right side and lower the residents' pants, remove the brief, clean bowel material from the peri area and rectum. Observation of Resident #64's right hip dressing dated 5/12/2025. Observation on 05/14/25 at 07:41 AM with LPN B of Resident #64's Coccyx wound with heavy drainage observed and removed. Resident #64's sacral/buttock region is observed with 2 open areas. BM noted to bottom area; wash clothes used repeatedly to cleanse area. LPN then used a dressing package measure scale to measure the sacral wound at length 4.5cm x width 3.5cm open stage III to fingernail depth with under mining noted from 10 o'clock to 5 O'clock not measured. Serosanguinous bloody drainage noted as stage III pressure ulcer. Observation of a second smaller pressure wound measured at 3cm x 4cm stage III. LPN B applied wound cleanser spray, patted dry with gauze, (Did not change her gloves nor did the CNA after cleaning BM from buttock region). Nurse LPN B then open the package of Alginate treatment and ripped the alginate to size with gloves to fit wound bed area, packed the alginate into wound. Then nurse LPN B applied the foam boarder dressing to the wound. LPN B changed her gloves, but did not wash her hands or sanitize her hands, reapplied new gloves. LPN B then reached into her uniform pocket to obtain a black felt pen and dated the foam boarder dressing. Cross contamination during dressing change observation. Resident #38: On 5/13/2025 at 2:40 PM, Resident #38 was observed resting in bed as he awaited EMS (Emergency Medical Services) to transport him to the hospital. He explained he was going to the hospital because his wounds were not healing, and he has refused to go to dialysis in four days. He is going to the hospital to get it together. He explained he understands the risks of refusing dialysis, but it is five days a week and he is lazy. As we chatted there was a heap of soiled linen to include sheets, pillow, blanket, fitted sheet and other items observed atop the recliner. The linen had multiple areas with dried red substances on it. Resident #38 was asked when his linen was changed, and he shared that it was from this morning when the staff cleaned him up. It can be noted Resident #38 is on contact precautions and upon doffing PPE (personal protection equipment), it was found there was no soap in the dispenser by the entrance to the resident's room. Upon walking out of the room, Infection Control Nurse I was walking by. She was asked if Resident #38 was the only contact room on this unit and she reported it was. She was informed soap was not accessible in the dispenser in the residents room where staff would doff their PPE. Nurse I stated the soap should be stocked for staff/visitors to suitably wash their hands. Nurse I was also shown the pile of soiled linen atop of recliner and she agreed it should not be there. On 5/13/2025 at approximately 3:45 PM, a review was conducted of Resident #38's medical record and it indicated he was admitted to the facility on [DATE] with diagnoses that included Diabetes, Foot drop, Alzheimer's disease, Peripheral Vascular Disease, Dementia, Anxiety Disorder, End Stage Renal Disease and Chronic Kidney Disease. Further review yielded the following: Care Plan: I am at risk for MDRO infection r/t (related to): HDC skin .Contact precautions r/t possible C-Diff . initiated 5/1/2025 . On 5/15/2025 at 1:35 PM, Infection Control Nurse I, stated the soap dispenser in Resident #38's room was full as it had recently been replaced. She explained the bag was not fully engaged with the mechanism to dispense the soap. On 5/15/2025 at 1:40 PM, a review was conducted of Infection Control Worksheet, it showed Resident #38 was diagnosed with C. difficile, (is a bacterium that causes an infection of the colon) on 5/2/2025 and begin antibiotic therapy on 5/3/2025.

Based on observation, interview and record review the facility failed to 1). Maintain food service equipment (steam table lids, food trays, plate warmers and refrigerator, 2) Ensure kitchen cookware was sanitary and dry; and 3). Maintain the walk- in freezer to be free of ice/snow buildup, resulting in an increased potential for cross-contamination and foodborne illness for all residents who consume meals from the kitchen. Findings include: On 5/13/2025 at approximately 10:00 AM, a kitchen tour was completed in the presence of Dietary Manager Q and the following was observed: Refrigerator: - At the bottom corner of right door, the seal was observed to be ripped/flapping. - There were crumbled food particles in the bottom right-side corner of the door. - The outside bottom of the refrigerator had streaks/smears and Manager Q explained when they attempted to wipe it off it would not come off. A dampened towel was requested and upon wiping the soiled area the streak marks were easily removed. Trays/Plate Warmer: - Seven trays (located next to the juice machine) were jagged on the edge. Manager Q stated the trays were utilized to serve residents meals on. - Four- clean and ready for use plate warmers were found to be dirty with dried food particles on them. Steam Table: -Five of the lids, had one or two bent corners and dried food particles atop them. Garbage Can: -The lid had white substance observed on the push door. Clean and ready for use rack: -Four small, stacked, metal pans all found wet inside. -A bin of lids and seven of the metal coverings had dried food particles and/or unknown debris on them. -One -long, stacked baking pan found wet inside Back Kitchen Hallway: -Three- tier trolley with resident eaten meal tray atop it and one foot pedal on the second tier. The trolley had a pink unknown substance on the outside of it. Manager Q stated upon residents completing their meal staff are supposed to place the trays on the metal rack, not on the trolleys. Walk in Cooler: -Cooler has trail of water leading into the freezer Walk in Freezer: -Door frame, top of ceiling, above fan and the inside of the door there is thick snow and ice buildup. The buildup hinders the door from being able to close properly. - There is condensation with ice buildup on the plastic curtains leading into the freezer and the door frame. -A delivery was occurring at the time of the tour and the top of the boxes had wet marks from the ceiling of the freezer dripping on the boxes. -The floor in the freezer was visibly wet and tracking back into the walk-in cooler. Manager Q stated she recently noticed the buildup of the ice/snow in the freezer. On 5/13/2025 at approximately 1:15 PM, Maintenance Director M explained he was aware of the ice/snow build up in the walk-in freezer and its form the dietary staff not tightly closing the freezer door. Review was completed of the facility policy entitled, Sanitization, dated October 2008. The policy stated, .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessment and documentation of incompetency prior to enacting a Durable Power of Attorney (DPOA) and accurate documentation of advance directive forms for one resident (Resident #28) of two residents reviewed for Advance Directives, resulting in DPOA enactment prior to incompetency determination, medical decisions being made for the resident without legal documentation of determination of incompetency, including consent for psychoactive medications and the likelihood for the resident's care wishes to not be followed. Findings include: Resident #28: Record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance, dysphagia (difficulty swallowing), osteoporosis, failure to thrive, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to maximum assistance to complete Activities of Daily Living (ADL). Review of Resident #28's face sheet in the Electronic Medical Record (EMR) specified, Advance Directive . CPR (Cardiopulmonary Resuscitation) indicating the Resident wished all medical interventions to be completed in an emergent life-threatening medical situation. Review of the form entitled, Advance Directives/Medical Treatment Decisions in Resident #28's EMR detailed the option, I do not choose to formulate or issue any Advance Directives at this time. I want efforts made to prolong my life and I want life-sustaining treatment to be provided was checked. The form included a signature section with spaces for a Facility Representative, Resident, and Legal Representative signatures and dates. The only signature present in the signature section of the form was a facility Licensed Practical Nurse (LPN) with the date [DATE]. Below the signature section, the form included, If legal Representative signed, please complete the following Print Name . Relationship . Type of Legal appointment. This section was completed with Family Member M's name, relationship and indicated their legal appointment was POA (Power of Attorney). A Durable Power of Attorney for Health Care Designation dated [DATE] was present in Resident #28's EMR. The document identified Family Member M as the Resident's patient advocate and detailed, My Patient Advocate is not authorized to exercise any powers conferred under this Designation while I am able to participate in medical treatment decisions. My attending physician and one other physician shall determine, after examining me, when I am unable to participate in making my own medical decisions . Review of incompetency documentation in Resident #28's EMR revealed the date of the second physician signature determining the Resident was incompetent to make medical decisions was completed on [DATE]. Further review of Resident #28's EMR revealed an Informed Consent for Psychoactive Medications form for Seroquel (antipsychotic medication used cautiously in adults with dementia). The consent was signed by Family Member M on [DATE]. An interview was completed with Social Services Director A on [DATE] at 1:30 PM. Resident #28's Advance Directives/Medical Treatment Decisions form was reviewed with Director A. When queried regarding the form not including the Resident's signature in the signature section, Director A indicated Family Member A had signed the form in the Print Name section and stated, Form not completed correctly. When asked how they know that was Family Member M's signature, Director A verbalized understanding and revealed they had not completed the form. Director A was then asked if Resident #28 was deemed incompetent on [DATE] when the form was completed. Director A reviewed the Resident's EMR and stated, Second incompetency determination was signed on 5/9 (2024). When queried if Resident #28 was not deemed incompetent until [DATE], Director A confirmed. Resident #28's Informed Consent for Psychoactive Medications form for Seroquel was reviewed with Director A. When asked if Family Member A should have signed the Advance Directives/Medical Treatment Decisions form and the Informed Consent for Psychoactive Medications form for Seroquel when Resident #28 had not been deemed incompetent, Director A replied, I would say no. On [DATE] at 2:10 PM, the Administrator was informed of Resident #28's family member signing documentation prior to incompetency determination being completed by two physicians. The Administrator verbalized understanding and indicated they would address the concern. No further explanation was provided. A policy/procedure was requested from the Administrator on [DATE] at 2:10 PM but not received by the conclusion of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #23: On 6/03/24, at 10:08 AM, Resident #23 was resting in bed. Resident #23 had their eyes open and did not respond to verbal communication. On 6/04/24, at 9:15 AM, Resident #23 was resting in bed. Resident #23 had their eyes open. On 6/04/24, at 2:00 PM, a record review of Resident #23's electronic medical record revealed an admission on [DATE] with diagnoses that included Stroke, Developmental disorder and Dementia. Resident #23 was dependent on staff for all Activities of Daily Living (ADL's). A review of the care plan revealed I have an ADL self-care performance deficit d/t dementia, cerebral infarct, hemiplegia . Interventions . I am totally dependent on (2) staff for repositioning and turning in bed . Broda chair for comfort/positioning . A review of the [NAME] revealed . PATIENT CARE . change position to offload Alternate periods of rest with activity out of bed . On 6/04/24, at 4:15 PM, Resident #23 was resting in bed. Nurse F entered the room and was asked if Resident #23 gets assisted out of bed and Nurse F stated, yes, she does get up and the aides put her in her reclining chair and they usually placed her near the front office as she likes to look around. On 6/04/24, at 4:32 PM, the Director of Nursing was made aware Resident #23 was in bed since survey began. On 6/05/24 11:26 AM, Resident #23 was sitting up in their reclining wheelchair and appeared comfortable. Based on observation, interview and record review, the facility failed to ensure that hygiene care was provided to two residents (Resident #23 and Resident #28) of four residents reviewed, resulting in a lack of comprehensive documentation and provision of daily care, long, visible facial hair on a female resident, and the likelihood for feelings of psychosocial distress utilizing the reasonable person concept. Findings include: Resident #28: On 6/3/24 at 1:40 PM, Resident #28 was observed sitting in a wheelchair in their room with a food tray in front of them on an overbed table. The Resident was female and had multiple, visible, thick colored hairs on their chin. An interview was attempted to be completed at this time. When spoke to, Resident #28 was pleasantly confused and did not consistently provide appropriate responses to questions when asked. Record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance, dysphagia (difficulty swallowing), osteoporosis, failure to thrive, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to maximum assistance to complete Activities of Daily Living (ADL), including one person assistance for personal hygiene. On 6/4/24 at 4:00 PM, Resident #28 was observed in their room sitting in a wheelchair. The visible, long thick chin hairs remained visible. An interview was completed with Certified Nursing Assistant (CNA) Q. When queried regarding facility policy/procedure related to removal of facial and chin hair for female residents, CNA Q stated, We ask them first. When queried what they do if a resident refuses to facial hair removal, CNA Q replied, Tell the nurse. When queried if they document if a female resident refuses facial hair removal, CNA Q revealed there was no specific area to document refusal of shaving for females like there is for men. When asked what they meant, CNA Q showed this Surveyor their documentation screen in the EMR. Male residents had a specific section for shaving and female residents did not. The personal hygiene section of the CNA charting included multiple items such as washing face, brushing hair, and shaving. When queried regarding the personal hygiene task documentation in Resident #28's EMR being documented as completed and why the Resident's facial hair was not removed if the task was documented as completed, CNA Q revealed they document the task was completed if any of the items were done. An interview was completed with the Director of Nursing (DON) on 6/5/24 at 11:36 AM. When queried regarding Resident #28's chin/facial hair, the DON indicated the Resident frequently refuses care due to behaviors. When queried regarding documentation demonstrating the Resident had refused hair removal, the DON confirmed there was no specific area for documentation. The DON verbalized understanding. Review of facility provided policy/procedure entitled, Activities of Daily Living (ADL), Supporting (Reviewed: 9/2023) revealed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and operationalize a comprehensive Restorative Nursing program to ensure appropriate assessment, services, and treatment to maintain or improve Range of Motion (ROM) for two residents (Resident #36 and Resident #44) of two residents reviewed, resulting in a lack of ongoing and accurate assessment and documentation of Range of Motion (ROM) and contractures, a lack of implementation of Restorative Nursing services and residents with known contractures and limitations in ROM, and the likelihood for further decline in ROM, functional decline, and avoidable pain. Findings include: Resident #36: On 6/3/24 at 11:05 AM, Resident #36 was observed sitting in a wheelchair in their room. The Resident's right arm was bent at the elbow with their hand in a fist. Their arm was bent upwards and positioned against their chest. The wheelchair had one leg rest on the right side and the Resident's right foot was positioned on the leg rest. Their left foot was on the floor and the Resident was propelling themselves in the wheelchair in their room. An interview was attempted to be completed at this time. Resident #36 made eye contact when spoke to and made unintelligible verbalization and sounds when asked questions. When asked if they could move their right leg, Resident #36 did not provide a meaningful response. This Surveyor proceeded to point to Resident's right leg and ask them if they were able to move it, Resident #36 shook their head indicating they could not. This Surveyor then pointed at Resident #36's right arm and asked the Resident if they were able to move their arm and shook their head to indicate no. Record review revealed Resident #36 was originally admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, severe vascular dementia, and cerebral infarction (stroke) with right sided hemiplegia (one sided paralysis), dysphagia (difficulty swallowing), dysarthria (difficulty speaking), apraxia (brain damage where an individual understands but had difficulty with speech and/or performing tasks or purposeful movements upon request). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required substantial to maximum assistance with personal hygiene, bathing, and toileting. The MDS also detailed the Resident had one sided upper extremity impaired ROM. A review of Resident #36's previous MDS assessments dated 11/3/23 and 2/3/24 revealed the Resident required partial to moderate assistance for toileting and bathing and had impaired ROM on one side in their upper and lower extremities. On 6/3/24 at 1:52 PM, Resident #36 was observed sitting in their wheelchair in their room. The Resident's right arm remained bent upward at the elbow towards their chest and their hand was in a fist. Their right lower leg remained in place on the footrest. There were no splints and/or braces observed in the Resident's room. Review of Resident #36's Electronic Medical Record (EMR) revealed the Resident did not have a care plan in place for Restorative Nursing and/or completion of ROM. A care plan entitled, I have pain r/t (related to) . hemiplegia affecting right dominant side, reduced mobility, contractures affecting right hand and arm (Initiated: 10/26/22; Revised: 2/16/24) was noted in Resident #36's EMR. However, the care plan did not include any interventions related to Restorative Nursing Services and/or ROM exercises. Further review of Resident #36's EMR revealed a care plan entitled, I have an ADL self-care performance deficit d/t (due to) CVA (Cerebral Vascular Accident- stroke), right hemiplegia (Initiated: 10/26/22; Revised: 1/27/24). This care plan included the interventions: - Ambulation: I do not walk (Initiated: 7/12/23) - Bathing/Showering: I require extensive assistance by (1) staff with bathing/showering (Initiated: 1/30/23) - Bed Mobility: I require limited assistance by (1) staff to turn and reposition in bed (Initiated: 3/20/24) - Dressing: I require extensive assistance by (1) staff to dress . (Initiated: 1/30/23; 5/28/24) - Locomotion: I am independent for locomotion with use of high back w/c (wheelchair) with R (right) leg pedal . (Initiated: 9/11/23) - Splint/Brace Right arm elbow extension splint and resting hand splint, when up as I will allow. Skin inspection with donning/doffing (Initiated: 7/12/23; Revised: 6/5/24) Resident #36 had another care plan in their EMR titled, I am at risk for altered skin integrity related to decreased mobility . Hemiplegia affecting right dominant side, use of rt elbow extension splint and resting hand split, right arm trough to W/C (wheelchair), increased muscle tone . (Initiated: 10/26/22; Revised: 11/10/23). This care plan included the intervention, Assist me with donning my Rt (right) arm elbow extension splint and resting hand splint, when up as I will allow. Skin inspection with donning/doffing (Initiated: 1/31/23; Revised: 5/28/24). Review of Resident #36's [NAME] and Task documentation in the EMR revealed no tasks and/or documentation related to Restorative, ROM, and/or splint/brace use/application. Review of Resident #36's EMR revealed the Resident was at high risk for contracture development. Additional review revealed the following progress notes: - 12/19/22 at 12:24 AM: Physician/Practitioner Progress Note . Physiatry . No pain or discomfort was noted with a passive range of motion to the right upper extremity contracture . Neurologic: Mental status: Alert, attempting to verbalize. Speech is very difficult to understand Moving left upper and lower extremities with generalized weakness, right upper extremity flaccid, right lower extremity weakness . - 6/20/23 at 7:24 AM: Physician/Practitioner Progress Note . Chief complaints: Functional assessment medications review and clinical evaluation . Patient requires assistance in basic necessities and activities . daily life . requires assistance in cleaning for both upper and the lower half of the body . requires assistance with self-cleaning, grooming and changing. Patient also has difficulty ambulating. Transfers were also quite difficult and requires assistance . Joint examination revealed diffuse scattered deforming joint changes. Flexion contractures . - 8/15/23 at 10:26 AM: Skilled Note . For ADL function . independent for eating (with restorative nursing services to improve ability to eat/consume meals), independent for bed mobility (with restorative nursing services to improve ability to perform bed mobility), independent for transfers (with restorative nursing services to improve ability to perform transfers), independent for hygiene (with restorative nursing services to improve ability to perform hygiene activities), independent for ambulation (with restorative nursing services to improve ambulation/mobility). A review of Resident #36's Health Care Provider Orders revealed no order for Restorative Nursing Services. Resident #44: On 6/3/24 at 10:19 AM, Resident #44 was not in their room. Multiple splints/braces were observed in the room piled on top of their closet. Record review revealed Resident #44 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included Type 1 Diabetes Mellitus (juvenile diabetes or insulin-dependent), anoxic brain damage (brain injury caused by lack of oxygen), convulsions, abnormal posture, and depression. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required maximum to total assistance to complete all Activities of Daily Living (ADL) including eating. The MDS further detailed Resident #44 had impaired ROM in both upper and lower extremities. On 6/4/24 at 7:47 AM, Resident #44 was observed in their room. The Resident was in bed, positioned on their back. An interview was completed at this time. When queried regarding the level of assistance they require from staff to get out of bed, Resident #44 revealed they are unable to walk and are transferred by staff using a Hoyer (mechanical) lift. Resident #44's arm movements were stiff, and they did not bend their arms at their elbows. Their right hand was visible over and was noted to be open with the fingers spaced and held straight. When queried if they were able to bend their fingers inward to make a fist, Resident #44 revealed they could not. When asked if they were able to bend their elbows, Resident #44 bent their elbow slightly but did not display full ROM. When queried regarding picking up items like a cup or silverware, Resident #44 revealed they were unable to grasp a cup without a handle. Resident #44 then stated, Supposed to have a thing to hook on my hand but I'm waiting on that. When asked what the device was for, Resident #44 revealed they could not hold silverware but the device for their hand would allow someone to hook it on their hand (universal cuff- device that slides over the hand to provide control and independence with eating and other tools). When asked why they were waiting, Resident #44 replied the one they had gotten was too big and the facility was supposed to be getting them a smaller one. Resident #44 was asked if they were able to move and bend their legs and revealed they had minimal movement in their lower extremities. When queried if they were receiving Therapy, Resident #44 revealed they had in the past but not currently. When queried if they were receiving Restorative Nursing services and if the facility staff were assisting them to complete ROM exercises, Resident #44 verbalized that staff used to stretch them and complete ROM exercises, but not anymore. When asked why they stopped, Resident #44 was unable to provide an explanation. Resident #44 then stated, We do chair exercises in activities. When queried if that was part of the facility Activities program, Resident #44 confirmed it was. Resident #44 was asked what they do during chair exercises and revealed they follow along with what they are able to do by themselves. When queried regarding all the braces on top of their closet, Resident #44 confirmed they were braces for their legs and arms. When asked if they wear the braces, Resident #44 replied, When they (staff) tell me. Resident #44 was then asked how they wear the braces and revealed they rarely wear them because no one tells them. On 6/4/24 at 12:19 PM, Certified Nursing Assistant (CNA) T was observed feeding Resident #44 lunch. The Resident had built up silverware on their tray but did not have a universal cuff/adaptor. Review of Resident #44's EMR revealed a care plan entitled, I have an ADL self-care performance deficit r/t h/o (history of) anoxic brain damage, abnormal posturing, muscle weakness, ataxia (lack of coordination and muscle control in arms and legs). I require extensive assist of staff for ADL (Initiated: 4/20/17; Revised: 2/21/24). The care plan included the interventions: - Resident to wear B/L (bilateral) KAFO (Knee, Ankle, Foot Orthosis- brace which extends from the thigh to the foot and is used to stabilize the leg joints, maintain alignment, and assist muscles) daily as I request and tolerated. Skin inspection to be completed prior to donning and doffing (Initiated: 10/9/20; Revised: 3/22/23) - Ambulation: I do not ambulate (Initiated: 7/12/23) - I use Broda chair (wheeled, reclining chair with solid leg/foot rest oftentimes used for positioning) (Initiated: 1/6/18; Revised: 2/2/23) - Transfer: I require total Mechanical Lift with (2) staff assistance for transfers . (Initiated: 4/20/17; Revised: 4/15/24) - Bed Mobility: I require extensive assistance by (1) staff to turn and reposition in bed (Initiated: 7/11/22) The care plan also included the discontinued interventions: - Resolved: Passive ROM Wrist flexion extension bend the wrist up and down, affected hand and wrist should be fully relaxed. 10xs (times) hold 3 second to sets BID (Twice a Day). Also use your thumb to slowly open up contracted hand. While cupping the hand with your fingers continue to slowly apply pressure using your thumb to the patient's fingers in the direction of the extension. Be aware that full extension may not be achievable. Proceed as resident will allow. 5xs (times) 5 sec 2 sets BID (Initiated: 7/26/21; Discontinued: 9/23/22) - Resolved: Right wrist support to be applied in the morning, removed at hs (bedtime) . (Initiated: 8/13/18; Discontinued: 1/1/20) - Resolved: I am to wear my CTS brace (brace which holds wrist in neutral position) on left hand during the day time hours . (Initiated: 7/9/21; Discontinued: 9/23/22) A review of Resident #44's [NAME] revealed no mention of ROM, Restorative Nursing, and/or brace/splint application. Review of Resident #44's Active, Completed, Discontinued, On hold, Pending Clinical Review, Pending Confirmation, Pending Order Signature, Struck out Health Care Provider Orders in the EMR revealed the Resident did not have a current and/or discontinued order for Restorative Nursing and/or ROM. Further review revealed the Resident did not have an active order for KAFO brace use. Further review revealed the Resident the most recent order for Physical Therapy (PT) was dated start: 8/17/23 and end: 10/12/23. The order specified, Skilled PT 3 x per week . as needed for 8 Weeks . The most recent Occupational Therapy (OT) ordered detailed, Effective 8/17/23, Skilled OT 3 x per week for 8 weeks . (Ordered: 8/18/23; Discontinued: 11/2/23) Review of documentation in Resident #44's EMR revealed the Resident was known to have contractures. Review revealed the following progress notes: - 1/7/22 at 5:41 PM: Nursing/Clinical . Resident noted to have R (right) sided contracture . - 7/25/22 at 4:57 PM: Physician/Practitioner Progress Note . Physiatry (rehabilitation medicine) progress note . The patient was seen for ongoing contracture management . being followed for bilateral lower extremity contracture . uses braces for support . Extremities . Bilateral foot deformity noted. Unable to fully extend the bilateral lower extremity, knee and hip contractures were noted. Tightness of the hamstrings and Achilles noted. Neurologic . Moving all extremities with lower extremity weakness left is greater than right. Weakness of the upper extremities also, hand grasp is poor . Right lower extremity spasticity. Left lower extremity spasticity . - 8/16/23 at 9:12 AM: PMR (Physical Medicine and Rehabilitation) Initial Evaluation . Mobility and ADL dysfunction secondary to mechanical fall . (Resident #44) is a [AGE] year-old . Neuro: Mental status: Alert and oriented . Moving all extremities with generalized weakness. Mild contractures of all extremities. Sensation grossly intact to light touch . Patient has high risk for developing contractures . An interview was completed with Licensed Practical Nurse (LPN) P on 6/4/24 at 4:30 PM. When queried regarding the braces observed in Resident #44's room, on top of their closet, LPN P stated, That was from their fracture. When asked what fracture they were referring to, LPN P replied, (Resident #44's) leg got fractured when they were transferred in the facility transport van. LPN P was then queried regarding Resident #44's ROM and revealed the Resident had upper and lower extremity limitations. When queried if Resident #44 was able to grasp a Styrofoam cup to drink from it, LPN P stated, No, not be to grab that but they would be able to use a cup with a handle. With further inquiry, LPN P specified the Resident was unable to close their hand into a fist. LPN P was asked if the Resident had contractures and revealed they were unsure. An interview was completed with Physical Therapy Assistant (PTA) R and Physical Therapist (PT) S on 6/5/24 at 9:43 AM. When queried if Resident #44 was receiving OT or PT, the staff responded the Resident was not. PT S revealed Resident #44 had not been on PT caseload for quite some time. When queried regarding if Resident #44 had contractures, PT S verbalized the Resident had limitations in ROM. When asked if the Resident was receiving Restorative Nursing Services, PTA R stated, No Restorative and verbalized the facility did not have a Restorative Nursing Program in place for ROM. When asked how contracture development and/or worsening of limitations in ROM were prevented if PROM and/or AROM were not completed/performed. PTA R stated therapy staff encouraged residents to complete ROM exercises following therapy discharge. At 9:59 AM, Occupational Therapist Therapy Director D joined the interview. When queried regarding progress note documentation in the EMR indicating Resident #44 had contractures and documentation of PT and OT evaluations and assessments of the Resident, Director D revealed they would need to ask for assistance due to the company switching documentation systems and not having access to prior documentation. The Therapy Staff were then asked if they were assisting Resident #44 to obtain and use a universal cuff for their hand to promote independence and self-feeding, the staff revealed they were not aware the Resident needed the adaptive equipment and indicated Resident #44 preferred to have staff feed them. When queried if Resident #44 was supposed to wear the KAFO brace as indicated in their care plan, Therapy Staff revealed the Resident had not been assessed for brace use recently. When queried regarding the facility process/procedure for Restorative Nursing services including referrals following therapy, Director D then stated that the facility was implementing a walk to dine program for a few residents and were in the beginning stages of developing a Restorative Program. When asked if the facility had a Restorative Certified Nursing Assistant (CNA) and/or staff, Director D indicated floor CNA's were responsible for walking residents on the walk to dine program to the dining room. The Therapy Staff were then asked if Resident #36 was receiving therapy services and PT S responded they were not. When queried if Resident #36 had impaired ROM, PTA R, PT S, and Director D confirmed they did. The staff were then asked where the Resident had impaired ROM and indicated their right arm and right leg. When queried why the MDS assessment dated [DATE] specified the Resident had impaired ROM in one upper extremity but no impairment in their lower extremities, PT S replied that Resident #36 had limited ROM in their right upper and right lower extremities but only had a contracture in their right upper extremity. The Therapy Staff were then asked if the Resident's ROM had improved as the two prior MDS assessments specified the Resident had impaired ROM in one upper and one lower extremity, Director D replied that therapy services do not complete the MDS assessments, and they were unable to provide an explanation. When queried regarding the Resident's contracture and ROM, PT S deferred to PTA R to respond. PTA R replied, Right side Passive ROM (PROM) is okay with active assist (someone else moves extremity). PTA R revealed Resident #36's contracture is in their right upper extremity and detailed they have increased tone in the extremity. Director D revealed Resident #36 tenses and had pain. When queried why the Resident was not receiving ROM to prevent worsening of the contracture and/or additional contracture development, PTA R indicated the Resident has ROM completed when staff assist them to get dressed. When queried if the ROM performed when getting dressed is the same as purposeful ROM exercises to stretch muscles, PT S and PTA R confirmed it was not and did not provide the same benefit as purposeful ROM completion. Director D then stated, (Resident #36) has an elbow splint and hand splint in their room. When queried how frequently staff should apply the splints and how long the Resident should wear them at a time, Director D stated, Per (Resident #36's) choice. When asked what per their choice meant, Director D indicated it meant what the Resident wanted. When queried why the splints were not observed in Resident #36's room and the Resident had not been observed wearing them, a response was not provided. When queried how staff know to apply the splints, Director D responded it was on the Resident's care plan. When queried where staff document splint application, Director D reviewed the EMR and stated, Splints were not on the [NAME], so it does not show for the CNA's (Certified Nursing Assistant) to do and document. Director D indicated they were going to add the splints to the Resident's [NAME]. When asked if staff would have to document if the splints were offered, applied, and/or refused if they added it to the [NAME], Director D revealed staff would not have to document application. With further discussion, Director D verified they were unable to track if the splints were utilized or not due to lack of documentation. Resident #36's most recent Physical and Occupational Therapy Evaluation and Discharge documentation were requested for review at this time. Director D revealed they were only able to access Resident #36's Occupational Therapy documentation at this time due to the change in documentation systems. Review of the provided Occupational Therapy (OT) . Evaluation & Plan of Treatment dated, Start of Care: 3/19/24 revealed, Current Referral: Reason for Referral/Current Illness: Pt (patient) referred to OT services following nursing report of increased weakness and recent fall during toilet transfer . Musculoskeletal System Assessment . UE (Upper Extremity): RUE (Right Upper Extremity) ROM = Impaired; LUE ROM = WFL (Within Functional Limits). RUE ROM - Shoulder = Impaired; Elbow/Forearm = Impaired; Wrist = Impaired; Hand = Impaired; Thumb = Impaired; Index Finger = Impaired; Middle Finger = Impaired; Ring Finger = Impaired; Little Finger - Impaired. AROM (Active Range of Motion) - (R) Shoulder: Flexion = 0 (degrees); Extension = 0 (degrees); AROM - (R) Elbow/ Forearm: Flexion = 0 (degrees); Extension = 0 (degrees); AROM - (R) Wrist: Flexion = 0 (degrees); Extension = 0 (degrees); RUE Strength = DNT (Did not Test); Clinical Reason(s) = Other (contracture) . Contracture: Functional Limitations Present due to Contracture = Yes . Will OT treat to address Contracture impairment? = no, Nursing is managing patient's contracture impairment . Review of the provided Occupational Therapy (OT) . Discharge Summary signed 5/27/24 for Dates of Service: 3/18/24-5/24/24 revealed Skilled Interventions provided: Direct hands on care with patient . focused on the following skilled interventions: LUE (Left Upper Extremity) strengthening, decreased extensor tone and increase truck, pelvic ROM, functional transfer and ADL (Activity of Daily Living) training . Discharge Recommendations and Status . Restorative Programs: Restorative Program Established/Trained = Not Indicated at this Time . Prognosis to Maintain CLOF (Current Level of Functioning) = Good with consistent staff follow-through . The Therapy staff were asked why Restorative was not recommended for Resident #36, Therapy Director D stated, We could. When asked if someone with a known contracture and risk for additional contracture development should receive Restorative/ROM services to prevent further ROM limitations and contracture development, a response was not provided. When asked if anyone was able to access the prior documentation system, Director D revealed they would contact someone else in their company to request Resident #36 and Resident #44's therapy documentation. On 6/5/24 at 10:45 AM, Therapy Director D provided OT documentation for Resident #44. Review of the OT Evaluation & Plan of Treatment for Certification Period: 8/14/23-10/9/23 revealed the Resident was revered to therapy for Restoration, compensation, and adaptation and their goal was I want to do more for myself so I can get out of here. The evaluation did not include any assessment/documentation of degree of ROM but indicated upper extremities were within functional limits (WFL- less than normal). When queried how they were able to thoroughly assess and determine if the Resident's ROM is declining without measurements, Director D confirmed they could not. PT and OT documentation for comparison from the previous documentation system were requested again at this time for Resident #36 and Resident #44. On 6/5/24 at 10:49 AM, an interview was completed with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). When queried regarding the facility Restorative Nursing Program, the DON stated, We are working on expanding the program. When asked what they currently had in place, the DON stated, There are a couple people (residents) on functional maintenance. We are working on getting them to walk to meals. The DON was asked if that was the walk to dine initiative Therapy Manager D had referred to and they confirmed it was. When queried who was in charge of the Restorative Nursing Program, the DON replied, (Therapy Manager D) and the MDS nurse. When asked if the facility had a dedicated Restorative CNA, the DON revealed they did not. When queried regarding Resident #36, the DON verified the Resident had a contracture. The DON was then asked why the Resident was not receiving Restorative nursing services and/or specific ROM exercises to prevent further contracture development and/or worsening limitations in ROM and did not provide an explanation. When queried regarding Resident #44 including documentation of contractures, lack of measurements of degree of movement to identify worsening contractures/limitations, and the DON verbalized understand but did not provide further explanation. When asked about the MDS documentation change pertaining to ROM limitations and lack of therapy evaluation to demonstrate, the DON indicated there must have been an error. When queried regarding concerns related to assessment, documentation, and provision of services related to contractures and limitation in ROM, the DON verbalized understanding and reiterated the facility is in the process of developing and implementing a Restorative Nursing Program. No additional PT and/or OT documentation for Resident #36 and/or Resident #44 was received as requested prior the completion of the survey. A policy/procedure pertaining to Restorative Nursing was requested from the facility Administrator on 6/5/24 at 1:29 PM but not received by the conclusion of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure adequate staff training, equipment monitoring, prevention, reporting, investigation, and a thorough analysis of accidents for one resident (Resident #44) of four residents reviewed for falls, resulting in a lack of reporting, thorough investigation, comprehensive procedures to prevent accidents, Resident #44 experiencing a fractured tibia and fibula bones (both bones in lower leg) necessitating emergency medical treatment, unnecessary pain, and the likelihood for decline in overall functioning and health status. Findings include: Resident #44: On 6/3/24 at 10:19 AM, Resident #44 was not in their room. A raised edge mattress was present on the Resident's bed and multiple splints/braces were observed on top of the Resident's closet. Record review revealed Resident #44 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included Type 1 Diabetes Mellitus (juvenile diabetes or insulin-dependent), anoxic brain damage (brain injury caused by lack of oxygen), convulsions, abnormal posture, and depression. Bicondylar right tibia fracture (severe fracture also known as a tibial plateau fracture where the tibia breaks into two or more fragments) and right fibula shaft fracture were added to the Resident's diagnoses on 8/16/23. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required maximum to total assistance to complete all Activities of Daily Living (ADL) including eating. The MDS further detailed Resident #44 had impaired ROM in both upper and lower extremities. On 6/4/24 at 7:47 AM, Resident #44 was observed in their room. The Resident was in bed, positioned on their back. An interview was completed at this time. When queried regarding the level of assistance they require from staff to get out of bed, Resident #44 revealed they are unable to walk and are transferred by staff using a Hoyer (mechanical) lift. When asked if they had fell at the facility, Resident #44 stated, My right leg got broke because they didn't secure me right in my chair. With further inquiry, Resident #44 revealed they were in the facility transport van to go to an appointment and when the driver stepped on the brakes, they slid out of their wheelchair and their leg got broke. When asked what chair they were in, Resident #44 revealed it was the same chair they currently use and indicated the Broda Chair (wheeled, reclining chair with solid leg/footrest oftentimes used for positioning) in the room. With further inquiry, Resident #44 revealed there were two staff present in the transport van when the incident occurred, and the staff picked them up and put them back in their wheelchair. Resident #44 verbalized that by the time they returned to the facility their right leg was extremely swollen and they were in extreme pain. Resident #44 was asked if they went to the hospital and responded that they came back to the facility and then went to the ER. When asked, Resident #44 indicated they were not a candidate for surgery and revealed they returned to the facility with a brace. When queried regarding mobility and movement, Resident #44 revealed their mobility decreased following the accident. Review of Resident #44's Electronic Medical Record (EMR) revealed the following: - 8/15/23 at 11:08 AM: SBAR/Change in Condition . Situation . Falls . Pain (uncontrolled) . Started on 8/15/23 . Morning . Functional Status Evaluation . Changes . Fall . Associated with any suspected serious injury . Edema . RLE (Right Lower Extremity) . Pain . Rate pain on a scale of 0 to 10 (0=no pain, 4-5=moderate pain, 10=excruciating pain) = 9 . Marked localized bruising, swelling, or pain over joint or bone . RLE . Things that make the condition or symptom worse are: movement or palpitation . Send to ER for eval and treatment . - 8/15/23 at 11:59 AM: IDT Note . send to ER for eval and treatment for right leg pain. - 8/15/23 at 12:34 PM: IDT Note . IDT day 1 . Resident was secured and during transport. During this resident was noted to have slid forward and out of chair onto buttocks. Resident returned and further eval and treatment per PCP (Primary Care Provider) at ER . - 8/16/23 at 11:22 AM: IDT Note . Fall note day #2: Resident remains at hospital for observation at this time . - 8/16/23: PMR initial evaluation . Date of Service: 8/16/23 at 1:12 PM . Hospital Course . presented to the acute hospital with mechanical fall, right leg pain and generalized weakness. According to the hospital notes, x-rays of the right ankle and foot showed right distal fibula fracture, x-rays of right tibia and fibula showed right proximal tibia (larger bone in lower leg) and fibula (smaller bone in lower leg) fracture, comminuted (bone broken into three or more pieces) and displaced (bone broken with space between the broken bones). The note reported that when (Resident #44) was on their way to an appointment in Bay City when the seat belt strap on their wheelchair broke, this resulted in (Resident #44) falling out of the wheelchair and their right leg got caught under the wheelchair .seen by an Orthopedic surgeon and was recommended non-operative treatment with right standard hinged knee brace . readmitted . on 8/16/23 . Assessment/Plan . Recommend continuing therapy; Pain 6/10 Oxycodone (narcotic pain medication). Tylenol . - 8/16/23 at 2:23 PM: Nursing/Clinical . Patient arrived from Covenant hospital by stretcher. Patient is readmit due to a rt (right) Tibia and fibula fracture . - 8/16/23 at 3:50 PM: Nursing/Clinical . Upon arrival patient appeared to be experiencing a lot of pain by moaning and crying. I the writer had given patient pain medication which appeared to be effective . Review of requested Incident and Accident (I and A's) for Resident #44 revealed an Incident and Accident Form dated 8/15/23 at 11:25 AM. The form detailed, Fall . Location: Outside . Nursing Description: Resident was out to appointment wearing pick cotton leggings and grey shirt and resident was in specialty chair in van with driver and staff present. Resident was secured in van prior to leaving facility and resident slid out of chair onto floor of van onto buttocks. Resident was placed back into chair and returned to facility. Resident returned to facility and assessment completed and PCP (Primary Care Provider) ordered for eval and treatment. Resident Description: Resident stated that they slid when van turned onto buttocks and did not hit had and stated that . thought was ok when it occurred . Immediate Action Taken: w/c (Wheelchair) assessed and in proper working condition. Van assessed and seatbelts in proper working condition. Education on seatbelt use. Resident was assessment and PCP and family notified and sent to ER for eval and treatment . No injuries observed at time of incident . Witnesses: Certified Nursing Assistant (CNA) V . No additional investigation documentation was provided by the facility. An interview was completed with the Director of Nursing (DON) and facility Administrator on 6/5/24 at 8:02 AM. When queried regarding the incident involving Resident #44 on 8/15/23, the DON revealed they were not in their current position at the time of the accident. The Administrator stated, (Resident #44) went out for an appointment in our van. When the brakes were applied, (Resident #44) slid out of their chair. When queried if the transport van in use when the incident occurred was the same van currently in use at the facility, the Administrator stated, We don't have that van anymore. When queried if the facility reported the incident to the State Agency, the Administrator stated, No, nothing reportable. When asked how the Resident slid out of their chair and broke their leg if they were properly secured in their wheelchair, the Administrator stated, When we went and investigated it, the seat belt buckle clicked but it didn't actually engage. It was able to be pulled apart with a little force. The Administrator continued, When (CNA V) hit the brakes it was enough to come apart. When queried regarding if there were other staff and/or other residents in the van at the time of the incident, the Administrator stated, (CNA V) was the only one in the van. When asked, the Administrator revealed CNA V was a CNA who had recently transferred position in the facility from a CNA to the Transport Staff position. When asked why the Incident and Accident Report specified there were two staff members, the driver and staff member, in the van, a response was not provided. The Administrator was then queried regarding CNA V and revealed they were no longer employed at the facility. When asked the reason CNA V was no longer employed at the facility, the Administrator verbalized their employment was terminated because they did not notify the Administrator immediately of the incident. With further inquiry, the Administrator verbalized CNA V did not notify anyone at the facility until the Resident returned from their appointment. When queried if the facility completed an investigation including interviews/witness statement related to the incident, the Administrator replied, No statements. When asked why they did not obtain interviews and complete a thorough investigation, the Administrator replied, (Resident #44) can tell you what happened. Any facility investigation documentation, other than the Incident and Accident Report, pertaining to the incident as well as CNA V's personnel and training file were requested at this time. A follow up interview was completed with Resident #44 on 6/5/24 at 9:09 AM. When queried regarding their right leg fracture in the facility wheelchair van, Resident #44 stated, My legs got caught. When what they meant, Resident #44 explained that their legs went under the bottom of their Broda chair and got caught. Resident #44 then stated, They had to pull my legs out. Resident #44 was asked who was with them in the transport van and pulled their legs out and replied, The driver (CNA V) and (CNA W). This Surveyor proceeded to imitate the calves of their legs being under a chair with their body forward as though on the ground and asked the Resident is that was how their legs were when they fell. Resident #44 confirmed and verbalized their legs got caught under their Broda Chair. When asked where the rest of their body was, Resident #44 revealed they could not really remember because they were focused on their legs. Resident #44 then stated, My right was swollen completely up by the time they got back to the facility. Resident #44 was asked who secured them in the van and buckled the seat belt and replied, CNA V. With further inquiry, Resident #44 revealed the van had a shoulder and lap belt and stated, The one to go across my waist didn't clamp all the way. When asked if the staff member pulled on the seat belt to ensure it was latched or clamped after connecting it, Resident #44 replied, They didn't pull on it. The Resident indicated they heard a click and assumed it was latched. Resident #44 stated, It's my fault. When asked why they felt like it was their fault Resident #44 displayed signs of emotional distress including tearfulness and stated, (The Administrator) told me it was their fault, and they should have checked it. (The Administrator) felt like it was her fault, so I told her it was my fault. I told her I would them (State Surveyors) it was my fault. Resident #44 continued, (The Administrator) cried for days after it happened. She is the only one here for me that love me. When asked if the Administrator had spoken to them following our first conversation, Resident #44 revealed they had and stated, I talked to (the Administrator) about and told her I talked to (State Surveyors) about it. I don't want (Administrator) to get in trouble. Resident #44 revealed they had no where else to go and indicated they were concerned what would happen to them if the Administrator got in trouble. When asked why they were concerned what would happen to them and why they weren't concerned before speaking to the Administrator when they told this Surveyor about the incident initially, Resident #44 did not provide a direct response but verbalized they did not want there to be any confusion. This Surveyor reviewed what they were told by Resident #44 with them. Resident #44 confirmed that was what happened. When queried regarding the van, Resident #44 stated, Got the new bus after that. When asked how long after the accident, Resident #44 indicated it was right away but was unable to provide a specific amount of time. A review CNA V's employee and education file on 6/5/24 at 11:15 AM. The file did not contain documentation of education related to demonstration of competency related to transportation of Residents including securement of Residents and safety belts. The following was present in the file: - Driver Safety Responsibilities document signed by CNA V on 8/9/23. The document included, Seat Belts: A. The driver and passengers are required to wear seat belts and shoulder harnesses . - Van Driver Job Position Description signed by CNA V on 8/9/23. - Employee In-Service/Education Attendance Record dated 8/15/23 and signed by CNA V. The document specified, Summary of Content: Review of Van/Bus Securement of residents. Review of reporting incidents to supervisors at time of occurrence. Review of first aid box and when to utilize and report to supervisor. An interview was completed with the DON on 6/5/24 at 11:34 AM. When queried how long the facility has had the new transportation van, the DON replied, Not sure. CNA V was attempted to be contacted via phone at the number provided by the facility on 6/5/24 at 12:45 PM. The phone number provided was not in service. On 6/5/24 at 12:50 PM, an interview was completed with the Administrator and DON. The Administrator and DON were informed that the phone number provided for CNA V was not in service and asked if an alternative phone number was available. When queried what had happened to the transport van that Resident #44 was injured in, the Administrator indicated they thought it had gone to a sister facility but were unsure of the date. Information regarding the facility van was requested at this time including year, model, maintenance documentation, and wheelchair safety belts. The alternative number provided for CNA V was called on 6/5/24 at 1:00 PM. A voicemail message with request for return phone call was left. A review of additional investigation documentation pertaining to the incident involving Resident #44 on 8/15/323 was reviewed. The following information was provided: - Disciplinary Action Form . Date . 8/15/24 (sic) . Nature of Offense . Suspension pending investigation for transport incident . The form was signed by the Administrator on 8/15/24 (sic) and not signed by CNA V. - Transportation Audit form with the columns, Name; Date; Concerns; Initials. The audit form did not specify what was being audited nor did it include the names/signatures of the individuals whose initials were included in the initial column of the form or documentation of training/competency for those individuals. An interview was conducted with Maintenance Director C on 6/5/24 at 1:52 PM. When queried, Director C confirmed they were familiar with the incident when Resident #44 suffering a fractured leg while being transported in the facility van. When queried regarding the Van and the wheelchair securement devices including safety belts, Director C revealed the safety belts for the wheelchairs are not a factory part. Director C verbalized that after the accident occurred, the seat belt was checked, and it made the click sound when inserted but would when pulled without pressing the release button. Director C verbalized that the belt was changed after the accident involving Resident #44. When asked when the belt was changed and when it was ordered, Director C revealed they did not order a replacement as Corporate Maintenance Consultant X had extras on hand and did not have documentation of when the belt was changed. When queried who monitors safety recalls for aftermarket parts such as the safety belt and ensures compatibility, Director C replied, (Corporate Maintenance Consultant X) checks them. When asked if they kept the belt in place which was replaced following the accident, Director C replied that the Administrator had a video on their phone, but they had not kept the belt. When queried how many residents and/or staff the previous van held, Director C replied, Had a bench for two ambulatory residents and one or two wheelchairs, I'm really not sure. When queried regarding routine inspection and/or checks or the transportation van, Director C indicated everything was completed in the facility TELS system for work orders. Documentation related to the transport van in use at the facility in August 2023 was requested again at this time. CNA W was attempted to be contacted via phone on 6/5/24 at 2:10 PM, A voicemail message with return phone number was left but a return phone call was not received. A follow up interview and review of transportation van documentation was completed with Maintenance Director C on 6/5/24 at 2:15 PM. When queried, Director C revealed they received the documentation from the Administrator. Review of provided documentation related to the transportation van included the following: - TELS work order history with 2008 Ford E350 written on the front - Bus/Van Maintenance Checklist sheet specifying Use the Maintenance Checklist on all Bus/Van Functions. Including Wheelchair lift lubrication and safety check. Schedule major repairs/oil changes accordingly. Dates for monthly Task Completion were included for January to December 2023 with No uploads of logs or Docs written next to the Task Completion section. - Safety Inspection list with a list of items including, 11. Seat belts not frayed, cut or torn and are in good working order. The list also included a Task Completion section which detailed, Marked done on time by (Maintenance Director C) on 9/29/23, 10/31/23, 11/21/23, and 12/29/23. No uploads of logs or Docs was handwritten next to the Task Completion section on the provided documentation. Note: No documentation of Safety Inspection completion was provided for January to August 2023. Maintenance Director C was asked why no Safety Inspection completion task documentation was provided for January to August 2023 and indicated they were not sure. When queried what the did when checking the seat belts during the Safety Inspection and stated, Make sure they aren't frayed or torn. When asked if they connected or latched the belts, Director C indicated they would make sure they click and release when pushed. When queried if they would pull on the belt to ensure it was engaged as part of the Safety Inspection, Director C replied, I do now. When queried regarding transportation staff training, Director C verbalized they show staff how to transport and secure residents in the transport van. When asked if a form or checkoff sheet was utilized as part of the training process to show what each transportation staff member had been trained to do and had demonstrated competency in, Director C stated, Not a check off. Director C was asked how they document and show what tasks staff have been trained and demonstrated competency in without a check off and stated, I understand what you're saying. Do not have one, but I will make one. On 6/5/24 at 3:08 PM, an interview was completed with the facility Administrator. When queried if there was any additional investigation completed and/or documentation related to the accident involving Resident #44, the Administrator verbalized they were attempting to upload the video of the seat belt, but all other documentation had been provided. The Administrator was then asked what time and where the accident occurred where Resident #44 came out of their wheelchair and revealed they did not know. When asked if it was on their way to their appointment in Bay City, the Administrator stated, On their way there. When asked where Resident #44's appointment was in Bay City, the Administrator indicated they were not sure of the specific location. The Administrator was then asked what time the Resident left the facility and returned on 8/15/23. The Administrator reviewed a calendar and other EMR communication notes not accessible to State Surveyors and stated, Pick up time was 7:00 AM and got back around 11:00 AM. When asked, the Administrator confirmed the drive to Bay City was approximately 30 minutes depending on traffic and the specific location of the appointment and the accident which resulted in Resident #44's fractured leg had occurred on the way to the appointment. A review of the video provided by the facility was completed. The video did not include a date/time stamp nor any other identifying information to demonstrate the vehicle in which the video taken. In the video, an individual is seen connecting the metal tongue of a seat belt into the buckle. A click can be heard and then the metal tongue is pulled out of the buckle without depressing the release button. An interview was conducted with the Administrator on 6/5/24 at 4:17 PM. When queried if CNA W was in the transport van with CNA V on 8/15/23 when Resident #44 was injured, the Administrator replied they were not sure. Review of EMS documentation for Resident #44 revealed EMS staff arrived at the facility and began assessment of Resident #44 on 8/15/23 at 11:07 AM. The Ambulance left the facility with Resident #44 on 8/15/23 at 11:33 AM and arrived at the hospital ER at 11:50 AM. EMS documentation detailed, Prehospital Care Report . Impressions: Possible Injury: Yes . Provider's Primary Impression : Pain, Right Lower Leg . Swelling, right leg, Unspecified fracture of right lower leg . Medications Administered: Yes . 8/15/23 at 11:32 AM . Fentanyl (narcotic pain medication for severe pain) 25 Micrograms (mcg) Intravenous (IV) . Patient Care Report Narrative . Arrived to find the patient laying in bed . complaining of 10/10 pain to right lower leg . has limited movement of extremities due to a previous CVA (stroke) . (Resident #44) was seat belted in a wheelchair and was being transported in a van . the seatbelt strap broke and fell out of the wheelchair . landed on right side with right leg folded under them. The van driver was able to pick them up and place back onto the wheelchair. (Resident #44) went to their appointment and was then taken back to (facility) . had swelling to right lower leg, pedal pulses were present, and was able to move toes. (Resident #44) can normally pick up that leg but was unable to today . IV established and given Fentanyl. Transported . Review of Hospital documentation for Resident #44 revealed the following: - 8/15/23 at 3:01 PM: ED Provider Notes . presenting to the ED . for evaluation . Per (EMS) the patent was on way to disability appointment in Bay City when the seatbelt strap broke . resulted in falling out of wheelchair and right leg getting caught under the wheelchair. The patient took Norco (narcotic medication for severe pain) at 1040 . for right leg pain and did not experience any relief . Physical Exam . Pain over right tibia. Mild contractures of all extremities . ED Course . Morphine (narcotic medication for severe pain) IV and . Toradol (controlled medication for pain) for pain . 3:40 PM . Versed (benzodiazepine class medication frequently used for sedation, anxiety, and adjunct pain control) IV for pain control . 5:01 PM . Dilaudid (narcotic pain medication) IV for pain control . patient is still symptomatic with comminuted displaced tibial fracture . I am concerned that if discharged today, the current condition will worsen, and an adverse event like severe unrelenting pain may occur . medically necessary hospitalization due to the need for intravenous analgesia, evaluation by Orthopedic surgery . Condition: Guarded . - 8/16/23 at 9:11 AM: History and Physical Examination . Orthopedic surgery was consulted . advised right standard hinged knee brace . admitted for right tibia fibula fracture . Assessment/Plan: Right proximal tibia fibula and right distal fibula fracture. Orthopedic surgery had been consulted, plan for non-operative treatment with hinged brace . should be removed or loosened daily for check for underlying skin breakdown, right heel should be completely off any underlying surface to prevent decubitus (pressure ulcer - wounds caused by pressure), repeat x-rays in 2 weeks, follow-up in the office . - Hospital Imaging: XR (X-Ray) Foot . Right: 1. Subtle post traumatic nondisplaced fracture of the distal fibula extending to the lateral malleolus (bone on the outside of the ankle joint) with significant soft tissue swelling. 2. Subtle fractures of the foot cannot be entirely excluded . Signed . 8/15/23 at 1:38 PM Ankle 3+ View Right: 1. Subtle post traumatic nondisplaced fracture of the distal fibula extending to the lateral malleolus with significant soft tissue swelling . Signed . 8/15/23 at 1:35 PM Tib/Fib Right: 1. Acute post traumatic comminuted and displaced fracture of the proximal tibia and fibula with deformity and soft tissue swelling. Follow-up is recommended . Signed . 8/15/23 at 1:15 PM - Knee . Right: 1. Acute post traumatic comminuted and displaced fracture of the proximal tibia and fibula with deformity and soft tissue swelling. Follow-up is recommended . Signed . 8/15/23 at 1:08 PM - Femur 2 View Right . Subtle right femoral neck cortical break cannot be excluded. If there is concern, follow-up CT (cat scan) of the pelvis may be obtained for further evaluation. 2. Partially visualized comminuted fracture of the tibia and possibly fibula . 4. Soft tissue swelling seen . Signed . 8/15/23 at 1:04 PM - XR Portable Pelvis 1-2V: 1. Chronic deformity of the hip joints . Subtle cortical break cannot be excluded. If there a concern, follow-up CT (cat scan) of the pelvis may be obtained for further evaluation . Signed . 8/15/23 at 1:01 PM Review of Resident #44's hospital discharge instructions titled, After Visit Summary dated 8/16/23 at 11:59 AM revealed the Resident returned to the facility with the new medications Oxycodone (narcotic pain medication) 5 milligram (mg) capsules, every six hours as needed, and acetaminophen (Tylenol) 650 mg every four hours as needed. The Resident's home Norco (narcotic) medication was discontinued due to the need for stronger pain management. A return phone call was received from CNA V on 6/17/24 at 7:42 AM and an interview was completed. When queried, CNA V confirmed they did. When asked what happened, CNA V confirmed they were driving the facility transportation van and stated, I believe (Resident #44) had a Social Security meeting at a doctor's office north of Bay City by Kawkawlin. When asked if they assisted and secured Resident #44 in the transportation van, CNA V revealed they took Resident #44 out of the building and got them into the van. With further inquiry, CNA V revealed they took the expressway to go to the appointment and stated, I was getting off the expressway and when I stepped on the brakes, the seatbelt just swung off. When asked what swung off meant, CNA V stated, It just swung off towards the door. It came undone. CNA V was asked if the upper (chest) and lower (lap) belts both came undone and replied, It all connects. When asked, CNA V revealed the shoulder and lap belt connected. When asked if any part of the seat belt remained in place, CNA V reiterated it had come undone and stated, There was no seat belt on (Resident #44) and indicated the Resident came out of the wheelchair. CNA V was asked what position the Resident was in and replied, I found (Resident #44) on their back when I could stop. When queried what exit they were at, CNA V replied, The [NAME] Road exit. CNA V verbalized it was not safe to get out of the van on the exit, so they stopped as soon as possible. With further inquiry regarding the Resident's position, CNA V verbalized Resident #44 was on their back on the floor of the van with their legs under their Broda chair. When queried what they did, CNA V stated, We had to get (Resident #44) up. (Resident #44) wanted to go to their appointment no matter what because they wanted to get out of the facility. When queried if they were alone, CNA V replied, No, there was another aide (CNA) there with me. CNA V was asked the name of the CNA with them and indicated they were not sure revealed they could not recall. CNA V was able to provide a physical description of the CNA and stated, She was really new. When queried if it was CNA W, CNA V replied, That sounds like her name! When asked if Resident #44 complained of pain, CNA V stated, (Resident #44) was more in shock, I think. They complained of pain when we got back. When queried regarding the transport van, CNA V stated, They had gotten that van like two or three weeks before, hadn't had a month. When queried how long they had transporting residents in the transport van, CNA V revealed they had recently moved to the transportation position when the incident occurred. When asked about the training they received related to transporting residents in the van including securement, CNA V stated, (The Administrator) gave me papers to sign and the policy which included scheduling and scanning medical records. CNA V explained the Transport position also included scheduling resident appointments and scanning documents into resident EMR's. CNA V was then asked if they had to complete a check off and/or demonstrate competency related to securing residents in wheelchairs in the facility van and replied, No. CNA V continued, The maintenance guy showed me how to buckle the chair in the floor but not the individual seat belt. When asked if different types of wheelchairs had to be secured differently, CNA V indicated all chairs buckled to the floor the same way as far as they knew. When asked if there were any differences in the shoulder/lap safety belt usage/connections for different type of chairs (Broda chairs,[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure assessment, maintenance and care of an indwelling urinary catheter, per professional standards of practice, for one resident (Resident #39), and failed to complete treatment of a Urinary Tract Infection (UTI) for one resident (Resident#18) of four residents reviewed, resulting in an indwelling urinary catheter being maintained in an unsanitary manner, a lack of a urinary catheter securement device, delayed, and incomplete antibiotic therapy with the likelihood of ongoing UTI's with continued and increased Multi-Drug Resistant Organisms (MDRO- infections caused by microorganisms that are resistant to treatment), difficulty in treatment, and a decline in overall health. Resident #18: On 6/04/24, at 9:19 AM, During infection control task, the line listings were reviewed which revealed Resident #18 had been treated for a urinary tract infection (UTI) on 4/24/2024. On 6/4/2024, at 1:30 PM, a record review of Resident #18's electronic medical record revealed a readmission on [DATE] after a discharge to the hospital on 4/19/2024 with diagnoses that included Stroke and recurrent UTI. Resident #18 required assistance with Activities of Daily Living. A review of the physician orders revealed Cefpodoxime Proxetil Oral Tablet 100 MG (milligrams) (Cefpodoxime Proxetil) Give 1 tablet by mouth twice Start Date 4/25/2024 08:00 End Date 5/4/2024 A review of the Medication Administration Record (MAR) 4/1/2024 - 4/30/2024 revealed Cefpodoxime Proxetil Oral Tablet 100 MG (Cefpodoxime Proxetil) Give 1 tablet by mouth two times a day for UTI until 05/04/2024 23:59 1 Tab by mouth twice daily for 18 doses -Start Date- 04/25/2024 The record revealed on the days of Thu 25 0800 2000 Fri 26 0800 there was a 9 documented which revealed the resident did not receive the first dose until Friday 26th, at 8:00 PM. A review of the Medication Administration Record (MAR) 5/1/2024 - 5/31/2024 revealed the resident received the Cefpodoxime Proxetil twice a day on 5/1 through 5/4/2024 with the last dose being at 2000 (8:00 PM) of a total amount of 17 doses. A review of the progress notes revealed the following: 4/25/2024 10:05 (10:05 AM) Note Text: Cefpodoxime Proxetil . Medication isn't available at this time. Checked back up medication wasn't available. Medication has been ordered. Will administer to pt once medication is received. Dr. aware . 4/25/2024 19:34 (7:34 PM) Note Text: Cefpodoxime Proxetil . Awaiting arrival from pharmacy 4/26/2024 08:07 Note Text: Cefpodoxime Proxetil . Awaiting arrival from pharmacy 4/26/2024 14:22 Note Text: ABX (antibiotic) awaiting arrival VIA pharmacy . A review of the care plan revealed I have altered urinary status-neuromuscular dysfunction of bladder, bladder spasms, incontinence, chronic UTI, strong odor to urine . Date Initiated: 06/05/2021 . Interventions . Monitor/record/report to MD for s/sx of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, foul smelling urine, chills, altered mental status, change in behavior, change in eating patterns. Date Initiated: 06/05/2021 Offer toileting assist during routine rounds, ADL care and PRN. Provide incontinence care as needed Date Initiated: 03/14/2023 Use of incontinence products - I wear an incontinence product: bariatric brief Date Initiated: 06/05/2021 Revision on: 03/31/2023 I may be resistive to and/or refuse care including: Not allowing staff to assist me with toileting/brief changes and incontinence care . Revision on 10/05/2023 . Interventions . Educate on the possible outcome (s) of not complying with treatment or care. Date Initiated: 02/02/2022 . I may be resistive to and/or refuse care including: Not allowing staff to assist me with toileting/brief changes and incontinence care . Revision on 03/15/2024 . On 6/05/24, at 9:18 AM, During infection control task, a record review of Resident #18's electronic medical record was conducted along with IC Nurse B. IC Nurse B explained that they received Intravenous Meropenum in the hospital and was discharged back to the facility on oral Vantin (Cefpodoxime Proxetil). IC Nurse B was asked if the resident returned on 4/24/24 why the Vantin wasn't started until 4/26/24 and IC Nurse B stated, they don't have Vantin in the back up medications. IC Nurse B was asked if Resident #18 received all 18 doses of the order Vantin and IC Nurse B stated the resident did. IC Nurse B was asked why the pharmacy didn't drop ship the Vantin so that the resident didn't go with out and IC Nurse B stated, we could have reached out to the pharmacy for a drop ship. IC Nurse B was asked what time on 4/24/24 did Resident #18 return to the facility and IC Nurse B opened up the nursing admission note which was time stamped 4/25/24 334 AM. IC Nurse B was asked to review the progress notes which revealed medication orders were placed on 4/24/24 at 10:30 PM. IC Nurse B was asked when the medication orders are normally placed and IC Nurse B offered, they are placed when the resident arrives. IC Nurse B was asked to clarify when the Vantin actually started and IC Nurse B stated, it appears she went all of 4/25 and am of 4/26 without the antibiotic. IC Nurse B was asked to provide a copy of every Infection Control Audit they do in the facility and staff education for perineal care (peri-care) for residents with recurrent UTI's. A review of the infection control reports along with IC Nurse B for Resident #18 revealed numerous and recurrent UTI's. On 6/5/24, at 11:30 AM, a record review of Infection Control Audits along with the Director of Nursing (DON) and IC Nurse B revealed no peri-care audits. The DON was asked how they could ensure the staff were doing peri-care correctly if they didn't audit them and the DON explained that the facility does do peri-care audits on the staff but didn't have documentation for them. Resident #39: On 6/04/24, at 1:00 PM, an observation of Resident #39 who was in their bed along with Nurse N was conducted. Nurse N donned the appropriate Personal Protective Equipment and exposed the urinary catheter tubing which was draped tight over their right thigh. There was a securement device to their right thigh which was soiled brown in color and appeared old. The catheter tubing was not secured inside the securement device. The urinary catheter tubing was soiled with brown substance. Nurse N was asked what they thought the brown substance was and Nurse N stated, it looks like BM (bowel movement). On 6/04/2024, at 2:45 PM, a record review of Resident #39's electronic medical record revealed an admission on [DATE] with diagnoses that include stroke, retention of urine and urinary tract infection (UTI). Resident #39 required extensive assistance with Activities of Daily Living (ADL) and had intact cognition. A review of the care plan revealed I have altered urinary status r/t urinary retention Date Initiated: 05/07/2024 . Interventions Catheter care every shift and PRN . Ensure tubing is secured. Date Initiated: 05/13/2024 . On 6/05/24 3:24 PM, a review of the facility provided Catheter Care, Urinary Revision 5/2024 revealed . Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Peripherally Inserted Central Catheter (PICC line - catheter inserted in the body through the arm that extends to the heart and is utilized for long term administration of intravenous [IV] medications) care was provided, per professional standards of practice and health care provider's order, for one resident (Resident #37) of one resident reviewed, resulting in a lack of dressing change completion, a lack of sterile technique during dressing change, resident verbalizations of concerns related to a lack of care, and the likelihood for infection and alteration in overall health status. Findings include: Resident #37: On 6/3/24 at 11:04 AM, Resident #37 was observed in their room, laying in bed. An IV pole with an empty bag of Meropenem (IV antibiotic medication) was present in the room. The medication bag was labeled for administration to Resident #37 but did not include the date/time the medication was hung and the IV tubing was not dated. A PICC line was present in Resident #37's Right Upper Extremity (RUE). The dressing on the PICC line was dated 5/24/24. An interview was completed at this time. When queried regarding their PICC line, Resident #37 stated, It's supposed to be changed and they ain't done it. With further inquiry, Resident #37 revealed they informed facility nursing staff it needed to be changed but they had not changed it. Record review revealed Resident #37 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included right ankle and foot osteomyelitis (bone infection), diabetes mellitus, kidney disease, and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required set-up to substantial assistance to complete all Activities of Daily Living (ADL) with the exception of eating. The MDS further indicated the Resident was receiving IV medications. On 6/3/24 at 1:45 PM, Resident #37's IV was heard beeping from the hallway of the facility. Upon entering the room, Meropenem 500 milligrams (mg)/50 milliliters (mL) was hung and programmed to infuse at 100 mL/ hour via the beeping IV pump. The Resident's PICC line dressing remained dated 5/24/24. At 1:52 PM on 06/03/24, Licensed Practical Nurse (LPN) F entered the room to address the beeping IV infusion. The staff did not look at nor address the PICC line dressing. Review of Resident #37's Medication Administration Record (MAR) for June 2024 revealed documentation that the PICC line dressing had been changed on 6/2/24 by LPN U. Review of the Resident's EMR revealed the PICC line was replaced and the dressing was last changed on 5/24/24. On 6/3/24 at 2:30 PM, an interview was completed with the Director of Nursing (DON). When queried how frequently transparent PICC line dressings should be changed, the DON replied, Weekly. The DON was then asked to go to Resident #37's room with this Surveyor to observe the Resident's PICC line dressing. The DON entered the room and confirmed the PICC line was dated 5/24/24. The DON verbalized they would have a nurse change the dressing. When queried why the Resident's MAR included documentation that the dressing was changed by LPN U on 6/2/24, when the dressing was dated 5/24/24, the DON was unable to provide an explanation but stated they would address the concern. An observation of Resident #37's PICC line dressing change was completed on 6/3/24 at 3:03 PM with the Assistant Director of Nursing (ADON). During the sterile dressing change procedure, the ADON turned their back on the sterile field and the uncovered PICC line entry site two separate time allowing for contamination of the field and breaking sterile technique. Following the PICC line dressing change, an interview was completed with the ADON after exiting the Resident's room. When queried if PICC line dressing changes should be completed using sterile technique, the ADON confirmed they should. When asked if they should turn their back on their sterile field while completing a procedure requiring sterile technique, the ADON verbalized they should not and realized what they did incorrectly after they did it. Review of Resident #37's Electronic Medical Record (EMR) revealed a care plan entitled, I have a PICC line to RUE (Initiated and Revised: 5/11/24). The Care Plan included the intervention, Change IV dressing per order AND as needed for soiling or break in integrity (Initiated and Revised: 5/11/24). Review of Resident #37's Health Care Provider Orders revealed the following active orders: - Change IV dressing every day shift every Sun for PICC line Right Arm (Ordered: 5/21/24; Start Date: 5/26/24) - Change IV dressing as needed for soiling or break in integrity (Ordered and Start: 5/21/24) Review of facility policy/procedure entitled, PICC Placement and Maintenance (Reviewed: 3/30/24) revealed, 7. Dressings will be changed as follows: a. ANTT (Aseptic Non-Touch Technique) is adhered to when providing site care and dressing changes . b. The entire infusion system, including the VAD (Vascular Access Device)/CVAD (Central Vascular Access Device) will be routinely assessed for system integrity, infusion accuracy, identification of complications, and expiration dates of the infusate, dressing, and administration set. i. Transparent dressing changes will be done at minimum of every seven (7) days, or sooner if soiled, wet or nonocclusive . 10. Tubing changes are to be completed according to Infusion Nurses Society (INS) Standards a. Label administration sets with date of initiation, date of change due, time and initials

Based on observation, interview and record review, the facility failed to act upon grievances reported in Resident Council meetings and provide responses to grievances as reported during Resident Council with the potential to affect all residents that attend the council meetings, resulting in, unresolved resident concerns and a decreased quality of life. Findings Include: During Resident Council on June 4,2024 at 3:30 PM, the four residents in attendance were asked if their concerns voiced in the meetings were followed up on and resolution/update provided at the next scheduled meeting. The attendees reported staff will ask generalized questions regarding if their issues have been resolved but there is no other discussion past issues or how the facility will resolve them. On 6/5/2024 at approximately 9:00 AM, a review was completed of Resident Council Notes from June 2023 to May 2024. While residents voice their concerns in resident council the notes did not specify the issues with that specific discipline. Furthermore, there was not a response documented to the residents' concerns voiced at the next meeting, via concern form or other methods. June 12, 2023: Dietary: Five residents had food palatability and portions concerns. Therapy: Four residents had concerns with lack of therapy services. Nursing: Three residents expressed concerns. Social Services: Three residents had concerns regarding the social worker. Housekeeping/Laundry: Two residents expressed concerns with the cleanliness of their rooms. July 10,2023: Nursing: One resident expressed concern but the documentation was not clear as to the resident's issue. Housekeeping/Laundry: Two residents had concerns regarding missing clothing and lack of towels when showering. Dietary: Had varying complaints on staff following preferences and palatability. August 10, 2023: Residents expressed they were not offered night snacks. Housekeeping/Laundry: One resident had concerns regarding missing clothing. Dietary: Had varying complaints on staff following preferences and palatability. September 11, 2023: Snacks are not available at the nurse station and aides say there are not any snacks. Housekeeping/Laundry: One resident had concerns regarding a missing blanket. 10/10/2023: Therapy: Three residents expressed concern. 11/9/2023: Social Services: One resident expressed concern, but said concern was not detailed. Activities: Two residents expressed concern with the program but it was not elaborated upon. Dietary: Two expressed resident concerns. Therapy: Seven resident had concerns for lack of therapy services. Maintenance: Three residents expressed concern, but staff did not annotate what the problem was. 12/11/2023: Dietary: Concern with food being cold. Therapy: One resident requested a walker or cane. Maintenance: Residents stated there was metal sticking out his bed. 1/10/2024: Dietary: Concern regarding food being cold. 2/10/2024: Dietary: Three residents had specific concerns regarding their food preferences. Nursing: One resident stated he was not being administer his medications timely. Housekeeping/Laundry: One resident had concerns as her laundry was being dyed different colors. 3/5/2024: Therapy: One resident expressed wanting to be reassessed for therapy services. 4/4/2024: Maintenance: Resident stated his television needed to be fixed. 5/8/2024: Resident suggested placing an ice machine in the dining room. On 6/5/2024 at an interview was conducted with Activities Director O regarding resident concerns voiced during resident council. Director O stated when residents bring up a concern during the meeting she will bring the issue to morning meeting the following day and the concerns are addressed during caring partner rounds. This writer and Director O reviewed Resident Council notes and found once an issue was stated there was no documented follow up. Director O clarified there was no documentation that resident concerns from resident council were being addressed and the resolution/update being provided at the next meeting. Review was completed of the facility policy entitled, Grievance/Concern Procedural Guidelines, review 1/2024. The policy stated, .All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including rationale for the response .

On 6/04/24, at 12:34 PM, during lunch meal service, the kitchen was asked to provide a lunch meal for observation. The tray was passed from the serving line directly to the surveyor and walked to the conference room. The lunch tray consisted of two soft taco shells filled with shredded chicken and cheese. There was a small portion of lettuce with cut up tomatoes on top and one scoop of rice. There was one cup of lemonade, one small dish of tropical fruit, one set of silverware and one napkin. There was no salt, pepper, no taco sauce/salsa, no sour cream, and no dressing. The lemonade did not have ice in it and was not cold. The lemonade was checked for the temperature and resulted a Fahrenheit temperature of 60 degrees. The tropical fruit resulted a Fahrenheit temperature of 59 degrees. On 6/05/24, at 12:06 PM, DM E was asked to obtain a temperature of the next punch/lemonade provided. A tray was set down and the punch did not have ice cubes in it. DM E obtained a Fahrenheit temperature of the punch which resulted 57.4 degrees. On 6/05/24, at 12:53 PM, an observation along with DM E of the 300 hall tray cart revealed the cart door to be closed. There was a glass of punch on a lunch tray which now had ice cubes in it. This Citation pertains to Intake Number MI000144366. Based on observation, interview and record review, the facility failed to that ensure residents' food choices were honored, food was palatable (with temperature maintained), and an adequate amount of food was offered to one resident (Resident #47), and 4 of 4 residents in the Resident Council Meeting on 06/04/24 at 3:20 PM, resulting in anger, frustration and verbalizations of being hungry. Findings Include: Observation done on 6/3/24 at the noon meal revealed chili, a salad and beverages were served in the main dining room. The facility menu dated 6/3/24, revealed lunch was to include Texas toast. The resident's were not offered any toast, bread nor crackers to go with the chili. During an interview done on 6/3/24 at 1:50 p.m., Dietary Manager E stated (food company name given) makes our menu's; we follow the menu. They (resident's) didn't have bread or crackers today, it wasn't on the menu. The cook must of overlooked the toast today (Texas toast). We are getting tablets to take resident's orders. The Dietary Aide or the Aide will go to each room and ask what they want each day. We don't have a policy yet. We were approved two months ago to hire a dietary staff to do this; the hold-up is staffing; sometimes I am short and I can't afford to have someone out of the kitchen. Dietary Manager E revealed she has not hired anyone to implement the daily meal preferences, due to not having any time to hire someone. Resident #47: Review of the Face Sheet, diagnosis sheet and nursing notes dated 5/1/24 through 6/3/24, revealed Resident #47 was alert and able to make healthcare decisions. On 06/03/24 at 11:10 AM, during an interview, Resident #47 stated, Sometimes it's (facility food) cold and sometimes I just let them keep it, I can't eat some of that stuff. I told them I can't eat the oatmeal and they still sent it today (on 6/3/24 for breakfast meal), I can't eat that stuff. Sometimes it's not enough like the spoon of dried eggs, just a spoon of it. I have to try to eat it because there is nothing else. Sometimes it's cold and sometimes I just let them keep it; I can't eat some of that stuff. I told them I can't eat the oatmeal and they still sent it today (on 6/3/24), I can't eat that stuff. Sometimes it's not enough like the spoon of dried eggs, just a spoon of it. I have to try to eat it because there is nothing else. Observation revealed a white and blue alternative menu on the door of the room. Resident #47 denied being informed by staff about alternative foods available and that he could ask for more food, and he was not aware of the alternative menu in his room. Review of Resident #47's facility meal card (un-dated), stated dislikes oatmeal. During an interview done on 6/3/24 at 12:38 p.m., Dietary Manager E stated, they (resident's) can ask for double portions when we do dietary assessments, and they have to ask for alternatives. We don't have a policy for portions. Dietary Manager E acknowledged Resident #47 should not of had oatmeal on his tray. Food Council Meeting: Review of the facility Food Council Minutes dated 11/9/23, stated Resident concerns about food portion. Resident Council: During Resident Council on 6/4/2024 at 3:20 PM, the four attendees were asked if they had any concerns with dietary. They shared the following with this writer: - If they consume meals in their room, they are 30 to 45 minutes late. - The food lacks flavor and more times than often they do not enjoy their meals. - Many times, the meals are not at their preferred temperature. - One resident stated the food proportions are small and when they request a 2nd helping, they are informed they are out of food (for that meal that was served). - It's not consistent if their meals will have the appropriate accompaniments.

On 6/05/24, at 12:05 PM, Dietary Manager (DM) E was asked to enter the main dining room with their thermometer. Resident #30 was sitting at a table with two glasses of milk; one with sips taken. The temperature was checked of the full glass of milk and resulted a Fahrenheit temperature of 51.3 degrees. DM E offered to get Resident #30 another glass of milk and they denied. On 6/05/24, at 12:07 PM, DM E was asked to obtain a milk temperature of the next tray leaving the kitchen. A tray was provided directly from the tray line. The milk was checked for the Fahrenheit temperature which resulted 52.3 degrees. No new milk was provided to the residents in the dining room. On 6/05/24, at 12:13 PM, the Administrator was alerted of the milk temperature results of the milk provided in the dining room for lunch and the Administrator offered that they discard the milk after the four-hour time. On 6/05/24, at 12:53 PM, an observation along with DM E of the 300 hall tray cart revealed the cart door to be closed. DM E was asked to obtain a Fahrenheit temperature of a glass of milk which resulted 48 degrees at the bottom of the glass and 47.5 degrees at the top of the glass. The glass of milk had ice cubes in it. DM E was asked if the kitchen staff was asked to place ice cubes into the milk glasses for lunch and DM E stated, yes and that sometimes they do. DM E was alerted of the complaints of warm milk and warm juices and DM E stated, I know what we have to do to fix it. DM E was asked if the fridge door being left open during meal service was the problem and DM E stated, yes and planned to now set up the drinks first thing in the am and place them in the walk in cooler prior to meal service. On 6/05/2024, at 1:56 PM, DM E was asked to provide the food temperature logs for the months of May and June, 24. On 6/05/24, at 2:56 PM, a record review of the temperature logs revealed May 27, 28 and 29, 2024 was not provided by the facility for review. The temperature logs reviewed did not have a column for the start time or the discard time for the milk served out of the kitchen and did not reveal any four-hour time frame of when the milk left the refrigerator and was to be discarded by the kitchen staff. The logs revealed that milk was not routinely checked for a serving temperature and revealed the following Milk temperatures: 5/1/2024 Supper . Food Serving Temp Start . Milk 52 5/2/2024 Lunch . Milk 50 5/4/2024 Supper . Milk 48 5/5/2024 Supper . Milk 44 5/8/2024 Lunch . Milk 50 5/9/2024 Supper . Milk 54 5/22/2024 Supper . Milk 44 5/23/2024 Supper . Milk 45 A review of the Food Preparation and Service Policy Revised April 2019 revealed Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices . Food Preparation, Cooking and Holding Time/Temperatures The danger zone for food temperatures is between 41F and 135F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. The longer the foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefor, PHF must be maintained below 41F . Based on observation, interview, and record review the facility failed to maintain cold holding refrigeration temperatures of potentially hazardous food in the kitchen resulting in an increased potential for foodborne illness, potentially affecting the facility's total census of 79 residents who receive meal services. Findings include: On 6/4/24 at 11:47 AM, while observing lunch being plated from the kitchen's steam table, the surveyor observed the two door reach-in cooler located between the juice and coffee stations with both doors in the fully opened position. At this time the surveyor inquired with Dietary Manager, staff E, on if this was a normal practice during meal service to which they replied, yes. On 6/4/24 at 1:10 PM, upon review of the contents in the two door reach-in cooler the surveyor asked staff E, if they could take a temperature of the remaining portion of milk from the days lunch service to which they stated, of course. On 6/4/24 at 1:12 PM, temperature verification from staff E's thermometer probe revealed a temperature of 55 degrees F. At this time the surveyor inquired with staff E on what they would normally do when identifying a potentially hazardous food product at a temperature such as this they replied, we would put it in the trash. Review of 2017 U.S. Public Health Service Food Code, Chapter 3-501.16, Time/Temperature Control for Safety Food, Hot and Cold Holding directs that: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (2) At 5ºC (41ºF) or less.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00129842. Based on interview and record review, the facility failed to give information and direct Resident Representatives in obtaining an advance directive or guardianship for one resident (Resident #135), who was incapacitated, two residents reviewed for advance directives, resulting in not having arrangements for appropriate representation for health care decisions and a lack of care coordination. Findings Include: Resident #135: A review of Resident #135's medical records revealed an admission into the facility on 4/13/21, re-admission on [DATE] and discharged on 2/23/22, with diagnoses that included sepsis, acute respiratory failure with hypercapnia, altered mental status, dysphasia, dementia, Schizophrenia, bipolar disorder, cerebral infarction, cognitive communication deficit, aphasia, major depressive disorder, need for assistance with personal care, and metabolic encephalopathy. A review of Resident #135's Minimum Data Set assessment, dated 2/23/22, revealed a Brief Interview of Mental Status score of 6/15 that indicated severely impaired cognition and the Resident needed extensive assistance with two-person physical assist with bed mobility, toilet use and personal hygiene. A review of Resident #135's medical record revealed a document titled, Statement of Capacity, that revealed Resident #135 Is unable to understand rights and responsibilities and participate in medical treatment decisions . and signed by the Attending Physician on 1/18/22 and the Consulting Physician or Licensed Psychologist on 1/14/22. A review of Resident #135's admission Record, revealed the Resident was listed as her own Responsible Party. On 3/24/23 at 2:23 PM, an interview was conducted with a Resident's Family Member S regarding care at the facility. The Family Member was asked about Advance Directives or Guardianship information given by the facility. The Family Member indicated that they had not been approached by the facility regarding setting up an Advance Directive or Guardianship but had to get guardianship proof before the facility would let medical records to be requested. On 3/24/23 at 12:19 PM, an interview was conducted with the Social Worker D regarding Resident #135. The Social Worker was not the Social Worker at the time the Resident had been residing at the facility. It was reviewed with the Social Worker (SW) that the medical records indicated the Resident was her own responsible party and also had a Statement of Capacity that indicated the Resident was not competent to understand rights, responsibilities and participate in medical treatment decisions. The SW stated, Reading this she should not have been her own responsible party. When asked what the facility roll was in ensuring Advance Directives or Guardianship was addressed with the family, the SW indicated that conversation would start on admission. The SW indicated that if family did not apply then they would notify their attorney and ensure guardianship was applied for. When asked if the facility had given information to the family or discussed with the family, the SW reviewed the medical record and reported she did not see notes regarding discussions with the family. The SW indicated that if a Resident admits and does not have a POA, then they should have that conversation about obtaining the advance directives. When asked if that discussion would be documented, the SW indicated that it should. A review of facility policy titled, Advance Directives, revealed, .Policy Interpretation and Implementation: 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative . 6. Prior to or upon admission of a resident, the Social Services Director of designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives .8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow up on a contaminated urine sample for one resident (Resident #37) of three residents reviewed for catheter care and Urinary Tract Infections (UTI), resulting in the potential for a urinary tract infection to be unidentified and untreated. Findings include: Resident #37: A review of Resident #37's medical record revealed an admission into the facility on 8/23/22 with a re-admission on [DATE] with diagnoses that included diabetes, stroke, heart failure, pneumonia, sepsis due to Methicillin Resistant Staphylococcus aureus, acute kidney failure, acute cystitis with hematuria, severe sepsis with septic shock, obstructive and reflux uropathy, and urinary tract infection. A review of the Minimum Data Set (MDS) assessment, dated 1/11/23, revealed a Brief Interview of Mental Status of 12/15 which indicated moderately impaired cognition and needed limited assistance with bed mobility, transfer, and dressing and needed extensive assistance with eating, toilet use and personal hygiene. Further review of the MDS revealed the Resident had an indwelling urinary catheter. A review of Resident #37's orders revealed the following: an order dated 11/29/22 for Urinalysis with Culture and Sensitivity; order dated 12/1/22 for urinalysis with Culture and Sensitivity; and 12/7/22, Repeat UA with C&S (culture and sensitivity) due to contamination. A review of Resident #37's Urine Culture revealed a collection date on 12/1/22, cultures result notes indicated Mixed Flora [multiple Species Present]; Indicative of contamination. Urinalysis results revealed, trace UA Protein, moderate UA Blood, positive UA Nitrite, 81 UA Blood, present UA Bacteria. Review of the medical record revealed no UA results for the ordered repeat UA with C&S due to contamination. A review of the Medication Administration Record revealed a specimen was collected on 12/1/22 and one on 12/8/22. No other information/documentation was found in the progress notes for Resident #37 of the specimens collected or how the collection was conducted. On 3/22/23 at 11:29 AM, an observation was made of Resident #37 lying in bed. The Resident was observed to have a urinary catheter with the tubing and collection bag hanging on the side of the bed. The urine inside the tubing was cloudy and the tubing was stained cloudy. On 3/28/23 at 2:26 PM, an interview was conducted with the Infection Control Preventionist (ICP), Nurse L regarding Resident #37's UTI history. The ICP indicated that the Resident had a UTI on 9/8/22 and was treated with antibiotics. The urine specimen sent for UA on 12/1/22 was reviewed with the ICP. When asked if the specimen was obtained again and how was the first specimen obtained, the ICP reviewed the Resident's medical record and was unable to determine how the specimen was obtained. The ICP was unable to find results for the ordered repeated urinalysis with culture and sensitivity. The ICP was asked about the Resident's presenting signs and symptoms and reported the Resident was having confusion and after review of the medical record, the Resident had multiple falls. The ICP indicated that the Doctor had been notified of the contaminated urine and that the Nurse Practitioner had ordered for the repeat UA. The ICP indicated that according to the Medication Administration Record (MAR), a specimen had been collected but the facility had not received any results and reviewed the laboratory portal and indicated that the specimen had no results. The ICP did not have an explanation and there was a lack of documentation of the UA being sent and follow-up on results. The was asked that the UA was ordered to be repeated, the ICP stated, Yes. We have on the MAR that one was collected, but I have no results. On 3/28/23 at 4:13 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #37's contaminated specimen and the lack of results of a repeat urinalysis, culture and sensitivity. The DON was asked about the lack of results for the follow-up UA. The DON indicated she had reviewed the Resident's medical record and lab results but was unable to find results for the repeat UA and indicated she had not seen a follow-up or a progress note in relation to either the specimen or UA results. The DON stated, Going forward I have a running list of X-rays, UA's, Labs, and not taken off my list until the test is completed and results are back. A review of facility policy titled, Routine Urinalysis Specimen, reviewed 3/23, revealed, .Preparation: 1. Verify that there is a physician's order for this procedure . Steps in the Procedure: .24. Send the specimen to the laboratory for testing as ordered . Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the specimen was collected. 2. The name and title of the individual(s) who performed the procedure. 3. The character, clarity and color of urine. 4. All assessment data obtained during the procedure. 5. How the resident tolerated the procedure. 6. If the resident refused the procedure, the reason(s) why and the intervention taken. 7. The signature and title of the person recording the data. Reporting: .2. Report other information in accordance with facility policy and professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide medications per physician's orders and timely delivery from the pharmacy for two residents (Resident #22, Resident #238) and administer insulin pen per standards of practice for one resident (Resident #22) out of five residents reviewed during medication administration, resulting in missed medications, a high heart rate, feelings of nervousness with the likelihood of increased medical symptoms. Findings include: On 3/23/23, at 12:34 PM, During medication administration, Nurse Q prepared Resident #22's insulin supplies. Nurse Q dialed the insulin pen to 3 units. Nurse Q was asked what the dose of insulin was for Resident #22 and Nurse Q clarified the dose to be 3 units. Nurse Q did not prime the needle with the required 2 units of insulin. Nurse Q entered Resident #22's room, cleansed the area and placed the needle tip, pushed down on the pen leaving the pen in skin for only 5 seconds. Resident #22 dose of sevelamer carbonate was not prepped and given. Nurse Q was asked why they didn't administer the dose of Sevelamer (a medication given with meals to aid in phosphorus absorption) and Nurse Q stated, I didn't give it because it's not here and that they put an order in for it. On 3/23/23, at 1:03 PM, During medication administration task, Nurse Q was observed to open the medication record for Resident #238 with multiple medications noted in red. Nurse Q entered Resident #238's room and obtained their vitals. Resident #238's heart rate/pulse was 117. Resident #238 stated, well, I haven't had my three heart pills yet and I get sinus tach if don't take them. Resident #238 explained that they got to the facility the day prior around lunch time. Resident #238 had a fresh surgical incision noted to their knee. Resident #238 complained of pain and also complained that they started to have an asthma attack the evening prior and stated, thank god I had a rescue inhaler in my purse. Nurse Q left Resident #238's room walked to the medication cart and was asked why Resident #238 hadn't received any of their morning medications and Nurse Q stated, they were not in yet. Nurse Q stated that they were going to go call the doctor as they walked down the hall. On 3/23/23, at 1:25 PM, Nurse Q returned to the medication cart. An observation of the drawer that housed Resident #238's medications revealed the medication sleeves were located in the drawer in numerical order along with the other residents' medications. Resident #238's Metoprolol a heart medication was noted to not have any pills removed from the sleeve and Nurse Q was questioned further why the medications that were do at breakfast time were not given and Nurse stated, the night nurse had just put the mediations in the cart drawer at 6:00 AM. Again, Nurse Q stated, they would call the doctor to ensure the resident could have their morning medications late. On 3/23/23, at 2:00 PM, the Director of Nursing (DON) was asked to provide the most recent nursing competency for Nurse Q and the DON stated, I will have to check into that. On 3/24/23, at 9:49 AM, a record review of Resident #238's electronic medical record revealed and admission on [DATE] at 13:00 (1:00 PM.) A review of the physician's orders revealed Spironolactone . Start Date 3/22/2023 19:00 (7:00 PM) Metoprolol Tartrate Oral . Start Date 3/22/2023 20:00 (8:00 PM) . Chlorthalidone . Start Date 3/23/2023 07:00 . amlodipine . Start Date 3/22/2023 19:00 Albuterol Sulfate Nebulization Solution . Start Date 3/22/2023 13:58 . On 3/24/23, at 10:33 AM, The DON was again asked to provide Nurse Q's competency for medication administration. The DON stated, what I understand about the competency is that they take them with them and then hand them in when completed. On 3/24/23, at 4:04 PM, a record review along with the DON was completed of Resident #22's medication administration record (MAR) which revealed for the dates 3/23/23 .--- there was a number 1 along with Nurse Q's initials. The DON was asked what that meant and the key on the MAR revealed that 1 meant absent from home with meds. The DON was unsure why the nurse documented that as the resident's dialysis is done in the facility. The DON was asked what the expectation was for medication delivery from the pharmacy and the DON stated, there is a cut off but as long as we get them ordered in time they come the same day. The DON was asked to clarify what that meant and the DON stated that (the electronic medical record) they use is linked together with the pharmacy and the meds shouldn't be delivered late. On 3/29/23, at 8:29 AM, The Assistant Director of Nursing (ADON) was asked to provide the competency for Nurse Q. On 3/29/23, at 8:34 AM, a record review along with the ADON of Resident #238's electronic medical record was conducted. The ADON was asked when Resident #238 was admitted and the ADON stated, on 3/22 at 1300. The ADON was asked to review the MAR and respond as to why the resident did not receive medications timely and the documentation revealed 1 which meant absent from home with meds. The ADON was alerted Resident #238 complained of needing an emergency inhaler and that they felt they were in sinus tach because their heart medications were not given although they were in the drawer and the ADON stated, Nurse Q needs more orientation. The ADON was also alerted that Resident #22 didn't receive their lunch medication Sevilmer as Nurse Q stated, it wasn't available and the ADON stated, dialysis is done in house and there is no reason why they shouldn't have administered that medication. The ADON was also alerted that Nurse Q failed to perform hand hygiene during the insulin preparation and administration for Resident #22 and failed to hold the insulin pen the required 10 seconds and the ADON planned to offer more orientation for Nurse Q. On 3/29/23, at 9:00 AM, a record review of Nurse Q's competency document revealed that on 2/24/23 they were noted to have competency in preparing and administering medications. On 3/29/23, at 10:30 AM, Resident #238 was in their bed and was asked to explain how they felt not getting their medications on time and Resident #238 stated, on a scale of 1 to 10 and 10 being the worse, I was a 10. Resident #238 stated, I was nervous and was unsure the pharmacy rule on getting meds but they did say the pharmacy hadn't delivered them yet. A record review of Resident #22's electronic medical record revealed an admission on [DATE] with diagnoses that include congestive heart failure, end-stage renal disease (ESRD) requiring hemodialysis and diabetes mellitus type 2. A review of the Medication Administration Record 3/01/2023 -3/31/2023 revealed Sevelamer Carbonate Oral Tablet . Give 1 tablet by mouth with meals for ESRD . For the date Thu 23 it was documented 1 with Nurse Q's initials.

On 3/23/23, at 12:34 PM, During medication administration, Nurse Q prepared Resident # 22's blood glucose testing supplies. Nurse Q prepared the glucose meter, lancet and bottle of testing strips on top of the medication cart. Nurse Q donned gloves, picked up all the supplies and entered Resident #22's room. Nurse Q cleaned Resident #22's finger, used the lancet and opened up the multi-use bottle of testing strips, put their gloved fingertip inside the bottle and pulled out a testing strip. Once the test was complete, Nurse Q removed their gloves and walked back to the medication cart without performing hand hygiene. Nurse Q used a cleansing wipe for the blood glucose meter. Nurse Q was asked if they normally took the multi-use bottle of testing strips into the residents rooms and Nurse Q stated, No. I usually just take a couple. Nurse Q disposed of the contaminated multi-use bottle of strips as they stated, I know they are dirty now. Nurse Q cleansed their hands and began gathering Resident #22's insulin supplies. Nurse Q opened up the medication drawer and pulled out Resident #22's insulin pen and set it down on the top of the cart. Nurse Q donned gloves, opened up the medication drawer pulled out an alcohol wipe, closed the drawer, cleansed the top of the insulin pen, then opened up the drawer again with their gloved hands, pulled out a needle, closed the drawer. Opened the needle package and placed it on the pen. Nurse Q entered Resident #22's room, cleansed the area and placed the needle tip, pushed down on the pen leaving the pen in skin for only 5 seconds. On 3/23/23, at 2:00 PM, the Director of Nursing (DON) was asked to provide the most recent nursing competency for Nurse Q and the DON stated, I will have to check into that. On 3/24/23, at 10:33 AM, The DON was again asked to provide Nurse Q's competency for medication administration. The DON stated, what I understand about the competency is that they take them with them and then hand them in when completed. On 3/29/23, at 8:29 AM, The Assistant Director of Nursing (ADON) was asked to provide the competency for Nurse Q. On 3/29/23, at 8:34 AM, The ADON was also alerted that Nurse Q failed to perform hand hygiene during the insulin preparation and administration for Resident #22 the ADON planned to offer more orientation for Nurse Q. Based on observation, interview, and record review the facility failed to 1) Ensure that resident monthly infection data was analyzed for 1/23 and 2/23, and 2) ensure proper hand hygiene during medication pass for a census of 95 residents, resulting in the likelihood for cross contamination, resident, and staff illness, antibiotic usage with possible hospitalization. Findings Include: Infection Control Data Analyzing: Review of the Infection Control Guideline dated 11/28/17, reported The Infection Control Preventionist and the Infection Control Prevention and Control Committee will utilize the information collected from both Process and Outcome Surveillance activities in order to analyze the data to identify opportunities for improved care and process and identify an action plan for follow up and corrective action. The analyzing will compare current and past infection control surveillance data, compare the reported incidence of infections by type and location. Based on analysis of data, develop and implement an action plan that includes correction actions, staff education, and measurable goals; data is reported to the Quality Control Committee. Review of the monthly resident and staff data collection dated 11/22, 12/22 and 1/23, revealed incomplete data analyzing. The documentation did not have all the components of the facility Infection Control Guideline (dated 11/17). No staff illnesses/call-in's were documented nor analyzed in the monthly infection control report. During an interview done on 3/28/23 at 8:00 a.m., the Infection Control Nurse L said she did not analyze staff illnesses related to resident infections; she did have the data however she was not able to produce staff call-in's (illnesses) data upon request. Review of the facility Infection Preventionist job description (un-dated), revealed the Infection Control Nurse was responsible for the facility's infection control program including surveillance, data collection and analysis of the data (including staff illnesses) to determine corrective measures (staff education).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 3/22/23, at 2:00 PM, during resident council, there were multiple complaints regarding the way staff answer their call lights. The following complaints were shared during council from the residents: The always menu isn't always available. I asked for a hamburger a couple days ago and I was told No. You put your light on and ask for ice water and they never come back. It's every shift. They answer your light. They say they will be back but never come back. They don't' just hand out ice water. You have to ask for it, Now. You put your light on for a snack and they never come back with it. It's every shift. They never come back. I see how they treat others and if you don't have family that visits, it's a real problem. They will say they are shorthanded. They always have excuses why they don't come back. They can do whatever they want, but when we need help, we need help. On 3/22/23, during the initial tour of the facility, an observation was made during dining observation of a Resident eating in her room [ROOM NUMBER]. The Resident was sitting in her wheelchair with the overbed table in front of her with her lunch tray and was eating. When asked how lunch was, the Resident indicated she was having a hard time eating. The Resident had a denture cup with liquid and dentures in the cup. When asked if she used dentures when she ate, the Resident reported she usually ate with her dentures but wasn't given her dentures and didn't know where they were. The denture cup was on the overbed table with the top still on the cup. The Resident was observed to have food on her clothing and lap. The Resident did not have a shirt protector on, and one was not noted in the Resident's vicinity. On 3/23/23 at 10:18 AM, during the initial tour of the facility, Resident #29 was asked about concerns. The Resident reported a concern of call lights wait times to be answered by staff of an average of an hour. When asked if the Resident had to wait two hours, the Resident stated, yes. The Resident indicated that they had issues with incontinence and was able to change her brief but that her bed would get wet and she would sit up in her wheelchair and wait sometimes waiting up until 2 hours or would go out in the hall and try to find staff to change her bed linen before getting back into bed. On 3/23/23 at 11:22 AM, during the initial tour of the facility, Resident #21 was asked about concerns. The Resident reported a concern of call lights not being answered for a average of two hours. The Resident reported that after an hour of waiting, they would call the front desk and have them alert staff to assist her. The Resident indicated they called often to be changed of incontinence episodes. Resident #18: A review of Resident #18's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included peripheral vascular disease, cataracts bilateral, psychotic disorder, stroke affecting left dominant side, dementia, anxiety disorder, and heart disease. A review of the Minimum Data Set (MDS) assessment, dated 2/8/23, revealed a Brief Interview of Mental Status (BIMS) score of 3 that indicated severely impaired cognition, and needed extensive assistance with two persons physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene and needed supervision and set up help for eating. Further review of the MDS revealed the Resident had upper and lower extremity impairment on one side. On 3/22/23 at 9:28 AM, an observation was made of Resident #18 in bed with the head of the bed elevated. The Resident had his eyes closed but aroused when his name was called. The Resident answers simple questions and will elaborate on occasional questions. The Resident was observed to have his gown falling off his shoulders down to mid upper arms bilaterally leaving the shoulders and much of his chest exposed. The Resident could be seen from the hallway. The Resident had crumbs in his beard, on his chest, and in the creases of his clavicle/shoulder area. The same kind of crumbs were observed on the floor near the Resident's bed. There appeared to be some liquid, that looked like juice, in the Resident's mustache and beard. The Resident did not have a breakfast tray on his overbed table. When asked, the Resident indicated he had already eaten. On 3/22/23 at 12:55 PM, an observation was made during the initial tour of the facility during dining of the lunch meal of Residents eating in their room. Resident #18 was observed sitting up in bed in the same position as seen earlier during the Resident interview. The Resident had his overbed table with his lunch meal tray with the top off. The Resident was sleeping and had not eaten any of the meal. The Resident's gown was falling off his shoulders and exposing his bare chest. The crumbs that had been observed earlier remained in the clavicle crevasse, on his chest hair and in his beard. The crumbs remained on the floor near the Resident's bed. The Resident did not have a shirt protector on to protect his clothing, bed linen or bare skin. The Resident aroused and was groggy but answers simple questions and begins to eat. The Resident indicated the food was cold. The Resident was asked about a shirt protector and reported he had asked for them before and stated, but it's not here. The Resident was observed to take a bite of the spaghetti but some of what was on the fork fell onto the Resident's bare chest area. On 3/22/23 at 1:18 PM, Resident #18 was observed from the hallway, attempting to continue to eat. The Resident was observed to have more of the meal fall onto his bare chest. No shirt protector had been given to the Resident and an observation was made of spaghetti on his bed linen as well. A staff member came into the room and used a walkie-talkie to request assistance for the Resident, no one responded, and the staff member was observed to leave the room and returned with fresh linen. Resident # 57: A review of Resident #57's medical record revealed an admission into the facility on 2/26/21 with diagnoses that included stroke, pressure ulcer, diabetes, reduced mobility, need for assistance with personal care, depression, and anxiety disorder. A review of the MDS, dated [DATE], revealed a BIMS score of 14 that indicated intact cognition, and needed extensive assistance with bed mobility, dressing, and personal hygiene and was independent with setup help only for eating. The Resident had upper and lower extremity impairment on one side. On 3/22/23 at 12:41 PM, during observation of the lunch meal, the Resident was observed to be eating in his room. The Residents head of bed was not elevated very high, and the Resident laid supine in bed with the overbed table with his lunch tray. The Resident asked this surveyor if I could open his bag of chips. An observation was made of Resident #57 with chocolate pudding on his bed linen covers and, on the mattress, fitted sheet, and his gown. The Resident had a puddle of pudding on the bed at his left side between his elbow and shoulder area. The puddle of pudding had a fork standing upwards in the pudding. The Resident did not have a shirt protector on. This surveyor went out of the room and found a Nurse at the medication cart and was told Resident #57 needed assistance. The Nurse went into the Resident's room and was observed leaving without cleaning the Resident. On 3/22/23 at 1:17 PM, an observation was made of the Resident with pudding over his gown, bed linen, himself with the puddle of pudding that remained at the Resident's left side with the plastic fork in the puddle. The Resident was eating his bag of chips. On 3/22/23 at 1:45 PM, an observation was made of Resident #57 lying in bed. The Resident was done eating and the food tray was gone from the overbed table. The resident had the pudding on himself, bed linen and with the puddle on his left side. On 3/22/23 at 2:16 PM, an observation was made of Resident #57 to have a new gown and bed linen on his bed. The Resident remained in bed and not dressed. Resident #74: A review of Resident #74's medical record revealed an admission into the facility on 9/9/22 with diagnoses that included cancer, coronary artery disease, dementia, and anxiety disorder. A review of the MDS revealed the Resident had a BIMS score of 00 that indicated severely impaired cognition and needed extensive assistance with bed mobility, dressing, toilet use and personal hygiene and needed supervision with one-person physical assistance with eating. On 3/22/23 at 1:33 PM, an interview was conducted with Resident #74's family member S. An observation was made of Resident #74 sitting in bed and eating lunch. The Resident had spaghetti sauce and some noodles on his bed linen and shirt. The Family Member was asked about shirt protectors and the Family Member reported the staff had not offered one and that the Resident needs one. The Family Member indicated they come to visit occasionally and complained of the Resident with food on his clothing, clothing not cleaned and reported they hang the Resident's dirty clothes in the closet instead of getting them washed and will put the dirty clothes back on him. When asked if family does the laundry or the facility, the Family Member reported the facility is supposed to be washing the Resident's clothes. Resident #34: A review of Resident #34's medical record revealed an admission into the facility on 9/7/22 with diagnoses that included mechanical complication of internal right hip prosthesis, acute respiratory failure with hypoxia, mood disorder, adjustment disorder with mixed anxiety and depressed mood, restlessness and agitation, dementia, psychotic disorder, depression, anxiety disorder, and fall. A review of the MDS, dated [DATE], revealed a BIMS score of 3/15 which indicated severely impaired cognition and needed extensive assistance with two persons physical assistance with bed mobility, transfer, toilet use and personal hygiene and needed limited assistance of two persons physical assist for locomotion on unit. On 3/22/23 at 1:02 PM, during the initial tour of the facility, an observation was made of Resident #34 sitting up in her wheelchair with her lunch meal on her overbed table and was eating. The Resident was positioned in the middle of the room with her wheelchair facing towards the inside of the room, with her back positioned towards the open doorway. An observation was made of the call light clipped to the top corner of her bed and hung down towards the floor. The call light was not in reach of the Resident. On 3/22/23 at 1:28 PM, an observation was made of Resident #34 sitting with her back towards the door and not looking out to the hallway. The Resident had been yelling out for help for the last eight minutes. No one was observed to assist the Resident. An observation was made of a CNA's in the hall, a nurse at the nurses' station, and housekeeping in the hall going in and out of resident room. On 3/22/23 at 1:30 PM, the Resident was heard to be yelling at the top of her lungs for help. Two staff come in but leave the room. The Resident was observed to be sitting in the same position facing away from the hallway with the overbed table in front of her and her meal tray was gone. There was no activity for the Resident to do at her overbed table that was in front of her. The call light remains out of reach of the Resident. On 3/22/23 at 1:47 PM, Resident #34 can be heard yelling frequently, Help me, help me, over and over and occasionally changed her [NAME] or urgency in her voice. She was heard crying out, No one cares about me. The call light remains out of reach and staff were observed near the Resident's room in the hallway and was observed not to respond to the Resident crying out. On 3/22/23 at 1:51 PM, an observation was made of Resident #34 sitting in her wheelchair in the same position and without the call light in reach. The Resident was heard to be yelling for help off and on at frequent intervals, sometimes loud and other times at the top of her lungs. She was heard to be saying, Shit, Shit, Shit! No one cares about me! Staff did not respond to the Resident calling out and the Resident could be heard down the hallways and at the nurses' station. On 3/22/23 at 2:04 PM, an observation was made of Resident yelling for help until this time and staff had entered the room. Shortly after the Resident was observed laying in bed with the head of the bed elevated. The Resident was observed with her eyes closed, and her bottom jaw quivering/twitching. The call light remained clipped to the top of the mattress fitted sheet and not readily available to the Resident. On 3/24/23 at 12:26 PM, an interview with Social Worker (SW) D was conducted regarding Resident #34 calling out for help on 3/22/23. The Social Worker indicated that the Resident was not on my radar for behavior issues. The observations were reviewed with the SW. The SW indicated that the Resident can ask for what she wants and makes her needs known and indicated that staff should be responding and asking what she needs, what was wrong, did she need to be changed (for incontinence care), did she need companionship, they could have offered her things to do and reported that if she becomes tearful or upset, they could have brought her out of the room and stated, sometimes they just like the companionship. The SW indicated that the Resident liked to sit with her daughter. The SW indicated that staff should be responding when the Resident had called out. This Citation pertains to Intake Numbers MI00129714, MI00129826, and MI00131653. Based on observation, interview and record review, the facility failed to ensure residents' dignity by 1) Not ensuring that a shower was given for 1 resident (Resident #39), 2) Being left wet, 3) Environment odor (100 Hall), 4) Answering call lights timely, 5) Ensuring that clothing protectors were used during meals and staff assisted with meals, 6) Ensuring that a call for assistance was responded to by staff for (Resident #34), of a total of 20 residents reviewed for dignity, resulting in incontinence, resident and environmental odor, shame, and embarrassment, with the likelihood for isolation and decreased socialization and unmet care needs. Findings Include: Resident #39: Review of the Face Sheet, current Care Plans and orders dated 3/22 through 3/23, revealed Resident #39 was 75 years-old, had decreased cognitive ability with behaviors and was dependent on staff for assistance with Activities of daily Living. The resident's diagnosis included, dementia, hallucinations, incontinent of bowel and bladder, poor safety awareness and behavioral and perceptual disturbances. Observation of the resident done on 3/23/23 at 8:55 a.m., revealed she was sitting on the edge of her bed, and the breakfast tray was covered and sitting on the bedside table across the room from her. The resident's protective brief was half off and her gown was loosely tied, hanging down in the front. The resident and her room had an extremely offensive odor of urine; it could be smelled from outside the room. The resident's hair was greasy and needed to be washed. During an interview done on 2/23/23 at 9:00 a.m., Nursing Assistant/CNA A stated Third shift has been talked to before about not changing her (resident #39), (facility management) knows about this; she doesn't like showers, but she will do bed baths. Yes, it smells bad, I haven't gotten in there yet. During an interview done on 3/23/23 at 9:08 a.m., CNA F stated This is excessive (the odor from Resident #39' d room), thirds have been told before to check her, they're not doing it. During an interview done on 3/24/23 at 8:07 a.m. and at approximately 11:20 a.m., the Director of Nursing stated, I know she needs to be cleaned up, her room needs to be cleaned. Third shift was educated on ADSL's (Activities of daily Living) and showers this month in March. During an interview done on 2/23/23 at 9:30 a.m., Nurse Manager, RN B stated She (resident #39) is a fighter, she needs to be cleaned up. During an interview done on 2/28/23 at 9:10 a.m., Social Worker D stated She has not complained about her room to me, she doesn't talk much. The smell bothers me (Resident #39 room), I don't think it's right. I have had conversations about the smell. Review of the facility Dignity policy dated 10/22, reported Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall treat cognitively impaired residents with dignity and sensitivity. Review of the facility ADL (Activities of Daily Living) policy dated 10/22, reported Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care); If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to maintain a call light device, used to request needed assistance, within reach of 5 residents (Residents #8, Resident #18, Resident #34, Resident #38, and Resident #63) of 20 Residents reviewed for call light use/accessibility, resulting in the potential of care needs not met, feelings of frustration, anger, and safety concerns. Findings include: On 3/22/23, an initial tour of the facility was conducted. The following observations were made: -At 9:17 AM, Resident #38 was observed with the Resident in bed. The call light was observed on the floor and not in reach of the Resident. -At 9:23 AM, Resident #63 was observed sleeping in bed. An observation was made of the call light cord over the top corner of the bed with the call light function on the floor and not in reach of the Resident. -At 9:42 AM, Resident #8 was observed sleeping in bed with the head of the bed elevated. The Resident was observed further down in the bed. The call light cord was clipped to the very top corner of the bed on the fitted sheet and the call light function was hanging down past the mattress and not readily in reach for the Resident. Resident #18: A review of Resident #18's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included peripheral vascular disease, cataracts bilateral, psychotic disorder, stroke affecting left dominant side, dementia, anxiety disorder, and heart disease. A review of the Minimum Data Set (MDS) assessment, dated 2/8/23, revealed a Brief Interview of Mental Status (BIMS) score of 3 that indicated severely impaired cognition, and needed extensive assistance with two persons physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene and needed supervision and set up help for eating. Further review of the MDS revealed the Resident had upper and lower extremity impairment on one side. On 3/22/23 at 9:28 AM, an observation was made of Resident #18 in bed with the head of the bed elevated. The Resident had his eyes closed but aroused when his name was called. The Resident answers simple questions and will elaborate on occasional questions. An observation was made of the Resident with no call light in reach. Two call lights were observed near Resident #18's roommate's bed. The roommate was not in the room at the time observations were made. Resident #34: A review of Resident #34's medical record revealed an admission into the facility on 9/7/22 with diagnoses that included mechanical complication of internal right hip prosthesis, acute respiratory failure with hypoxia, mood disorder, adjustment disorder with mixed anxiety and depressed mood, restlessness and agitation, dementia, psychotic disorder, depression, anxiety disorder, and fall. A review of the MDS, dated [DATE], revealed a BIMS score of 3/15 which indicated severely impaired cognition and needed extensive assistance with two persons physical assistance with bed mobility, transfer, toilet use and personal hygiene and needed limited assistance of two persons physical assist for locomotion on unit. On 3/22/23 at 1:02 PM, during the initial tour of the facility, an observation was made of Resident #34 sitting up in her wheelchair with her lunch meal on her overbed table and was eating. The Resident was positioned in the middle of the room with her wheelchair facing towards the inside of the room, with her back positioned towards the open doorway. An observation was made of the call light clipped to the top corner of her bed and hung down towards the floor. The call light was not in reach of the Resident. On 3/22/23 at 1:30 PM, Resident #34 was heard to be yelling at the top of her lungs for help. Two staff come in but leave the room. The Resident was observed to be sitting in the same position facing away from the hallway with the overbed table in front of her and her meal tray was gone. There was no activity for the Resident to do at her overbed table that was in front of her. The call light remains out of reach of the Resident. On 3/22/23 at 1:47 PM, Resident #34 can be heard yelling frequently, Help me, help me, over and over and occasionally changed her [NAME] or urgency in her voice. She was heard crying out, No one cares about me. The call light remains out of reach and staff were observed near the Resident's room in the hallway and was observed not to respond to the Resident crying out. On 3/22/23 at 2:04 PM, an observation was made of Resident yelling for help until this time and staff had entered the room. Shortly after the Resident was observed laying in bed with the head of the bed elevated. The Resident was observed with her eyes closed, and her bottom jaw quivering/twitching. The call light remained clipped to the top of the mattress fitted sheet and not readily available to the Resident. Resident #63: On 3/22/23 at 12:49 PM, an observation was made during the dining observation of the lunch meal of Resident #63 sitting in his wheelchair in his room with his overbed table in front of him and was eating lunch. The call light cord was observed to be placed over the top of the bed with the call light function hanging over the opposite side of the bed from where the Resident was seated. The call light was not in reach for the Resident and the bed was positioned close to the wall with the window and not enough room to maneuver a wheelchair to the side of the bed where the call light was positioned. On 3/28/23 at 4:37 PM, an interview was conducted with the Director of Nursing (DON) regarding call lights accessible to Residents. The DON indicated that call lights were to be reach for Residents and positioned so the Resident can reach the call light if needed. The DON indicated that some Residents were care planned to have their call lights positioned in certain areas, as for example, inside a drawer where the Resident preferred to have the call light. A review of facility policy titled, Call Light, Use of, revised 3/23, revealed, .Procedure Details: . 4. When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light . 7. Place call light on the bed or preferred location stated by the resident prior to leaving the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1 On 3/23/23, at 10:16 AM, Resident #1 was lying on their back in bed. There was a white and pink reusable cup sitting on the windowsill which was noted to be full of black mold. There was a plastic rebreather oxygen mask (used in an emergency) lying face down on their nightstand. There was a strong odor to the room. On 3/24/23, at 9:30 AM, Resident #1 was lying in their bed. The dirty cup and oxygen mask remained in the room. On 3/24/23, at 10:45 AM, The Director of Nursing (DON) was alerted of Resident #1's room had a dirty oxygen mask, moldy cup and had odor and the DON stated, we honed in a couple we noticed odors on and who is going to want to go to activities if they aren't dressed and their teeth aren't brushed. On 3/24/23, at 2:09 PM, Unit Manager (UM) B was interviewed regarding Resident #1's room. UM B was asked who cleaned up Resident #1's room and where the moldy cup and dirty oxygen mask went and UM B stated, they cleaned the room. UM B was asked why there was a rebreather oxygen mask in the room and UM B stated, they had a code (emergency CPR) in that room a while back. UM B was asked to share the residents name that was in the room for the code and a record review revealed the code in that room was on 3/12/23 therefor it appeared the room hadn't been picked up/cleaned in 11 days. UM B did not respond. This Citation pertains to Intake Number MI00131653. Based on observation, interview and record review, the facility failed to 1) Ensure that residents' rooms were clean, well maintained, homelike and free of offensive odors for Rooms 105, 111, 113, 115, 117 and 201, 2) Ensure that razors were properly disposed of in the bathroom between rooms [ROOM NUMBERS] and rooms [ROOM NUMBERS], and 3) Ensure that food spills cleaned for Resident #26, of all resident areas reviewed for cleanliness, sanitary and homelike environment, resulting in a safety hazard, potential spread of diseases, infection, dissatisfaction with living conditions, resident embarrassment and loss of dignity. Findings include: On 3/22/23 at 9:17 AM, an initial tour of the facility was conducted. The following observations were made: -At 9:33 AM, an observation was made in room [ROOM NUMBER]. Resident in bed one was in bed sleeping. The Resident in bed two was not in the room. The room had offensive urine odors throughout the room. An observation was made of bed two with linen that was wet on the unmade bed. -At 10:13 AM, an observation was made in room [ROOM NUMBER] of debris on the floor and the floor very sticky from upon entering the room, around the first bed, the nightstand and overbed table. A substance that looked like jelly was smeared on the floor and was dried but remained sticky. There was a strong odor of urine in the room, bathroom, and could be smelled in the hallway. -At 10:41 AM, an observation was made in room [ROOM NUMBER] of the floor in the room dirty with debris. The bathroom and bathroom had a strong offensive odor of urine, and the order could be smelled in the hallway outside of the room. The heater in the room was splattered with dried substance and had dust and debris on it. The metal of the venting of the heater was corroded. Room was very bare, with one decoration on her board on the wall. There were no personal items displayed in the room. -At 10:54 AM, an observation was made in room [ROOM NUMBER]. The room had built up debris, dust, and dirt around the heater and on the floor along the baseboards. The bathroom, that shared a bathroom with room [ROOM NUMBER], has two basins that are sitting on the floor without resident identifier on the basins and a graduated cylinder placed inside the basin. Resident #26: A review of Resident #26's medical record, revealed an admission into the facility on 4/27/17 with diagnoses that included stroke, depression, psychotic disorder, anxiety disorder, reduced mobility, vascular dementia, bipolar disorder, and Alzheimer's disease. A review of the Minimum Data Set assessment, dated 2/21/23, revealed a Brief Interview of Mental Status score of 15/15, that indicated intact cognition and needed extensive assistance with bed mobility, dressing, toileting, and personal hygiene. On 3/22/23 at 11:05 AM, an observation was made of Resident #26's room. The Resident was not in his room at the time. Observations were made of multiple ceiling tiles with a dried liquid on them, brown in color and looked like a drink had been thrown at the ceiling. There was dried debris that looked like food on the wall. The floor under and beside the bed had a dried spill of something creamy and brownish in color. The shade was pulled down over the window area and had dried debris on it. The debris was spattered over most of the shade and multiple colors of dried sticky substance of cream color, orange, pink and brown. On 3/22/23 at 1:10 PM, an interview was conducted with Nurse H who indicated she was Resident #26's assigned Nurse. The Nurse indicated she was not too familiar with the Resident due to a recent return to working. The Nurse reported that the Resident had been in room [ROOM NUMBER] but was transferred to room [ROOM NUMBER] to do a deep clean of his room. The Nurse indicated that the Resident had behaviors of spitting his food and throwing his food. The Nurse reported that housekeeping was to clean his room two times a day. When asked if they had cleaned yet today, the Nurse was unsure. When asked about the ceiling tiles and how long the substance had been on the ceiling, the Nurse was unsure. On 3/22/23 at 1:57 PM, an interview was conducted with Housekeeping Supervisor (HS) T regarding Resident #26 and the condition of his room. The Housekeeping Supervisor indicated that the Resident was care planned with behaviors of throwing his food. When asked when he was in there last, the HS reported that he had been in there yesterday and stated, I try to go in there everyday, and indicated that Housekeeping tries to clean his room twice a day. When asked how long the substance had been on the ceiling the HS was unsure and indicated it had been on there yesterday and a few days prior to that. The HS indicated that Maintenance Staff would change out the tiles when needed and indicated about once a month they would change them out. When asked about the shade, the HS stated, That needs to be changed as well, and reported the shade would need to be taken to a high-pressure wash to remove the build up food. On 3/23/23 09:58 AM, and observation was made in the hallway of near room [ROOM NUMBER] and 113 of offensive urine smell. The second bed in room [ROOM NUMBER] had been stripped and was cleaned, still wet but drying. The room floor continued to be sticky but was better than the day before. On 3/24/23 at 1:02 PM, an interview was conducted with the Housekeeping Supervisor regarding the cleaning schedules for room [ROOM NUMBER]. The cleaning schedules for room [ROOM NUMBER] revealed that the room was cleaned once a day not twice a day as indicated. The Housekeeping Supervisor indicated that they don't chart the second cleaning. On 3/28/23 at 12:50 PM, an observation was made in room [ROOM NUMBER] and 113's bathroom. The bathroom was shared by the Residents in room [ROOM NUMBER] and 113. A box was on the wall that would hold a sharps container but there was no container on the wall. Inside the box was razors that were dropped into the box but were not secured within a sharp's container. An observation was made in room [ROOM NUMBER] and 117's bathroom. The two rooms shared a bathroom. There was a box on the wall that did not hold secured sharps container as in the bathroom for rooms [ROOM NUMBERS]. There were razors in the box on the wall with a door that was opened, and the razors were accessible. On 3/28/23 at 2:58 PM, an observation was made with the Infection Control Preventionist (ICP), Nurse L of the bathrooms with the razors in the box on the walls and accessible razors in the bathrooms of rooms [ROOM NUMBERS] and rooms [ROOM NUMBERS]. The ICP Nurse indicated that the razors should not be left in the boxes and stated, They shouldn't be in there, I will have someone come clean this out. An observation was made with the ICP Nurse of a strong odor in the room of 117. The Resident was not in the room at the time of the observation. When asked about the odor, the ICP Nurse stated, I know, we have to do some deep cleaning. He probably needs more frequent showers, and indicated that as a Resident who was on dialysis treatments, that could be part of the problem with body odor and the strong urine odor. On 3/28/23 at 4:37 PM, an interview was conducted with the Director of Nursing (DON) regarding the environment concerns. The concerns were reviewed with the DON. The DON indicated that the Resident in room [ROOM NUMBER] was moved to a different room to let staff do a deep clean of the room to try to room the odors and room [ROOM NUMBER] was cleaned today. The DON was asked about the food spills and build-up of the spills in room [ROOM NUMBER]. The DON indicated that the Unit Manager and Administrator were working with the Resident on the behavior of throwing his food. The DON stated, If he spills something then they have to clean it up right away and not leave it. If he drops stuff or throws stuff then it needs to be cleaned up right then, and indicated that would help keep the build-up from occurring. Observation of room [ROOM NUMBER]: Observation of the resident was done on 3/23/23 at 8:55 a.m., revealed room [ROOM NUMBER] had an extremely offensive odor of urine; it could be smelled from outside the room. During an interview done on 2/23/23 at 9:00 a.m., Nursing Assistant/CNA A stated Third shift has been talked to before about not changing her (Resident who occupies room [ROOM NUMBER]), (Facility Management) Yes, it smells bad, I haven't gotten in there yet. During an interview done on 3/24/23 at approximately 11:20 a.m., the Director of Nursing stated, I know she (Resident #39) needs to be cleaned up, her room needs to be cleaned. Observation of room [ROOM NUMBER]: Observation was made on 3/22/23 at approximately 10:00 a.m., the resident was in his bed, blinds closed and the heater under the window was observed to have an area of about 4 to 5 inches across the whole front of black marks. During an interview done on 3/24/23 at approximately 2:30 p.m., the Director of Maintenance C said he was not informed by staff of the black marks on the resident's room heater. During an interview done on 2/28/23 at 9:10 a.m., Social Worker D stated The facility smell bothers me. Review of the facility Cleaning and Disinfecting Resident's Rooms policy dated 3/23, reported Environmental surfaces will be disinfected on a regular basis and when surfaces are visibly soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DPS #2: Based on interview and record review, the facility failed to follow up on a level II (two) recommendation for one resident (Resident #15, resulting in no level 2 follow up since 2019 with the likelihood of unmet care needs. Findings include: Resident #15: On 3/22/23, at 3:36 PM, a record review of Resident #15's electronic medical record revealed an admission on [DATE]. The resident had diagnoses that included Bipolar Disease, Anxiety and major depressive disorder. A review of the miscellaneous tab PASARR in Resident #15's record revealed no PASARR for this admission. On 3/23/23, at 3:03 PM, social worker D was interviewed regarding the lack of follow up on Resident #15's level II and Social Worker D stated, that they just started in December 2022 and would follow up. On 3/24/23, at 9:00 AM, a further record review revealed an uploaded document into the miscellaneous tab PASARR that revealed a date of 3/23/2023. The Level 1 Screening Date 10/17/2022 document uploaded during survey revealed the box for Hospital Exemption Discharge was still check marked. There was no further follow up noted for a required Level II for the resident diagnosis of metal illness. This Citation has two Deficient Practice Statements (DPS). DPS #1: Based on interview and record review, the facility failed to update a Preadmission Screening and Resident Review (PASARR) for four residents (Resident #18, Resident #19, Resident #39, and Resident #57) of five residents reviewed for PASARR screenings, resulting in the potential for unmet mental health and psychiatric care needs. Findings include: Resident #18: A review of Resident #18's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included peripheral vascular disease, cataracts bilateral, psychotic disorder, stroke affecting left dominant side, dementia, anxiety disorder, and heart disease. A review of the Minimum Data Set (MDS) assessment, dated 2/8/23, revealed a Brief Interview of Mental Status (BIMS) score of 3 that indicated severely impaired cognition, and needed extensive assistance with two persons physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene and needed supervision and set up help for eating. Further review of the MDS revealed the Resident had upper and lower extremity impairment on one side. A review of Resident #18's medical record revealed the PASARR document for Annual Resident Review, Michigan Department of Health and Human Services, Level I Screening, Section II- Screening Criteria revealed the Resident had yes a current diagnoses of mental illness and dementia and the Resident yes received treatment. The Resident did not have a follow up noted or document for a required Level II or exemption form DCH-3878 in the medical record. Resident #39: A review of Resident #39's medical record revealed an admission into the facility on [DATE] and re-admission on [DATE] with diagnoses that included dementia, psychotic disorder with delusions, adjustment disorder with anxiety, and hallucinations. A review of the MDS, dated [DATE] revealed a BIMS score of 6/15 that indicated severely impaired cognition and needed supervision with transfers, locomotion on and off unit and limited assistance with dressing, toilet use and personal hygiene. A review of Resident #39's medical record of the PASARR document for Annual Resident Review, Michigan Department of Health and Human Services, dated 12/15/22, Level I Screening, Section II- Screening Criteria revealed the Resident had yes a current diagnoses of mental illness and dementia and the Resident yes received treatment for mental illness with diagnoses: dementia, adjustment disorder, psychotic disorder; receives Seroquel (psychotropic medication). The Resident did not have a follow up noted for a required Level II for the resident diagnosis of mental illness or exemption form DCH-3878 in the medical record. Resident # 57: A review of Resident #57's medical record revealed an admission into the facility on 2/26/21 with diagnoses that included stroke, pressure ulcer, diabetes, reduced mobility, need for assistance with personal care, depression, dementia, and anxiety disorder. A review of the MDS, dated [DATE], revealed a BIMS score of 14 that indicated intact cognition, and needed extensive assistance with bed mobility, dressing, and personal hygiene and was independent with setup help only for eating. The Resident had upper and lower extremity impairment on one side. A review of Resident #57's medical record revealed the PASARR document for Annual Resident Review, Michigan Department of Health and Human Services, Level I Screening, Section II- Screening Criteria revealed the Resident had yes a current diagnoses of mental illness and dementia and the Resident yes received treatment. The Resident did not have a follow up noted or document for a required Level II or exemption form DCH-3878 in the medical record. On 3/23/23 at 3:12 PM, an interview was conducted with Social Worker (SW) D regarding the PASARR document for Resident #18. After review of Resident #18's PASARR, the SW was asked about a Level II screening or exemption. The SW indicated that A Level II or exemption needed to be completed and was unable to find it in the medical record. Resident #39 and 57 PASARR's were reviewed, and the SW indicated that both the Residents should have a Level II or exemption done and was unable to find one in either of Resident #39 or 57's medical record. The SW indicated that they had started in December 2022 and follow up on the missing screenings. Resident #19: Review of the Face Sheet, Diagnosis Sheet, Physician orders dated 12/22 through 3/23, care plans dated 1/23 and Social Worker notes dated 12/23 through 2/23, revealed Resident #19 was 64 years-old, cognitively impaired with an extensive mental health history and required staff assistance for all Activities of Daily Living. The resident's diagnosis included, Anemia, Schizophrenia, Anxiety, high blood pressure, Parkinson's Disease, altered mental status and organ dysfunction. Review of the facility BIMS (cognitive assessment) dated 5/6/2011, revealed the resident was not cognitively able to make any healthcare decisions. Review of the resident's medication orders dated 12/22, revealed he received Closapine 100 mg (an antipsychotic), Depakote Sprinkles 125 mg (for mania) and HydeOXYzine 50 mg (for antianxiety). Review of the resident's facility electronic record done by Social Worker D and this surveyor on 3/23/23, revealed no documentation at all of any PASARR's being done while at the facility (Preadmission Screening & Annual Resident Review/PASARR). During an interview done on 3/23/23 at 12:26 p.m., Social Worker D stated Looks like it was not done; it should have been done in February, his annual. Review of the facility PASARR policy dated 11/17, reported It is the policy of the facility to coordinate the assessment process with the preadmission screening and annual resident review (PASARR) program under Medicaid in Subpart C to the extent practicable to avoid duplicative testing and effort. The facility will not admit any new residents with: Mental Disorder- unless the State mental health authority has determined, prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by the facility and whether the individual requires specialized services: or Intellectual Disability - unless the State intellectual disability or developmental disability authority has determined, prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by the facility; and if the individual requires such level of services, whether the individual requires specialized services for intellectual disability. Level I and Level II Screen - In brief, the PASARR process requires that all applicants to Medicaid-certified Nursing Facilities be given a preliminary assessment to determine whether they might have SMI/SMD or ID. This is called a Level I screen. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASARR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1: On [DATE], at 10:16 AM, Resident #1 was lying on their back in bed. Their hair was greasy and their nails were long and jagged. CNA O entered the room and attempted to open Resident #1's left hand which was contracted closed. Resident #1's fingers opened only about 1 centimeter. There was a strong odor, and their nails were jagged and long. CNA O stated, they will wash and dry her hand and clip her nails. The resident was in a gown and was not dressed in their personal clothing. There was a white and pink reusable cup sitting on the windowsill which was noted to be full of black mold. There was a plastic rebreather oxygen mask (used in an emergency) lying face down on their nightstand. On [DATE], at 8:00 AM, a record review of Resident #1's electronic medical record revealed an admission on [DATE] and required extensive assistance with all Activities of Daily Living (ADL's.) On [DATE], at 9:30 AM, Resident #1 was lying in their bed with a gown on. The dirty cup and oxygen mask remained in the room. On [DATE], at 10:45 AM, The Director of Nursing (DON) was asked what their expectation was for the staff to assist with morning Activity of Daily Living care and the DON stated, I expect them to get up and get dressed. The DON was alerted of Resident #1's lack of ADL care and the DON stated, we honed in a couple we noticed odors on and who is going to want to go to activities if they aren't dressed and their teeth aren't brushed. On [DATE], at 11:14 AM, CNA N was asked if Resident #1 was going to get a shower and CNA N stated yes. CNA N was alerted the need for observation of the ADL care and CNA N stated, It's going to be a bed bath because I don't have time to give her a shower now. On [DATE], at 1:30 PM, Resident #1 was lying in their bed and remained in a gown. On [DATE], at 1:35 PM, Nurse H was asked when Resident #1 will be getting their shower and Nurse H stated, she got a bed bath because the CNA was running behind because they only had two CNA's in the morning. On [DATE], at 2:09 PM, Unit Manager (UM) B was interviewed regarding Resident #1 and UM B stated, I clipped her nails, washed, dried her hands and placed a carrot (type of splint) in her left hand. UM B was asked who cleaned up Resident #1's room and where the moldy cup and dirty oxygen mask went and UM B stated, they cleaned the room. UM B was asked why there was a rebreather oxygen mask in the room and UM B stated, they had a code (emergency CPR) in that room a while back. UM B was asked to share the residents name that was in the room for the code and a record review revealed the code in that room was on [DATE] therefor it appeared the room hadn't been picked up/cleaned in 11 days. Resident #12: On [DATE], at 9:00 AM, Resident #12 is in bed with their head elevated. Resident #12 has long jagged dirty nails. Resident #12 is grabbing their chocolate milk with their thumb and index finger and their dirty nails are noted to inside the chocolate milk. Resident #12 appears unkept with long facial hair, dirty gown and no personal clothing. There was an odor to the room. On [DATE], at 12:19 PM, During medication administration, Resident #12 remained in a gown, in bed with long dirty jagged nails. The odor to the room remained. On [DATE], at 8:07 AM, The Director of Nursing (DON) was alerted the Resident #12 had odor, long jagged dirty nails and hadn't been dressed since survey began and the DON stated, to me when you smell you're not getting take care of. On [DATE], at 9:00 AM, a record review of Resident #12's electronic medical record revealed and admission on [DATE] and required extensive assistance with ADL's. On [DATE], at 11:00 AM, Resident #12 was sitting in their chair and dressed in their personal clothing. Resident #12 was in the main dining room for a musical activity and was clapping and wiggling in their chair. Resident #60: On [DATE], at 12:32 PM, during dining observation, Resident #60 was observed sitting in the dining room. They had grey pants with a grey jacket that had a large, dried stain down the front. On [DATE], at 8:34 AM, Resident #60 was sitting in a dining chair in the main dining room. Their nails were quite long, dirty and jagged. Their was green frosting appearance under [NAME] their nails. Resident #60 had dark gray pants and a grey jacket on. The grey jacket had a large stain down the entire front. Resident #60 stated they would love their nails clipped but was unsure how much it cost and exclaimed they had no money on them. Resident #60 was told it didn't cost to get their nails clipped and cleaned and the resident stated, well, then yes please. On [DATE], at 10:55 AM, Resident #60 sitting in the same chair with the same clothing on and appears to be resting with their eyes closed. On [DATE], at 9:34 AM, Resident #60 was sitting in the dining room. Their nails remain long and dirty with the green frosting appearance. On [DATE], at 9:37 AM, an observation along with Nurse Consultant R was conducted of Resident #60's dirty long nails. Nurse Consultant R stated, they would get assistance for Resident #60. Nurse Consultant R was alerted that this was the third day the resident was in the same dirty clothing. On [DATE], at 10:00 AM, a record review of Resident #60's electronic medical record revealed an admission on [DATE]. A review of the most recent Minimal Data set Assessment revealed that Resident #60 required assistance with personal hygiene and was Independent - no help or staff oversight at any time for Dressing despite the resident had the same dirty clothes on for 3 days. This Citation pertains to Intake Number MI00131653. Based on observation, interview and record review, the facility failed to ensure that bathing/shower activities were provided and assist with dressing and shaving for six residents (Residents #1, Resident #4, Resident #12, Resident #18, Resident #57, and Resident #60) of 14 residents reviewed for Activities of Daily Living (ADL) care, resulting in poor hygiene and the potential for infection, skin irritation, body odor and feelings of embarrassment, diminished self-worth, and lack of dignity. Findings Include: Resident #4: A review of Resident #4's medical record, revealed an admission into the facility on [DATE] and re-admission on [DATE] with diagnoses that included diabetes, obesity, urinary tract infection, Alzheimer's disease, depression, and anxiety disorder. A review of the Minimum Data Set assessment, dated [DATE], revealed the Resident had intact cognition and needed extensive assistance with two persons physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene and two-person physical assist in part of bathing activity. On [DATE] at 10:30 AM, an observation was made of Resident #4 lying in bed. The Resident was interviewed, and the Resident conversed in conversation. The Resident was asked how often she was showered. The Resident indicated she has not always received a bed bath twice a week and has gone over a week with out a bed bath given. The Resident reported that she was told that CNA's did not show up for work and they were shorthanded. The Resident was asked if she was offered bathing activity the next shift or next day. The Resident reported that she had gone without bathing. The bathing activity for Resident #4 was requested from the Director of Nursing. A review of the received bathing activity for Resident #4's documented task for bathing in February 2023 revealed a bath given on 2/8, 2/11 and 2/15. The Resident had gone from [DATE] to February 8 without documented bathing activity and from February 16 to [DATE] without documented bathing activity. Resident #18: A review of Resident #18's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included peripheral vascular disease, cataracts bilateral, psychotic disorder, stroke affecting left dominant side, dementia, anxiety disorder, and heart disease. A review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 3 that indicated severely impaired cognition, and needed extensive assistance with two persons physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene and needed supervision and set up help for eating. Further review of the MDS revealed the Resident had upper and lower extremity impairment on one side. On [DATE] at 9:28 AM, an observation was made of Resident #18 in bed with the head of the bed elevated. The Resident had his eyes closed but aroused when his name was called. The Resident answers simple questions and will elaborate on occasional questions. The Resident was observed to have his gown falling off his shoulders down to mid upper arms bilaterally leaving the shoulders and much of his chest exposed. The Resident had a beard and mustache, and nails were long and had not been clipped recently. On [DATE] at 3:39 PM, an observation was made of Resident #18 was in bed, dressed in a gown and had the head of the bed elevated. On [DATE] at 3:40 PM, an observation was made of Resident #18 in bed, dressed in a gown and had the head of the bed elevated. The room had an odor of urine. The Resident was asked when he had a shower last and reported he was unsure and indicated he usually gets a bed bath. When asked about his preference, the Resident indicated he would like to go in the shower sometimes. When asked if they offer for him to take a shower or bed bath, the Resident indicated they give him bed bath and don't ask. On [DATE] at 10:01 AM, Resident #18 was observed in bed with a gown on. Resident #18 reported he had gotten a shower and stated, It felt GOOD! The Resident also indicated his fingernails had been clipped. When asked about shaving, the Resident reported that staff had clipped it. When asked about his preference to have a full beard and mustache or clean shaven, the Resident indicated he liked to clean shaven. The bathing activity for Resident #18 was requested from the Director of Nursing. A review of the received bathing activity for Resident #18's documented task for bathing in [DATE] revealed one shower given on [DATE] and bed bath given on 12/5, 12/8, 12/19, and 12/26 with a time span of 10 days without documented bathing activity. In [DATE], revealed four bed baths documented. In February 2023, revealed seven bed baths given. For [DATE] from 3/1 to 3/23, the resident had documented three bed baths received. The last documented shower was on [DATE]. Resident # 57: A review of Resident #57's medical record revealed an admission into the facility on [DATE] with diagnoses that included stroke, pressure ulcer, diabetes, reduced mobility, need for assistance with personal care, depression, and anxiety disorder. A review of the MDS, dated [DATE], revealed a BIMS score of 14 that indicated intact cognition, and needed extensive assistance with bed mobility, dressing, and personal hygiene and was independent with setup help only for eating. The Resident had upper and lower extremity impairment on one side. On [DATE] at 3:54 PM, an interview was conducted with Resident #57. The Resident conversed in conversation. The Resident was asked about taking showers and the Resident indicated that staff give him a bed bath. An observation was made of the Resident lying in bed, dressed in a gown, there was an odor of body odor noted, and the Resident's hair was unkept and oily. The Resident was asked when he had a bed bath last but was unsure when. The Resident was asked if they shampoo his hair and he indicated that they have used one of those cap things and reported that staff do not wash his hair with all bed baths. When asked if the Resident gets dressed, the Resident stated, I get dressed when I got people coming to see me. No sense in getting dressed when no one comes to see me. The Resident was observed to have long whiskers. When asked about shaving, the Resident indicated that occasionally will have his beard cut with scissors and reported that his preference was to be clean shaven. The bathing activity for Resident #57 was requested from the Director of Nursing. A review of the received bathing activity for Resident #4's documented task for bathing in February 2023 revealed a bath given on 2/2, 2/19 and 2/16. The Resident had gone from February 17th through [DATE]st without documented bathing activity. On [DATE] at 4:37 PM, an interview was conducted with the Director of Nursing regarding concerns of lack of bathing activity, Resident complaints of getting a bed bath and not offered a shower, and nail care. A review of facility policy titled, Activities of Daily Living (ADL's), Supporting, reviewed 10/2022, revealed, Policy Statement: .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .

Based on observation, interview and record review, the facility failed to ensure 3 (Hall 2, 1 A and 1 B) of 4 medication carts were clean and sanitized, free of crushed pills, pieces of loose papers and dust in the drawers, resulting in the likelihood of cross contamination, low medications count with increased cost and missed resident medications (meds). Findings Include: Observation of facility medication carts done on 3/22/23 starting at 9:53 a.m., revealed the following: Cart 1 A: -In the first and 3rd drawers there was an excessive number of crushed medications and pieces of paper on the bottom of each drawer. During an interview done on 3/22/23 at 9:58 a.m., Nurse, LPN J stated Management did clean them out last week, night shift is supposed to clean them. -In the first drawer was observed a medication cup with 2 Tums inside, no resident name or date was on the cup. During an interview done on 3/22/23 at 10:00 a.m., Nurse, LPN They (Nurse's from third shift on 3/21/23) were from last shift. Cart: 1 B: During an interview done on 3/22/23 at 10:00 a.m., Nurse, K stated You caught me as I am cleaning it, I usually do it after med pass. -A Cup of Proheal (liquid wound protein supplement) was found sitting in left third drawer, already set-up to give. This cup of Proheal was approximately 3/4th's full and had spilled all over the bottom of the drawer. -The First drawer had a dark [NAME] sticky substance in the bottom and the second and third drawers had crushed meds and pieces of paper in them. Hall 2 Cart: -In the second drawer was found one round white loose pill and in the second and third drawers was observed excessive amounts of crushed pills and papers. During an interview done on 3/22/23 at 10:07 a.m., Nurse, LPN H stated If any of us (nurse's) see it, we clean it (referring to cleaning the med carts). During an interview done on 3/22/23 at 10:10 a.m., Nurse, RN I stated We all do our best to keep it (med cart) clean. During an interview done on 3/28/23 at 1:10 p.m., the Director of Nursing stated We all clean the med carts, we clean them when we use them. No medications should be set-up. Review of the facility Medication Storage in the Facility policy dated 2006, stated Medication storage areas (including the medication cart) are kept clean, well-light, and free of clutter and extreme humidity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide snacks and residents' choices of snacks for all residents, resulting in frustration of not getting snacks per their choice or no snack at all. Findings include: On 3/22/23, at 1:11 PM, an observation along with Nurse K of the medication room [ROOM NUMBER]B was conducted. Nurse K was asked where the snacks are stored for the residents and Nurse K pointed to a plastic bin approximate size 10 inches by about 14 inches that was sitting on top of the medication room counter. The plastic bin housed an empty box of oatmeal cream pies and only 1 single package of Fig Newtons. There was small jar of peanut butter. Nurse K opened the freezer which was full of personal purchased freezer items and had no ice cream treats for residents' snacks. The refrigerator housed 1 chocolate pudding and 1 apple sauce which the nurse stated they use for medication pass. There was a clear plastic container that housed 1 half deli lunch meat sandwich. There was 1 and ½ containers of kitchen made and dated fruit punch. There were numerous personal purchased items labeled stored in the refrigerator. Nurse K was asked if there was bread or jelly and Nurse K stated, no. On 3/22/23, at 1:19 PM, Dietary Manager (DM) G was interviewed regarding snack storage and choices for the residents. DM G stated that the snacks are stored in the 1B medication room and the choices were as follows chips, oatmeal cakes, fudge rounds, fig newtons, rice Krispy treats, cheese its, pudding, apple sauce, deli sandwiches, peanut butter and jelly sandwiches. DM G was asked if there were protein snack choices and DM G some request cottage cheese and we have vanilla yogurt when it's in stock. On 3/22/23, at 2:00 PM, during resident council, there were multiple complaints regarding the choice of nighttime snacks and that not everyone gets one. The following complaints were shared during resident council: My sister brings me snacks. Sometimes they put the snacks out, sometimes they don't. They put them on the desk, but they forget or don't get around to it. The kitchen closes at 8:00 PM. There is a guy that comes around late. He will go get me a peanut butter and jelly, but very seldom does that happen. There's a guy that comes in late and if I can catch him, he will get me a snack. I don't get snacks and if I do it's because I have to buy them. I second that. It's very upsetting because you should be able to get what you want. No fresh fruit. Sometimes with the meals but it would be nice to have as a snack. It would be nice to have ice cream treats for a snack. On 3/23/23, at 11:17 AM, an observation along with Nurse P of the 1B snacks was conducted. Nurse P was asked if she had handed out any snacks and Nurse P stated, No, I haven't handed any snacks out yet today. The following snacks were present: 3 oatmeal cream pies, 1 fudge round and 1 fig [NAME]. There were no sandwiches noted in the refrigerator and there were no other refrigerator choices. There were no frozen treat choices in the freezer. On 3/28/23, at 9:52 AM, Registered Dietician (RD) M was asked how the bedtime snacks are provided and RD M stated, there is a snack list and there is nourishment floor stock. RD M further offered that anybody can ask any staff member to get them a snack. RD M was asked if there was a time cut off to ask for the always menu and RD M stated, no they can ask anytime. RD M was asked if they provide ice cream treats or frozen treat choices for the residents and RD M stated, we had vanilla ice cream I know it was unavailable for a few days. RD M was alerted the 1B freezer did not have any frozen treat choices provide and was stocked full with personal purchased frozen treats. RD M further offered that a lady wanted pop cycles so they went to the local grocery store and purchased them for her. RD M was asked if there are fresh fruit choices for the residents as they suggested grapes would be a great nighttime snack and RD M stated, they always have apples, oranges and bananas.

Based on observation, interview and record review, the facility failed to 1) Maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) Ensure that kitchen hand washing sinks and freezer door were properly maintained, resulting in an increased likelihood for improper food temperatures maintained, food borne illness with hospitalization, and cross contamination affecting 94 residents who consumed oral nutrition from the facility kitchen and of a total census of 95 residents. Findings Include: During the initial kitchen tour done on 3/22/23 at 9:30 a.m., accompanied by Dietary Manager G, the following observations were made: -At 9:30 a.m., the hand washing sink at the front of the kitchen did not drain properly, it was very slow to drain the water. During an interview done on 2/22/23 at 9:35 a.m., Dietary Manager G stated It (the hand washing sink) does not drain good, we have problems with the pluming here, the whole facility, it's been for a while. -At 9:36 a.m., the resident microwave inside top had the white coating picking off; directly above where food would be put to warm. During an interview done on 2/22/23 at 9:36 a.m., Dietary Manager G stated Ya, I know it's (the resident microwave) old. -At 9:37 a.m., the kitchen freezer's right and left inside door seal area had ice build-up, the seal was not adhering flatly to the door. The seal was not secured properly to the door. During an interview done on 2/22/23 at 9:37 a.m., Dietary Manager G stated It's (the freezer seal) been like that for a while, they tried to fix it. -At 9:39 a.m., the large can opener was noted to have chipping silver paint on the blade. -At 9:40 a.m., the second kitchen hand washing sink at the back of the kitchen was slow to drain. -At 9:42 a.m., the large covered clean and ready for use mixer had dried food particles inside the clean mixer bowl. -At 9:43 a.m., the third kitchen sink in the dish room was slow to drain. -At 9:46 a.m., the water machine was observed to have dried food pieces on the outside (in the back hall behind the kitchen). During an interview done on 2/22/23 at 9:46 a.m., Dietary Manger G stated Maintenance cleans that (the water machine). -At 9:48 a.m., the walk-in cooler ceiling fan was noted to have dust and some rust on it. According to the 2017 FDA Food Code: 4-202.11 Food-Contact Surfaces. (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have SMOOTH welds and joints; 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (5) At any time during the operation when contamination may have occurred.