This Citation pertains to Intake Number MI00150127. Based on observation, interview and record review, the facility failed give prompt treatment for several fractures related to a roll/fall out of bed for one resident (Resident #301). Findings include: Record review of the facility Abuse Prevention Program policy, dated 1/2025, defined 'Neglect' as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Resident #301: Record review of Resident #301's hospital Emergency Department note, dated 2/3/2025 at 9:17 PM, noted acute left 5th through 10th rib fractures and medial left clavicle fractures. The emergency department noted that the resident was symptomatic with multiple rib fractures and left clavicle fracture and has not achieved medical stability for safe discharge from hospital . the current condition would worsen and an adverse event like worsening pain, pneumonia may occur . Record review of Resident #301's progress notes, dated 1/31/2025, documented pain medication administered. The next progress note was dated through 2/2/2025 at 5:02 AM related to insulin administration. Record review of 2/3/2025 Progress note written by Registered Nurse B was strike out of documentation. A late entry progress note dated 2/3/2025 noted that the resident complained of back pain. Resident told CNA she was dropped, and writer went to speak with her and assess her . Record review of Resident #301's Minimum Data Set (MDS) assessment, dated 1/2/2025, revealed an elderly female with Brief Interview of Mental Status (BIMS) score of 12 out of 15. Medical Diagnosis included: Medically complex conditions, anemia, hypertension, renal insufficiency, diabetes, hyponatremia, other fracture, cerebrovascular accident (CVA), hemiplegia/hemiparesis, malnutrition, depression and osteomyelitis of left foot. Section GG: functional abilities: Dependent- helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for toileting hygiene, shower/bathe, upper body dressing, lower body dressing, rolling left and right, sit to lying, lying to sitting, and chair/bed-to-chair transfer. Record review of Resident #301's care plans, page 1- 27, revealed Activity of Daily Living (ADL) care plan related to self-care performance deficit secondary to cardiovascular accident (CVA) related to left hemiparesis, left hand contractures, left lower extremity contracture, left side neglect, osteomyelitis of left foot, surgical amputation of left great toe. The care plan noted limited mobility, limited range of motion (ROM), decreased mobility . Interventions: Bed Mobility dated 11/10/2023: The resident requires extensive 2 staff to turn and reposition in bed. Dressing dated 11/10/2023: The resident requires extensive 2 staff to dress. Toilet Use dated 11/10/2023: The resident requires extensive 2 staff for bed pan/brief change. Record review of the facility 'Activity of Daily Living (ADL), Supporting' policy dated 1/2025 revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). 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. (2.) 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, mobility, elimination . Definitions: Total Dependence- Full staff performance of an activity with no participation by resident for any aspect of the ADL activity Observation and interview was conducted on 2/14/2025 at 11:30 AM with Resident #301 and family member at bedside. Resident #301 stated again that she was dropped and flat on her back. Observation with assist of family member of Resident #301 dressed in a hospital gown revealed left upper should/chest front view of a large bruising area of a green/yellow color, estimated to be the size of a basketball that went down the left side under the arm pit area. Observation of the left hip area visible through a brief the surveyor noted a dark purple in color bruising estimated 3 inches wide by 6 inches in length. Resident #301 stated that she does get back pain and shoulder pain with hiccups and coughing or being moved. Sleeping at night hurts also. The state surveyor observed black bilateral soft boots on while in bed, observed a right upper arm PICC (Peripheral Inserted Central Catheter) line with dressing dated 2/1/2025. A dressing was noted to the left lower arm estimated 2 inch wide by 3 inch in length with date of 2/13/2025. The family member stated that the resident spent 7 days in the hospital related to her fracture injuries and infection in her foot. An interview on 2/14/2025 at 1:07 PM with Registered Nurse (RN) B revealed that he was working when Certified Nurse Assistant (CNA) I called the nurse into Resident #301's room to see a skin tear on the left lower arm by the hand and then she mentioned that when she was getting Resident #301 ready for bed and giving a sponge bath that she said for me to look at the bruising from her left upper shoulder area that was blur in color. RN B stated 'It (the bruising) went from left upper chest to right upper chest. Around that time CNA I mentioned that the resident said that she was dropped from the bed. She fell or was dropped; it was around that time. She (Resident) stated to her grandson that she was dropped or fell. I was in the room doing assessment on Resident #301 and CNA I asked her about the bruising, and I heard Resident #301 say that she was dropped from the bed. Resident #301 said it, I heard her say it. Resident #301 was having a lot of back pain. The left upper arm had small bruising on her elbow and dark red color to arm. Resident #301 said severe back pain, left arm hurt and she hadn't ever complained of back pain before. I sent her to hospital around 8 PM that night (2/3/2025). CNA I had a couple of days off before this and saw the skin tear and asked if it was new. The skin tear was scabbed over with no dressing on it. I didn't know about the skin tear it was not given in report shift to shift, and not documented anywhere. The severe back pain, new bruising, scabbed skin tear, she was on Eliquis blood thinner, and I sent her to the hospital ER per protocol the black & blue was new with a blood thinner and an unwitnessed fall/drop?' Record review of facility 'Charting and Documentation' policy dated July 2017 revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medial, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. (2.) The following information is to be documented in the resident medical record: (a.) objective observations. (d.) Changes in the resident's condition. (e.) Events, incidents or accidents involving the resident . (8.) ADL (Activity of Daily Living) documentation shall be completed on each shift by Certified Nursing Assistants and will be monitored by nursing. An interview and record review on 2/14/2025 at 2:18 PM with the Director of Nursing (DON) about Resident #301's injuries revealed that she started staff education yesterday on 2/13/2025 for a change in elevation related to the incident. The DON stated, 'Residents Usually are lowered to the floor/ground. It was brought up last week about the change in elevation education. That's the only education that we have related to the incident. I put it out yesterday for the staff to sign the education. The Certified Nurse assistant (CNA) H reported to nurse Licensed Practical Nurse (LPN) E and the LPN went in and looked at the Resident #301 and then went to a second nurse, License Practical Nurse (LPN) G. LPN G went into the Resident #301's room and asked the resident about a fall. The CNA H explained that it was a roll out of bed. LPN G asked Resident #301 if she wanted to go to the hospital and she said no. CNA H stated that he was changing the resident while rolling her over from the bed he turned to get the wipes and she rolled from the bed, but that he caught her and she did not hit the floor. It happened on Sunday 2/2/2025 at around 8:56 PM. Then on 2/3/2025 at 8:01 PM Registered Nurse (RN) B received a report form CNA I that there was bruising to the left side of the resident's chest bruising and left hip bruising, left lower arm skin tear without a dressing. Record review of Resident #301's medical record with the DON of the resident assessments (skin, pain, and post injury of unknown origin) and progress notes from 2/1/2025 through 2/14/2025 revealed there was no assessment or progress notes written on 2/2/2025 the evening of the incident and not until on 2/3/2025 when the resident was sent to hospital. The state surveyor reached out to Licensed Practical Nurses (LPN) E and G who were on duty at the time that Resident #301's injury of unknown origin occurred, but they did not respond to the phone calls or voice messages left to return the phone call. Record review of facility investigation witness statements revealed: Certified Nurse Assistant (CNA) H written statement dated 2/5/2025 revealed the CNA went into Resident #301's room to change her. The CNA proceeded to change Resident #301 rolling her towards his body to change her and turned to get the brief and wipes that he placed in the window sill and, as he was turning to grab the items out of the windowsill, he saw the resident falling. CNA H noted he quickly grabbed resident with a swift force, but she unfortunately hit her shoulder and head on a chair. CNA H noted he placed the Resident #301 back into bed and went and got the nurse. They checked her (Resident #301) out, took her vitals and was seeing if she was OK. We checked on her through the night. She was sleeping and toward the ending of my shift me and the nurse went to go change her again. Record review of Resident #301's Medication Administration Record for the month of February 2025 revealed the medication Eliquis (anticoagulant/blood thinner) 2.5 mg give 1 tablet by mouth two times day for prophylaxis started on 3/20/2024 . Record review of 'Nursing 2017 Drug Handbook' Wolters Kluwer 2017, page 148- 149, revealed black box warning: Monitor patient for neurologic impairment (midline back pain, sensory or motor deficit, such as numbness or weakness in lower limbs, bowel or bladder dysfunction. Treat impairment urgently Record review of Resident #301's progress notes, dated 1/31/2025, documented pain medication administered. The next progress note was dated through 2/2/2025 at 5:02 AM related to insulin administration. Record review of 2/3/2025 Progress note written by Registered Nurse B was struck out of documentation. A late entry progress note dated 2/3/2025 noted that the resident complained of back pain. Resident told CNA she was dropped and writer went to speak with her and assess her . Record review of facility investigation witness statements revealed: Certified Nurse Assistant (CNA) H written statement dated 2/5/2025 revealed the CNA went into Resident #301's room to change her and put her into bed. The CNA put the resident into bed with a lift machine and placed her into bed. The CNA proceeded to change resident #301 rolling her towards his body to change her and turned to get the brief and wipes he placed in the windowsill and as he was turning to grab the items out of the windowsill he saw the resident falling. CNA H noted he quickly grabbed resident with a swift force, but she unfortunately hit her shoulder and head on a chair. CNA H noted he placed the Resident #301 back into bed and went and got the nurse. they checked her (Resident #301) out, took her vitals and was seeing if she was OK. We checked on her through the night. She was sleeping and toward the ending of my shift me and the nurse went to go change her again. Record review of Resident #301's Medication Administration Record for the month of February 2025 revealed the medication Eliquis (anticoagulant/blood thinner) 2.5 mg give 1 tablet by mouth two times day for prophylaxis started on 3/20/2024 . Record review of 'Nursing 2017 Drug Handbook' Wolters Kluwer 2017, page 148- 149, revealed black box warning: Monitor patient for neurologic impairment (midline back pain, sensory or motor deficit, such as numbness or weakness in lower limbs, bowel or bladder dysfunction. Treat impairment urgently

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8: During Resident Council on 11/19/2024 at 10:30 AM, Resident #8 shared she requested grits from the kitchen for breakfast and received them consistently for 3-4 days and suddenly she stopped being served them. When she asked dietary staff about it, they stated she could not have them as she was the only resident that requested them. On 11/19/2024 at 2:00 PM, Dietary Manager F was queried regarding Resident #8's request to have grits daily for breakfast. She reported her cook informed her she was making it for the resident, but it was coming back to the kitchen, so they stopped preparing it for the resident. Manager F was asked to clarify if dietary spoke to Resident #8 regarding removing grits from her plate or if it was assumed she did not want them because it was not being eaten. On 11/20/2024 at 7:55 AM, a review was completed of Resident #8's records and it indicated she admitted to the facility on [DATE] with diagnoses that included, Acute Pancreatitis, Anxiety, Pulmonary Hypertension, Diverticulitis, Syncope and Collapse. Further review yielded the following: Care Plan: .Offer (Resident #8) food preferences. Offer subs of same nutritional value if resident dislikes main meal .Provide (Resident #8) wit as much control as possible in routines, food preferences etc. On 11/20/24 03:35 PM, Dietary Manager F followed up on Resident #8's grits preference. She expressed she found their cook made the decision to stop making Resident #8's grits every morning because it was too many breakfast items to prepare. Manager F explained they are going to use instant grits for Resident #8 Review was completed of the facility policy entitled, Resident Food Preferences, reviewed 2/2024. The policy stated, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modification to diet will only be ordered with the resident's or representative consent . When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes . Based on observation, interview and record review, the facility failed to ensure that food preferences were identified and followed for 2 residents (#8 and #109) of 2 residents reviewed for food or choices, resulting in both Resident #8 and #109 becoming upset, and discouraged that they did not receive the food that they had requested. Findings Include: Resident #109: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #109 was admitted to the facility on [DATE] with diagnoses: Cirrhosis of the Liver with ascites, vitamin/mineral deficiency, dehydration, history of falls, left hip pain, hypertension, COPD, depression, Panic disorder, GERD and arthritis. The MDS assessment dated [DATE] indicated Resident #109 had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and needed some assistance with care. The MDS section K identified the resident was receiving a Therapeutic diet. On 11/19/2024 at 9:20 AM, Resident #109 was viewed sitting in a chair in his room. He said he had been at the facility for about 2 weeks, and he received 3 salads. The resident said it was difficult to get fresh fruit and salads, as he was trying to eat less processed foods. Resident #109 stated, I asked for a salad with every meal, like a side salad. I don't think they have salads every day here. I don't get milk unless I ask for it. The resident was asked if he had talked to anyone about not receiving the food he requested and he said he had spoken to several people from the kitchen. The resident showed his meal ticket on his breakfast tray. It listed his type of diet and fluids. There were no food preferences listed. On 11/20/2024 at 2:40 PM, the Certified Dietary Manager/CDM F was interviewed about Resident #109. She said she had spoken to him and he received a 4 week menu and alternative menu. The CDM said a side salad was an option on the alternative menu and included: lettuce, tomatoes, green pepper, cucumber, and onion. She said it was the only option for a salad and there was no chef salad. The CDM said Resident #109 could receive a salad and noted he had received several salads. The CDM said she would follow up with the resident, and flag his ticket to ensure he received a salad and fruit. During the interview with the CDM on 11/20/2024 at 2:45 PM, a dietary note dated 11/7/2024 was reviewed. It was created on 11/13/2024 and dated for 11/7/2024; a week after the resident was seen by the CDM. She said sometimes the notes were created late. Discussed with the CDM that Fruit was mentioned on the 11/7/2024 assessment but not addressed on the resident's food ticket. Salads were not mentioned on the notes/assessments, but the CDM said the resident had mentioned it to her and he had received them several times, although not consistently. On 11/21/2024 at 1:00 PM, Resident #109 was interviewed; his lunch tray was sitting on the bedside table. He said he talked to someone from the kitchen, and he said he didn't want a salad for breakfast but with lunch and supper It would be nice. He pointed at his meal tray and showed that he did not get a salad. In reviewing his lunch ticket, it did not identify any preferences or mention the resident would like fresh fruit and a salad. There was no fruit on the meal tray, but Resident #109 said he had some fruit the previous day and had an extra apple and orange in his room. On 11/21/2024 at 2:00 PM, during an interview with the CDM, it was pointed out that the resident did not receive a salad with his meal and his meal ticket did not identify food preferences. On 11/21/2024 at 2:45 PM, during an interview with the Administrator, Resident #109's food preferences were reviewed: the resident's meal ticket did not identify the resident's preferences, and he had been in the facility for 16 days. She said there were some challenges in the dietary department, and they were going to work on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a Minimum Data Set/MDS Comprehensive Assessment for 2 residents (#35 and #45) of 15 residents reviewed for Comprehensive Assessments, resulting in the potential for the misidentification of resident needs, treatments and services for Resident #35 and Resident #45. Findings Include: FACILITY Resident Assessment Resident #35: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: Dementia, heart disease, diabetes, kidney disease, depression and hypothyroidism. On 11/18/2024 at 10:27 AM, during a review of the MDS assessments for Resident #35 identified an admission assessment on 10/31/2023 and 4 quarterly assessments dated: 1/31/2024, 5/2/2024, 8/2/2024 and 11/2/2024. At the top of the MDS screen in the electronic medical record/EMR, identified Next Full: ARD (assessment reference date: 10/31/2024, 5 days overdue was highlighted in red print. There was no Full assessment for Resident #35 after his initial admission MDS on 10/31/2024. ON 11/19/2024 at 11:34 AM, MDS Nurse I was interviewed. She said she was the only MDS nurse at the facility and completed all MDS assessments for the residents. MDS Nurse I said the Director of Nursing/DON signed the MDS completion page when the assessment was completed. During the interview with MDS Nurse I on 11/19/2024 at 11:34 AM, it was reviewed that Resident #35 had 4 quarterly assessments in a row over the last year and an annual full assessment was not completed. The MDS Nurse I said the computer system cued her to complete 4 quarterly assessments instead of 3 quarterlies and an annual. She said it had happened before also. The MDS Nurse said she did not complete the required annual full MDS assessments for 2 residents currently residing in the facility: Resident #35 and Resident #45. Reviewed both residents' assessment screens with the MDS Nurse. The MDS screen for Resident #45 identified an admission to the facility on [DATE] and an admission MDS assessment dated [DATE]. There were then 4 quarterly assessments dated: 1/31/2024, 5/2/2024, 8/2/2024 and 11/2/2024. This was similar to Resident #35. The assessments were compared and reviewed with the MDS Nurse I. She said she had not completed the required annual assessments for either resident and was not sure why the computer program was cuing her to complete the wrong assessment. Resident #45's MDS page in the EMR also said Next Full ARD: 0/31/2024 5 days overdue highlighted in red. The MDS Nurse I said she would have to fix this as both full MDS assessments needed to be completed for Resident #35 and Resident #45. She said she wasn't sure why this was happening, but would have to check into it. On 11/21/2024 at 3:30 PM, during an interview with the Administrator and Assistant Administrator, it was reviewed that Residents #35 and #45 did not have the required Full MDS assessments completed. The Administrator said she had become aware of this and the assessments should have been completed. A review of the facility policy titled, MDS Completion and Submission Timeframes, dated revised July 2017 provided, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS . in accordance with current federal an state guidelines . Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update/revise individualized, person-centered care plans to reflect changing care needs for 2 residents (Resident #10, Resident #109), of 15 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #10: A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #10 indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Alzheimer's dementia, history of falls with right leg fracture, respiratory failure, history of a stroke and heart disease. The MDS assessment dated [DATE] indicated the resident had severe cognitive impairment with a Brief Interview for Mental Status/BIMS score of 0/15 and the resident needed assistance with all care. On 11/19/2024 at 9:50 AM, Resident #10 was observed sitting in the day room looking out the window. Her face was observed to have several very dry and scaly patches. A review of a skin assessment for Resident #10 dated 11/17/2024 did not mention the residents face was dry with scaly skin. A review of the Care Plans for Resident #10 provided the following: (Resident #10) has increased risk for skin impairment r/t (related to): Cognition impairment; need for extensive/dependent assist from staff for ADL's (activities of daily living); Decreased mobility, resident now spends most of the day in bed and rarely self propels in w/c (wheelchair) . resident occasionally refuses shower . date initiated 12/15/2022 and revised 10/25/2024. With Interventions including: CNA's (certified nursing assistants) will check skin daily with care and report anything unusual to the nurse, date initiated 5/29/2021; Nurse to assess skin twice a week, date initiated 12/28/2021; Keep skin clean and dry. May use lotion on dry skin areas, date initiated and revised 10/6/2023. There was no mention Resident #10 having very dry skin on her face. On 11/21/2024 at 1:39 PM, the Wound Nurse J and Unit Manager H were interviewed about Resident #10's dry skin. The Wound Nurse said she had not noticed the resident having dry skin on her face, but if she did, staff could apply lotion. The Wound Nurse and Unit Manager H said they would follow up on this. Resident #109: Care Planning A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #109 was admitted to the facility on [DATE] with diagnoses: Cirrhosis of the Liver with ascites, vitamin/mineral deficiency, dehydration, history of falls, left hip pain, hypertension, COPD, depression, Panic disorder, GERD and arthritis. The MDS assessment dated [DATE] indicated Resident #109 had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and needed some assistance with care. The MDS section K identified the resident was receiving a Therapeutic diet. On 11/19/2024 at 9:20 AM, Resident #109 was viewed sitting in a chair in his room. He said he had been at the facility for about 2 weeks, and he received 3 salads. The resident said it was difficult to get fresh fruit and salads, as he was trying to eat less processed foods. Resident #109 stated, I asked for a salad with every meal, like a side salad. I don't think they have salads every day here. I don't get milk unless I ask for it. The resident was asked if he had talked to anyone about not receiving the food he requested and he said he had spoken to several people from the kitchen. The resident showed his meal ticket on his breakfast tray. It listed his type of diet and fluids. There was no food preferences listed. On 11/20/2024 at 2:40 PM, the Certified Dietary Manager/CDM F was interviewed about Resident #109. She said she had spoken to him, and he received a 4 week menu and alternative menu. The CDM said a side salad was an option on the alternative menu and included: lettuce, tomatoes, green pepper, cucumber, and onion. The CDM said Resident #109 could receive a salad she said she would follow up with the resident and flag his ticket to ensure he received a salad and fruit. During the interview with the CDM on 11/20/2024 at 2:45 PM, a dietary note dated 11/7/2024 was reviewed. Discussed with the CDM that Fruit was mentioned on the 11/7/2024 assessment but not addressed on the resident's food ticket. Salads were not mentioned on the notes/assessments, but the CDM said the resident had mentioned it to her and he had received them several times, although not consistently. A review of the Care Plans for Resident #109 identified the following: (Resident #109) requires a therapeutic diet as ordered by physician: NAS (no added salt), Regular texture, Thin fluids . date initiated and revised 11/6/2024. With Interventions including: Acknowledge to the resident that his/her needs are unique. Convey a willingness to provide acceptable foods, date initiated 11/6/2024. Approach in a non-judgmental manner, dated 11/6/2024. Obtain dietary consult and follow recommendations, dated 1/6/2024. Offer residents food preferences . date initiated 11/6/2024. Provide the resident with as much control as possible in routines, food preferences, etc., date initiated 11/6/2024. A review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated revised December 2016 and reviewed 2/2024 provided, A comprehensive, person-centered are plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .

Based on observation, interview and record review, the facility failed to ensure 1) Appropriate narcotic medication practices including, prevention of discrepancies in the narcotic log count for one resident (Resident #49) from the 300 hall medication cart of 2 carts reviewed for narcotics administration, and 2) Storage and handling of medications for one medication room of one reviewed and one of two medication carts reviewed, in accordance with acceptable pharmaceutical standards of practice, resulting in the potential for inappropriate access to narcotic medications, residents not receiving medications as ordered and a lack of therapeutic benefits of medication. Findings Include: FACILITY Medication Storage and Labeling On 11/19/2024 at 1:59 PM, the 300 hall medication cart was reviewed with Nurse M. While reviewing the Narcotics log and narcotics medication cassettes, it was observed that Resident #49's Narcotic log for Norco 7.5-325 mg (Hydrocodone-Acetaminophen) tablet: Give one tablet by mouth every 6 hours as needed for Pain, did not match the cassette the medication was housed in. The Norco count on the log said 17 and there was 16 in the cassette. Nurse M looked in the electronic medical record/emr and it was documented the medication was given at 9:59 AM. Nurse M corrected the Narcotics log count. During the review of the 300 Hall Narcotics log on 11/19/2024 at 1:59 PM with Nurse M, it was observed that Resident #49 had an additional Narcotics log and medication cassette for Norco, but the dose was 5-325 mg: Take one tablet by mouth every 6 hours as needed for Pain. The count in the Narcotics log said 3, however, it had read 4 and then someone crossed out the 4 and wrote 3 next to it on 11/12/2024. The entry prior on 11/11/24 said the Narcotics log count was 5. The resident was supposed to receive one Norco at a time, but the count dropped from 5 to 3 indicating 2 were removed. There was no explanation documented. Nurse M said she had not crossed off the 4 and written 3 next to it, as it was her signature. On 11/19/2024 at 2:20 PM, the Narcotics count was reviewed with Nurse Manager G she said she would look into it. On 11/19/2024 at 2:20 PM during a review of the medication room with Nurse Manager G a treatment cart was observed with the following: Cerave moisture cream expired on 9/24. The wound treatment Medihoney's lid wouldn't close and was partially open; it was sticky all over. Three Biofreeze bottles had room numbers and no resident names on them. A large Silver absorbent pad was opened and undated no date. A Dakins solution for wound care was opened and not dated. A Hibiclens bottle was opened, and had something stuck on and running over the side of the bottle. There was a foam strap loose in the cart with no package. Upon entering the medication room with Nurse Manager G staff drinks and opened food items were observed on the medication counter. Staff coats, backpacks and purses were lying on the floor and surfaces. The Unit Manager G was asked if the facility had a break room for the staff, as the nurses were continuously in and out of the medication room and it was cluttered with their personal items. During the review of the medication room on 11/19/2024 at 2:20 PM with Nurse Manager G the medication Refrigerator was observed to have a lock on the door. It was unlocked. Nurse Manager G said there were items in the refrigerator that were part of the Medication Dispense system, including narcotics: Nurse Manager G stated, It's supposed to be locked. Lorazepam (an antianxiety medication) was in a lock box in the refrigerator and was not double locked. The TB serum had an unreadable date on the container to indicate when opened. Additional items expired in the medication room were: Fiber laxative dated expired on 8/24 and 4 green top laboratory test tubes for blood draws were expired on 8/2024. The Nurse Manager said, They are for Vanco (an IV antibiotic). There were also 4 bottles of liquor in the cabinet for residents who were no longer at the facility. A review of the facility policy titled, Administering medication, dated December 2012 provided, Medications shall be administered in a safe and timely manner, and as prescribed . Medications must be administered in accordance with the orders, including any required time frame . The individual administering the medication must check the label 3 times to verify the right resident, right medication, right dose, right time and right method . When opening a multi-dose container, the date opened shall be recorded on the container .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #24: During the initial tour on [DATE], Resident #24 shared she does not participate in many activities as she once did, because the common areas are cold. Even with a long sleeve shirt and sweatshirt on she is still cold in the common areas and hallways of the facility. Resident #24 stated many residents, and staff are bundled up when outside of their room given the cool temperatures in the facility. During Resident Council on [DATE] at 10:30 AM, all nine residents in attendance at the meeting expressed the common areas (theater, hallways, library and activity) are cold. They reported there is cool air blowing through the vents and they have to bundle up when coming out of their room as they anticipate being cold. Review was completed of Resident Council notes and the following was indicated in the notes from [DATE], .Facility is cold multiple residents . During the survey three facility staff members who requested their anonymity was maintained, stated residents have complained regarding it being cold in the hallways and common areas. They reported they typically wear jackets/fleeces throughout their shift and it's reasonable to believe that if they are cold so are the residents. The staff stated the residents have informed them they will not go to activities due to the cool temperatures. On [DATE] at 1:10 PM, the thermostat on 300 hall read 70.1 and it felt as if cool air was filtering from the vents on the ceiling. An infrared thermometer was utilized to measure temperatures in common areas and hallways the temperatures were as follows: Activity Area: 69.7 ° 100 Hall: Thermostat: 73.5 ° Between room [ROOM NUMBER] and 103: 68.3 ° Outside room [ROOM NUMBER]: 71.2 ° Outside room [ROOM NUMBER]: 71.0 ° Outside room [ROOM NUMBER]: 69.7 ° 200 Hall: Thermostat: 70.5 ° Outside room [ROOM NUMBER]-70.7° Outside room [ROOM NUMBER]-73.4°° Outside room [ROOM NUMBER]-71.3 Nurse Station-72.3° 300 Hall: Between room [ROOM NUMBER] and 303: 71.4 ° Outside room [ROOM NUMBER]: 69.9 ° Outside room [ROOM NUMBER]: 70.3 ° Outside room [ROOM NUMBER]: 68.5 ° 400 Hall: Nurse Station-68.8° Thermostat- 70.7° Outside room [ROOM NUMBER]-72.0° Between Room: 406-408-72° Outside room [ROOM NUMBER] 11-72.5° Outside room [ROOM NUMBER]-72.3° On [DATE] at 10:00 AM, an interview was conducted with Maintenance Director B regarding the resident complaints of the common areas being cold and the issues with heating/cooling units in residents' rooms. Director B explained they switched out a unit in a resident room and now they will have spare parts on hand in the event another unit malfunctions. The in-room units have a life expectancy of 8-10 years given how the residents run them continuously. He reported they maintain the facility at 71°-74°. Director B reported staff have complained the hallways are too warm as residents' room are close to 80° which push the hallway temperatures up. Director B was provided with concerns discussed from resident council, facility staff and initial tour on the coldness in the common areas and how they asked for it to be remedied without success. The Director explained there is a pinpoint size leak in the [NAME] line on the unit on the roof. There are six Fujitsu units on the roof, two outside units and units in the basement that work conjunctively to heat/ cool the common areas and hallways in the facility. The unit has been leaking Freon, which then causes the unit to continuously work and there is buildup on the copper tubing from it. They have to shut down the unit to defrost and contact an HVAC contractor to refill the Freon. They continuously go through this cycle as they do not know where the leak is. So, in the summer the building could be warmer and in winter cooler. Adding the Freon each time is a temporary fix to the main issue at hand and he stated it was recommended they mix an additive with the Freon and when the additive locates the leak it will mix and solder the pinpoint hole. But this solution has not yet to be presented and approved. Review was completed of facility's contracted HVAC work orders for [DATE]: [DATE]: Routine fall check. Due to current weather conditions, we are not finished. We are performing maintenance on HVAC. We found heat pumps units 1 and 6 low on refrigerant charge. Charged units and checked operation. Repaired 2 PTACH room units. Both units required blower repairs. I can forward the remaining repairs if there are any when the service is complete weather permitting. [DATE]: [DATE] @3:50 PM Maintenance Call ([NAME]) from facility stating some areas of facility are running cool, hall, library, movie theater. Also wants PTAC units in three rooms checked. Service call scheduled first available on Monday 11/18. Rooms 113, 414, 314. Complete indoor blower rebuild. Note: parts availability for these units are 3-6 weeks out. Review was completed of the facility policy entitled, Maintenance of Building Temperatures/Provisions for Extreme Heat or Cold, reviewed 2/2024. The policy stated, .Required temperatures range- the building temperature in all resident areas at the facility will be maintained between seventy- one degrees Fahrenheit and eighty- one degrees Fahrenheit .Maintenance department staff are responsible for adjusting temperature thermostats and servicing heating and cooling units during the change of seasons .all reports of temperature problems must be reported to the Administrator or DON. In conjunction with maintenance staff, Administrator and nursing will assess and determine the extent and length of the problem and determine what types of action will need to be taken . The facility failed to ensure comfortable room temperatures for two residents (Resident #24, Resident #110) from a census of 52 residents, resulting in Resident #110 becoming upset and disgruntled because he was too cold to eat and sleep. FACILITY Environment Resident #110: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #110 was admitted to the facility on [DATE] with diagnoses: Kidney disease, heart disease, pneumonia, COPD, and a history of falls with a fracture. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss with a Brief Interview for Mental Status/BIMS score of 11/15 and needed some assistance with all care. On [DATE] at 10:53 AM, Resident #110 was observed lying in bed, watching TV. He was awake, alert and talkative. The resident pointed at the heat register in the room; it read 68 degrees Fahrenheit. Resident #110 said he was very cold. He was very upset. He said he kept telling people that he was too cold and they would tell him they would send someone. He said no one came to look at the heat register. He said the staff offered an extra blanket. Resident #110 stated, It's just cold. I'm cold. Three days in a row, I'm used to 72 degrees at home. I want to be comfortable. I can't eat or sleep. I don't want an extra blanket. I want them to do something about it. On [DATE] at 11:02 AM, Maintenance staff K entered Resident #110's room. He said he just received a work order that morning for the cold temperature in Resident #110's room. Maintenance staff K stated, You can hear the heat duct running; there's nothing blowing. He said the temperature was set at 79 degrees, but now it was reading 69 degrees. Maintenance staff K said there had been other resident rooms with the same issue. He said some of those residents had to be moved to another room, so the heating unit/heat register could be repaired. Certified Nursing Assistant L said she worked over the weekend and Resident #110 said he was too cold, so she put the work order in. On [DATE] at 10:25 AM, Operations Manager B was interviewed, and he said the resident's wall unit was not working and Maintenance staff K reset it on [DATE] and it was currently working. He said the facility had issues with other wall heating units in the residents' rooms and he said the would have to make a plan to replace them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility 1) Failed to check blood sugars and administer insulin per physicians' orders for two residents (Resident #30, Resident #158) of two residents reviewed for timely medication administration and 2) Failed to ensure coordination and integration of hospice services for one resident (Resident #51) of one resident reviewed for hospice. Findings Include: Resident #30: During Resident Council on 11/19/2024 at 10:30 AM, Resident #30 shared many times her blood sugar is being checked after she had already completed breakfast. She continued the nurse typically has an excuse as to why it was not checked prior to meal service. On 11/19/2024 at approximately 2:00 PM, a review was conducted of Resident #30's medical record and it revealed she was admitted to the facility on [DATE] with diagnoses that include, Cellulitis, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Long term use of insulin and Heart Disease. Further review of Resident #30's records revealed the following: Physician Orders: Insulin Glargine 100 Unit/ML (milliliter)- inject 20 units subcutaneously one time a day for diabetes. Slated to be administer at 8:00 AM. Insulin Lispro Injection Solution 100 Unit/ML- inject subcutaneously with meals for diabetes Insulin Lispro Injection Solution 100 Unit/ML- inject as per sliding scale subcutaneously with meals for diabetes: If 0-124=x 125-150=2 151-200=4 201-250=6 251-300=8 301-350=10 351-400-12 401-9999= x Contact physician On 11/19/2024 at 2:00 PM, Dietary Manager F was asked what times meal service it completed on the halls and the order in which it is served. Manager F explained meals are at 8:00 AM, 12:30 PM and 5:00 PM. The dining room is served first, and halls are completed between 8:45 AM-9:00 AM, with 200 hall being served around 8:30 AM. On 11/19/2024 at 4:30 PM, Unit Manager G stated blood sugars should be checked prior to residents eating meals. Meal service begins in the dining room at 8:00 AM and then then hallways. Review was completed of the facility document that indicated the following mealtimes: Breakfast: 8:00 AM Lunch: 12:30 PM Dinner: 5:00 PM Review was completed of the times Resident #30's blood sugar was checked in relation to facility meal service times. It was found Resident #30's blood sugar was frequently checked well after meal service. The timeframes varied from 45 minutes to two hours after meal service. It can be noted 200 Hall receives their meals around 8:30 AM. The time frames are as follows: 11/17/2024 08:54 224.0 mg/dL 11/16/2024 08:47 216.0 mg/dL 11/15/2024 09:03 197.0 mg/dL 11/12/2024 10:14 200.0 mg/dL 11/12/2024 10:14 200.0 mg/dL 11/12/2024 10:14 200.0 mg/dL 11/10/2024 09:06 193.0 mg/dL 11/10/2024 09:06 193.0 mg/dL 11/10/2024 09:05 193.0 mg/dL 11/9/2024 09:04 157.0 mg/dL 11/9/2024 09:04 157.0 mg/dL 11/9/2024 09:03 157.0 mg/dL 11/8/2024 08:50 168.0 mg/dL 11/7/2024 08:41 189.0 mg/dL 11/7/2024 08:41 189.0 mg/dL 11/7/2024 08:41 189.0 mg/dL 11/6/2024 09:31 202.0 mg/dL 11/5/2024 18:03 217.0 mg/dL 11/5/2024 18:03 217.0 mg/dL 11/3/2024 17:46 227.0 mg/dL 11/3/2024 17:45 227.0 mg/dL 11/3/2024 09:32 220.0 mg/dL 11/3/2024 09:30 220.0 mg/dL 11/3/2024 09:30 220.0 mg/dL 10/31/2024 12:30 201.0 mg/dL 10/31/2024 11:06 208.0 mg/dL 10/31/2024 11:06 208.0 mg/dL 10/31/2024 08:40 208.0 mg/dL 10/31/2024 01:40 137.0 mg/dL 10/27/2024 09:04 185.0 mg/dL 10/27/2024 09:03 185.0 mg/dL 10/27/2024 09:03 185.0 mg/dL 10/26/2024 09:22 302.0 mg/dL 10/26/2024 09:22 302.0 mg/dL 10/26/2024 09:22 302.0 mg/dL 10/25/2024 09:01 235.0 mg/dL 10/25/2024 09:01 235.0 mg/dL 10/25/2024 09:00 235.0 mg/dL 10/20/2024 08:52 207.0 mg/dL 10/20/2024 08:51 207.0 mg/dL 10/20/2024 08:51 207.0 mg/dL 10/19/2024 08:46 244.0 mg/dL 10/13/2024 09:04 205.0 mg/dL 10/13/2024 09:04 205.0 mg/dL 10/13/2024 09:03 205.0 mg/dL 10/8/2024 09:17 181.0 mg/dL 10/8/2024 09:17 181.0 mg/dL 10/8/2024 09:16 181.0 mg/dL 10/7/2024 18:32 193.0 mg/dL 10/7/2024 18:32 193.0 mg/dL 10/5/2024 08:57 195.0 mg/dL 10/3/2024 18:16 297.0 mg/dL 10/3/2024 18:15 297.0 mg/dL Review was completed of Medication Audit Report from 10/1/2024 to 11/21/2024 and it revealed Resident #30 was administered her insulin well after her meal was completed which coincided with the untimely blood sugar checks. Both documents together show consistence in the resident receiving essential medications outside ordered timeframes. The document provides the following information: Insulin Lispro- injected per sliding scale subcutaneously with meals: 10/3/2024- administered at 18:16 10/5/2024- administered at 09:01 10/5/2024- administered at 18:31 10/7/2024- administered at 18:32 10/8/2024- administered at 09:16 10/13/2024- administered at 09:04 10/26/2024- administered at 09:22 10/27/2024- administered at 09:03 11/3/2024- administered at 09:30 11/5/2024: administered at 18:03 11/9/2024- administered at 09:04 11/10/2024- administered at 09:05 11/12/2024- administered at 10:14 11/15/2024- administered at 13:10 Insulin Lispro Injection- inject 10 unit subcutaneously with meals: 10/3/2024- administered at 18:15 10/7/2024- administered at 18:32 10/8/2024- administered at 09:17 10/13/2024- administered at 09:04 10/25/2024- administered at 09:01 10/26/2024- administered at 09:22 10/27/2024- administered at 09:03 10/31/2024- administered at 11:06 11/3/2024- administered at 09:30 11/5/2024- administered at 18:03 11/9/2024- administered at 09:04 11/10/2024- administered at 09:06 11/11/2024- administered at 09:20 On 11/21/24 at 01:38 PM, Resident #30 was having lunch her in her room, she reported the nurse that typically checks her blood sugar after she had consumed her meal, informed her if was because they (nurses) had to be in the dining room during meals. On 11/21/24 at 09:19 AM, Unit Manager G reviewed the Medication Audit Report, for Resident #30. The Unit Manager stated the nurses have not expressed their inability to check blood sugars and administer insulin timely. Morning medication pass is heavier and when reviewing the report, it was not isolated to one nurse, so she is not sure what the root cause is. Manager G understood the concern. Resident #158: On 11/20/2024 at approximately 3:15 PM, a review was completed of Resident #158's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included Cellulitis, Metabolic Encephalopathy, Bipolar Disorder, Type 2 Diabetes and Schizoaffective Disorder. Further review yielded the following: Physician Orders: Insulin Lispro Injection Solution (Insulin Lispro) Inject per sliding scale- subcutaneously before meals for diabetes. Review was completed of the times Resident #158's blood sugar was checked in relation to facility meal service times. It was found Resident #158's blood sugar was frequently checked well after meal service. The timeframes varied from 45 minutes to two hours after meal services. 11/18/2024 12:53 150.0 mg/dL 11/16/2024 17:55 239.0 mg/dL 11/15/2024 17:54 134.0 mg/dL 11/12/2024 13:13 131.0 mg/dL 11/9/2024 17:56 195.0 mg/dL 11/8/2024 19:56 202.0 mg/dL 11/8/2024 13:12 89.0 mg/dL 11/20/2024 17:46 147.0 mg/dL 11/16/2024 17:55 239.0 mg/dL 11/16/2024 15:01 132.0 mg/dL 11/15/2024 17:54 134.0 mg/dL 11/11/2024 08:43 130.0 mg/dL 11/9/2024 17:56 195.0 mg/dL 11/8/2024 19:56 202.0 mg/dL 11/8/2024 13:12 89.0 mg/dL 11/7/2024 18:41 238.0 mg/dL Review was completed of Medication Audit Report from 11/8/2024 to 11/21/2024 and it revealed Resident #158 was administered his insulin well after her meal was completed and coincided with the untimely blood sugar checks. The document provides the following information: Insulin Lispro Injection Solution- Inject per sliding scale subcutaneously before meals: 11/8/2024- administered at 13:12 11/8/2024- administered at 19:56 11/12/2024- administered at 13:13 11/16/2024- administered at 15:01 (lunch administration) On 11/21/2024 at 9:10 AM, an interview was conducted with Unit Manager H regarding the late administration of Resident #158's insulin and checking blood sugars after meals were consumed. Manager H reviewed the Medication Audit Report and reported she was unsure as to why his insulin was being administered after meals. Progress notes were reviewed as well and there was no reasoning located in the charting. Review was completed of the policy entitled, Administering Medications, revised December 2012. The policy stated, .Medications should be administered in accordance with the orders, including any required time frame . Resident #51: Hospice and End of Life A record review of the Face sheet and Minimum Data Set/MDS indicated Resident #51 was admitted to the facility on [DATE] with diagnoses: Huntington's disease, history of falls, and depression. The MDS assessment dated [DATE] indicated the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 0/15 and the resident needed some assistance with all care. On 11/18/2024 at 10:49 AM, Resident #51 was observed lying in bed, awake and alert. When asked questions he attempted to answer and stated, I don't know. A review of the Physician orders indicated Resident #51 was admitted to Hospice services on 10/9/2024. A record review of the electronic medical /EMR for Resident #51 indicated there was no Hospice notes or documentation related to resident care or visits with the resident. On 11/21/2024 at 1:26 PM, Unit Manager/UM Nurse G was interviewed about Resident #51 receiving Hospice services. She said the facility used several different Hospice services and some of the Hospice staff charted in the resident's EMR, but some used a separate paper chart in a binder at the nurse's desk. UM G looked around the nurse's desk and she said the resident did not have a Hospice book/chart at the desk. UM G also looked in the EMR and she said there was an order for Hospice, but nothing else. She said she would check further on it. On 11/21/2024 at 1:48 PM, UM H was interviewed about the Hospice documentation for Resident #51 and said there was no Hospice chart. UM H said she would call the Hospice service to see if they had any notes. On 11/21/2024 at 3:08 PM, the lack of Hospice service documentation of care for Resident #51 was reviewed with the Administrator and Assistant Administrator. They said they would look for documentation. On 11/21/2024 at 4:00 PM, UM H provided a stack of Hospice notes for Resident #51 dated from 10/8/2024 - 11/15/2024. She said they had been sent to the Social Worker's office and she was going to request that they were sent to the nursing department for placement into the resident's medical record in the future. A review of the facility contract with the Hospice service titled, . Hospice Services Agreement, dated March 11, 2022 provided, . Hospice shall communicate with the Resident, family members, Facility staff, and the attending physician to develop and update the content of the hospice plan of care .

Based on observation and interview the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food, foodborne illness and improper kitchen sanitization, potentially affecting all residents who consume meals from the kitchen. Findings Include: On 11/18/2024 at 7:45 AM, initial tour was conducted in the kitchen in the presence of Dietary Manager F, the following expired/outdated items were found: Dry Storage Room: - 3-1-gallon containers of [NAME] Vinegar with expiration date of 7/9/2024 - Manager F stated the vinegar is good for a year after they receive it and the date received was 7/9/2023. Walk-in Cooler: - 6-8 pieces of pureed toast- expiration date 11/16/24 - 1 - Gallon size of brownies with no use by date - Premium Parmesan Cheese- opened 10/9/241 with no use by date - Manger F stated the cheese should have been discarded of after 14 days (10/22/24) Walk-in Freezer: - 1 bag of pecans- expired 11/16/24 - Gallon size bag of marinara sauce- expired 10/18/24 - Gallon size bag of turkey- cooked 9/4/2024- with no use by date - 30 lb box of sliced carrots- bag was not sealed and without open or use by date - Large plastic bag of mixed veggies without use by date - 2- pieces of cornbread found in the corner of the freezer - 1 -box of gluten free pizza cheese pizza without use by date - 1 box of gluten free waffles- expired 6/31/24 - 6-8 mini pie crusts- expired 3/23/24 - 2 -individually wrapped breakfast sandwich - without a use by date - 1 -bag of granulated peanuts- expired 7/2024 - 1/4 bag hash browns- without use by date - 1-bag sliced almonds- expired 2/6/2022 - 1 bag of walnuts- without expiration date - 1-gallon bag of frozen bananas- expired 3/24/2024 - 1-gallon size bag of pork crumble- ex 7/27/2024 - 1/2 turkey- expired 4/8/2024 - 1 -gallon size of spaghetti sauce- expired 2/2022 - Gallon size bag of sweet and sour sauce- without expiration date - 1-gallon size bag of Swedish meatballs- expired 6/28/24 Dietary Manager F stated all items should be labeled with an open and use by date and upon expiration be discarded of. On 11/20/2024 at 7:50 AM, a follow up visit was conducted in the kitchen in the presence of Dietary Manager F. The manager reported the solution for their three-compartment sink is premixed through a mechanism installed by a contracted service provider. There were two red buckets utilized for sanitization and upon testing the strength of the solution both indicated 0 PPM (parts per million). Manager F reran the solution and rechecked it and it was barely at the 150 PPM mark, she stated she would contact the company for a service call. Manager F reported the sanitizing solution should be at 150 PPM. On 11/20/2024 at 4:00 PM, Dietary Manager F reported the technician did locate a plug in the tubing where the chemicals mix, which was not allowing the correct amount of chemicals to mix. The technician was last at the facility on 11/11/2024 but did not look at the mixing points for the three-compartment sink. It is unknown how long the plug has been present. Review was completed of Red Bucket PPM log, and it indicated the PPM on 11/20/2024 (prior to checking it with Manager F) was 200 PPM. From November 1, 20240 November 19, 2024, the log showed the PPM as 200 daily. It is unknown how the solution strength was up to par and then not within limits shortly thereafter. Review was completed of the Service Report from 11/20/2024 for the three-compartment sink. It stated, .reported sanitizer not working replaced metering tip and flushed unit is working fine . Review was completed of the policy entitled, Food Safety and Sanitation, reviewed 2/2024. The policy stated, .All leftovers are labeled, covered, and dated when stored. They are used within 72 hours (or discarded). Food with expiration dates are used prior to the date on the package . Review was completed of Sanitizer Test Procedures, it indicated the test for Quaternary Sanitizer should be at 150 PPM (at a minimum).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain Resident #23's dignity and thoroughly investigate a customer service complaint, resulting in Resident #23 reporting offensive statements made to her by CNA (Certified Nursing Assistant) N with inadequate facility follow-up and feelings of frustration, unimportance, and betrayal. Findings Include: Resident #23: During initial tour on [DATE], Resident #23 was observed resting in their reclining chair. She was in good spirits and spoke about her overall physical progress since admitting to the facility. Resident #23 reported about 1.5 months ago she pressed her call light and it took about 40 minutes for a CNA to respond. The CNA that responded was training a new aide as well and upon entering her room said curtly, what do you need? Resident #23 responded that she needed to use the restroom and the aide told her she wasn't going to be ready by the time she returned with her wheelchair (which was in the bathroom) as you don't even have your footrest (on the reclining chair) down. Resident #23 told the CNA not to worry as it would be down by the time she returned with her wheelchair. Resident #23 stated she pushed the footrest down prior to the CNA's return and stated to her, hey I am waiting for you but received no response from her. Resident #23 was asked if they normally interact in this way, and she stated they do not. She reported this was not a playful exchange and the CNA was being discourteous. Once in the bathroom Resident #23 recalled the CNA making a comment regarding her oxygen levels being low last night and then the CNA proceeded to say you could have died, I wish you would have. Resident #23 was taken aback by the statement and did not say anything to the CNA. But she was very upset and later called her sister and cried like a baby regarding the statements. Resident #23 reported she typically had a good rapport with the CNA and felt somewhat betrayed by the remarks made but took solace in knowing she no longer worked at the facility. She added the CNA orientating was also in the room when the interaction occurred. Resident #23 stated she was not going to report the incident but a nurse overhead it and told Unit Manager E who came and interviewed her about the incident. After the disclosure by Resident #23 this writer requested the FRI (Facility Reported Incidents) related to this incident. On [DATE] at 11:55 AM, an interview was conducted with Unit Manager E' regarding her involvement with the disclosure from Resident #23. Manager E recalled a staff member alerting her to the incident and she spoke to Resident #23 about it. The resident stated the CNA said something to the effect that we are going to die anyway. She stated it would not have been an FRI but she did mention it to the DON (Director of Nursing) that morning. Manager E was asked to provide any documentation related to the facility response. On [DATE] at approximately 12:55 PM, a review was completed of CNA N's Human Resource File. It revealed that the CNA resigned on [DATE] and there was no disciplinary action or one to one located in the file related to this incident. On [DATE] at approximately 7:55 AM, a review was completed of Resident #23's medical record and it revealed she was admitted to the facility on [DATE] with diagnoses that included, Chronic Obstructive Pulmonary Disease, Acute Respiratory Distress, Acute and Chronic Respiratory Failure with Hypoxia and Hypertension. Resident #23 was assessed as cognitively intact and able to make her wants/needs known to facility staff. On [DATE] at 10:55 AM, an interview was held with Social Services Director B regarding the disparaging remarks made to Resident #23. Director B recalled there were some rude remarks made by a CNA toward her during care that she brought up during Care Conferences. Director B reported she completed a concern from related to incident but was not certain of the outcome. Director B was asked for the concern form and all documents showing the facility response to this incident. On [DATE] at approximately 1:00 PM, Social Work Director B and Unit Manager E explained during Care Conference in [DATE], Resident #23 divulged a CNA made rude statement about her dying. Director B stated she completed the concern from that day and provided it the DON for further investigation. The Grievance Form dated [DATE] was reviewed in the presence of Unit Manager E and Director B and it stated, During Care Conference, stated most CNA's are good with exception of 1- made a rude statement about me dying. I talked to the manager about it- she came in sat w/me- the girl doesn't work here anymore so its been fine since, but that the CNA was one she liked so she was surprised. Under Findings and Investigation it read, It was found that the CNA did not say the statement to the resident. It was witnessed by another CNA. CNA no longer works at the facility. The form indicated it was completed on [DATE] and the resident was communicated the investigation results and resolution steps verbally. It can be noted the resident did not sign the form acknowledging the resolution to her complaint nor was there a witness that this was verbally communicated to the resident. Manager E provided two pieces of paper and indicated these were statements from the investigation. The following was not included in their documentation: - Neither document was dated - The CNA in question (CNA N) was not interviewed. - The nurse that alerted the manager to the incident was not interviewed. - Other cognitively intact residents assigned to CNA N were not interviewed. - Other staff members were not interviewed. - CNA M (CNA in training) was not questioned about CNA N disposition towards residents that night. Manager E recalled alerting the DON to the complaint and was instructed to interview CNA M who stated CNA N never made the statements Resident #23 alleged. They were queried as to how the conclusion was this incident did not occur when the resident had shared the story three times, over the course of three months and subpar investigation efforts into her allegation was completed by the facility. They did not offer an answer to this writers' question. They did, however, provide a Care Conference Summary and highlighted where Resident #23's son reported his mother is a chronic liar and If her mouth is moving -she is lying. When asked to clarify if the resident had been caught embellishing stories or being deceptive, they stated she had not. It was unclear why these specific statements were highlighted and provided to this writer in response to Resident #23's complaint on CNA N. There was no explanation offered on why CNA N was not interviewed. Further review was completed of the undated documents provided in the presence of Unit Manager E and Director B and the documents stated: Document #1: Nurse notified writer that resident would like to speak with writer. Spoke with resident, resident stated that 02 (oxygen) drop during the day, CNA was in a hurry toileting her and told resident we're going to die anyways. Resident states she still likes CNA and is ok with her caring or her. Resident states CNA was training and that the orientee was in room. Notified DON of resident's statement. DON states to speak with orientee. Document #2: Spoke with (CNA M) orientee asked her if (CNA N) made comment to resident about we're all going to die. (CNA M) stated no comment was ever made about death. On [DATE] at 1:15 PM, Social Services Director B and this writer spoke to Resident #23 regarding the resolution to the incident. Resident #23 was asked if she recalled anyone following up with her. She stated she spoke to Manager E initially but did not recall anyone else speaking to her about the findings. The resident was informed of the facility findings in the presence of Director B and expressed her frustration. She stated she would never lie regarding something of that nature as her word is all she has. On [DATE] at 1:44 PM, an interview was conducted with CNA M regarding Resident #23 and CNA N. The CNA stated she began at the facility in [DATE], and that was her first night was orientating on Eerie with CNA N. She recalled CNA N being rude to Resident #23 and acting like she did not want to do her job that evening. She stated she does not remember hearing CNA N make a comment about death or oxygen levels to Resident #23 but that does not mean it was not said as Resident #23 is in her right mind. CNA M shared throughout the shift CNA N was annoyed and somewhat agitated as they had to consistently toilet the same residents. She told residents before they rung their call light to ensure they were ready to go to the bathroom and already sitting upright. CNA M recalled CNA N saying this to a few residents during the shift. She also said to residents they were not going to be ready by the time she retrieved their wheelchair and brought it to where they were in the bedroom, with one of the residents being Resident #23. CNAM stated with it being her first night training she thought this was a routine she had established with the residents but after working there she saw this was not the case and CNA N making these comments to the residents and her demeanor during the shift was unnecessary. Resident #23 reported disparaging remarks were made to her by CNA N during care in [DATE] and the facility asserted they investigated said complaint, but their sparse investigative documents were not dated and lacked thoroughness. During Care Conferences on [DATE], Resident #23, for the 2nd time mentioned the remarks made by the CNA. A complaint form was completed, and it was concluded the incident did not occur, but this conclusion derived from merely one interview. During survey, Resident #23 for the third time brought up the incident, which showed consistency in her reporting but lack [NAME] follow through on the part of the facility to properly handle the occurrence. Instead, they simply stated it did not happen and insinuated Resident #23's account was deceptive. It was clear there were concerns from that evening as it related to respect, dignity, customer service and overall display of demeanor toward residents but unfortunately this was never addressed by the facility. Review was completed of the facility policy entitled, Resident Rights, reviewed 2/2023. The policy stated, Employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to; a. a dignified existence; b. be treated with respect, kindness, and dignity . Review was completed of the facility policy entitled, Dignity, reviewed 2/2023. The policy stated, Each resident shall be care for in a manner that promotes and enhances quality of life, dignity and respect and individuality. 1. Residents shall be treated with dignity and respect at all times .7. Staff shall speak respectfully to residents at all times .11c. Promptly respond to the residents request for toileting assistance .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement/update interventions of offering and documenting bedtime snacks for two residents (Resident #31, Resident #32) with noted weight loss, resulting in Resident #31 to experience weight loss and Resident #32 to have a decline in weight and not receive any bedtime snacks between meals with a diagnosis of diabetes. Findings include: Record review of the facility 'Care Plans, Comprehensive Person-Centered' policy dated 2/2023 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. (14.) the interdisciplinary team must review and update the care plan: (a.) When there has been a significant change in the resident's condition . Record review of the facility 'Frequency of Meals' policy dated 2/2023 revealed that each resident shall receive at least three meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests, and plan of care. The facility will serve at least three meals or their equivalent daily at scheduled times. There will not be more than fourteen (14) hours span between the evening meal and breakfast. Resident #31: Record review of Resident #31's quarterly Minimum Data Set (MDS) dated [DATE] noted an elderly resident with Brief Interview of Mental status (BIMS) score of 3 out of 15, severe cognitive impairment. Section K: Nutrition noted a weight of 138 pounds. Resident #31 was assessed at a loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Yes, not on a physician-prescribed weight loss regimen. Medical diagnosis included: coronary heart disease, hypertension, cerebral vascular accident (CVA), hemiparesis, and depression. Observation on 12/03/23 at 08:57 AM revealed that Resident #31 was seated up at edge of bed with over bed tray table pulled up to side of bed in the dark. Observation of the bedside tray table revealed a styro foam clam-shell container with a fried egg and sausages, with a bowl of cereal. Beverages were in styro-foam cups also. Resident #31 was attempting to cut the fried egg with a plastic knife and gave up and began to eat the egg and sausage links with her hands while in the dark. Resident #31 stated that they (staff) don't help do anything, it's all cold (food). Record review on 12/03/23 at 12:15 PM of Resident #31's medical records revealed a possible weight loss. Record review of the electronic medical record wight log revealed on 6/30/2023 Resident #31 weight was 138.2 pounds and on 9/20/2023 was at 129.8 pounds. The record revealed a three (3) month weight loss is 6.01%. An interview on 12/04/23 at 10:51 AM with the Certified Dietary Manager (CDM) C revealed that there was a Register Dietitian (RD) contracted services, and that the RD works remote. The CDM C stated that she has not ever seen the RD but communicate through text and email. The CMD C revealed that she does a weekly report of weight loss/gains on residents, then emails the report to all department heads, nursing, activities and to the RD. Discussion on Resident #31 the CDM C gave indications of diuretic and why a fluctuation decreased oral intake and Resident #31 was on supplements and refused, she use to have table mate that only ate hotdogs and then Resident #31 stated to eat only hotdogs that was a couple months ago. Now Resident #31 does not come out to the dining room, staff are to encourage snacks and fluids throughout the day and we off alternatives. The state surveyor discussed the observed breakfast on 12/3/23 of cold cereal and sausage links and an egg, in styro foam clam shell, resident stated the egg was cold. The CDM C revealed that if she has a specific issue with a resident the RD will go and look at the record for recommendations. Surveyor requested snack documents and snack lists from the CMD at this time. Record review of Resident #31's 'nutritional' care plan- The resident has nutritional problem or potential nutrition problem related to: diverticulosis of large intestine, dysphagia, malignant neoplasm of the kidney, depression, hearing loss and retention of urine. Goals: significant weight loss triggered during the review 7/14/2023, continue to offer Resident #31 snacks/fluids throughout the day. Interventions: convey a willingness to provide acceptable foods, approach in a non-judgmental manner, collaborate with Registered Dietitian and staff as needed (PRN) . Resident #32: Record review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed an elderly resident with Brief Interview of Mental status (BIMS) score of 8 out of 15, moderate cognitive impairment, decisions poor, cues/supervision required. Section I: Active diagnosis included: coronary artery disease, hypertension, renal insufficiency, pneumonia, diabetes, cerebrovascular accident (CVA), Non-Alzheimer's dementia, hemiplegia/hemiparesis, malnutrition, depression, and supra-pubic urinary opening. Section K: Nutritional status assessed Resident #32 at 145 pounds with loss of 5% or more in the last month or loss of 10% or more in the last 6 months, yes not on a physician-prescribed weight-loss regimen. Observation of Resident #32 during the annual survey from 12/3/2023 through 12/5/2023, revealed that Resident #32 took his meals in the dining room with meal setup. There was no cueing or supervision with the meal noted during observations. Record review of Resident #32's 'Nutritional' care plan noted the resident has a nutritional problem or potential nutritional problem related to severe protein-calorie malnutrition, dehydration, heart failure, chronic kidney failure, dysphagia, and type II diabetes. Goal: Resident will maintain adequate nutritional status as evidence by no significant weight changes. Interventions included: convey willingness to provide acceptable foods, collaborate with registered dietitian and staff as needed (PRN), explain to resident the risk versus benefits of following dietary regimen/restrictions, monitor weights and nutritional labs, obtain dietary consult and follow recommendations, review menu with resident and likes and dislikes, offer substitutions of same nutritional value if resident dislikes main meal, praise for good dietary compliance, supplemental health shakes 3 times daily, regular texture foods. There was no mention of a protein bedtime snack. Record review on 12/04/23 at 10:47 AM of Resident #32's weight log revealed that on 8/8/23 a weight of 153.4 pounds, and on 11/15/2023 a weight of 145.2 pound, that was a 5.34% weight loss in three months. An interview on 12/04/23 at 11:01 AM with the Certified Dietary Manager (CDM) C revealed that Resident #32's weight has bounced from being in 150 pounds to 145 pounds and would call that the residents base line. CDM C revealed that the registered Dietitian has full time job and is contracted with the facility. Record review of the facility provided 'Snack Cart Sign-Out Sheets' dated from October through November 2023 noted 12 sheets some without dates, were reviewed by the state surveyor. Record review of the 12 sheets provided noted that Resident #31 only received snacks four (4) different times and that Resident #32 had received no snack at all.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #252: On 12/04/23, at 8:24 AM, a review of Resident #252's electronic medical record revealed an admission on [DATE] at 12:05 AM with diagnoses of hypertension, encephalophy and infection requiring intravenous (IV) antibiotics to recover. On 12/04/23, at 9:57 AM, Nurse H was asked where Resident #252 was and Nurse H stated, per report, he went to the hospital and was admitted . On 12/04/23, at 3:57 PM, a record review along with Unit Manager E of Resident #252's record revealed the following medications were not provided: Maxzide-25 (anti-hypertensive) Oral Tablet . Give 1 tablet by mouth one time a day for HTN -Start Date-12/02/2023 Pantoprazole Sodium Oral Tablet Delayed Release 40 . for GERD . rifAXIMin (antibiotic) Oral Tablet 550 . Give 1 tablet by mouth two times a day for Encephalopathy . Neurontin (pain medication) Oral Capsule 400 . Give 1 capsule by mouth every 8 hours related to . Neuropathy . Ampicillin Sodium (IV antibiotic) Injection Sodium Injection Solution Reconstituted 1 GM (gram) . intravenously every 4 hours for Enterococcus Faecalis - Start Date- 12/02/2023 0400 The resident did not receive the 0400 0800 1200 1600 doses totaling 4 missed doses of the antibiotic. UM E was asked why the facility didn't provided the needed IV antibiotics, pain medication and blood pressure medications and UM E stated, the resident was supposed to be here at 7:00 PM but didn't arrive until after midnight and we can't order medications until they are in the building. UM E stated, that the resident went back out to the hospital and was admitted . A review of Resident #252's final progress note revealed Effective Date: 12/03/2023 02:18 . Resident has elevated BP 195/104 with complaints of being dizzy. (Nurse Practitioner) notified of resident's elevated blood pressure and c/o (complaints of) dizziness . Resident sent out to (hospital) ER via (ambulance) Resident is A+Ox 4, however is c/o pain in right arm and right shoulder due to fall last April per resident . Based on observation, interview and record review the facility failed to 1. Ensure medication administration for Resident #252; 2. Effectively assess, monitor, and implement timely interventions for hearing loss and wax build up for Resident #4; and 3. Assess and monitor ICD (Implantable cardioverter-defibrillator) after implantation and monitor usage of [NAME] Heart Transmitter for Resident #38, resulting in, Resident #252's blood pressure and intravenous antibiotics not being administered, Resident #4 ears being severely wax compacted and causing hearing loss without timely facility interventions and inability to monitor Resident #38's cardiac status as they failed to recognize his ICD implantation and usage of [NAME] Heart Transmitter. Findings Include: Resident #4: On 12/2/2023 during initial tour, Resident #4 was observed taking a nap in her wheelchair and was not able to be aroused. Her hearing aides were observed charging on the dresser. During Resident Council on 12/4/2023 at 11:30 AM, Resident #4 expressed frustration with being unable to hear what was being said and was going to leave the meeting. This writer was able position themselves next to the resident and repeat the questions to ensure inclusion and that her concerns were voiced. Resident #4 shared her hearing aides had been checked multiple times and are working but she is still unable to hear because her ears are full of wax. She continued she does not know why there is so much build up nor does she know when she is supposed to see a physician to have it rectified. Resident #4 reported this had been going on for some time and does not what the holdup is. On 12/4/2023 at approximately 1:00 PM, a review was completed of Resident #4's medical record and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Chronic Kidney Disease, Diabetes, Hypertension, Depression, Atrial Fibrillation and Unspecified Bilateral Hearing Loss. On 12/4/2023 at approximately 2:45 PM, an interview was conducted with Unit Manager A regarding Resident #4's hearing loss. Manager A explained it was recommended by Hearing Aide professionals that Resident #4 have a specialty consult for wax removal, for her bilateral ears, as both are severely compacted. She has an appointment on 12/27/23 with an ENT (Ear, Nose and Throat) Physician for the removal. Manager A was asked to provide a timeline when Resident #9's ear problems originated and steps the facility took. On 12/4/2023 at 3:16 PM, Nurse Manager A reported the concern appeared to originate around June 2023, as that is when Debrox Ear Drops were ordered by their Nurse Practitioner. She reported the order was for 5 days but was administered from 6/28/23 to 8/8/23. As when the order was inputted there was no stop date added. Manager A continued after the ear drops were completed, they thought it was something wrong with Resident #4's hearing aids and the Social Worker was taking them back and forth to the Hearing Aide company. At some point they (hearing aide company) instructed the facility to bring in the resident for evaluation and that is when they found her ears were compacted with ear wax. Manager A was queried if within the last few months if Resident #4's physician or Nurse Practitioner assessed her ears and she stated not that was documented in their notes. She was further asked if an otoscope is accessible to facility practitioners and nurses and she stated they are available in the nursing medication room. A discussion was held with Manager A regarding the concern that Resident #4's ears were not assessed during this time, and it took an outside entity to determine they were compacted. Further review was completed of Resident #4's chart and it yielded the following: Physician Orders: Debrox Otic Solution- Instill 5 drops in both ears two times a day for buildup wax - Ordered on 6/28/23 and ended on 8/8/2023 ENT consult r/t (related to) excessive wax build up - Ordered on 11/21/23 Progress Notes: 5/3/2023 10:24: .Resident was complaining that her hearing aids are not working. Upon placing them on charger, both hearing aids were fully charged. SW and activities director cleaned both hearing aids, and the left one worked, but the right one appears to have compacted debris in it. SW will take into (Hearing Aide Store) today . 6/6/2023 11:01: : Resident's right hearing aid continues to be giving her problems - reports she cannot hear out of it. SW has cleaned it, and it charges on the charger. SW scheduled a Ear appt for them to check it out on 6/12 at 4:00 pm. 6/12/2023 15:13: SW took (Resident #4) hearing aids to (Hearing Aide Store) for cleaning. Discussed with nursing about possible flushes for her ears as her hearing aids have been getting plugged up with wax continuously. 6/21/2023 13:44: SW returned resident's (R) hearing aid - had it cleaned and returned to its charger. 6/28/23 10:05: .Patient being seen today for follow up on excessive ear wax, difficulty hearing . Staff concerns with excess ear wax that continues to plug up hearing aids, has had to send out multiple times to have fixed/cleaned. Excess cerumen noted to bilateral ears, unable to visualize TM's. Ear wax removal not attempted due to hardness of wax and pain with mobility of wax. Will start debrox BID for 4 days and re evaluate on Friday with attempts to remove . 6/30/23 11:45: .Patient being seen today for follow up on excessive ear wax, difficulty hearing . Staff has been administering debrox twice daily with some softening of wax. Able to remove small amounts from bilateral ears with tool. Continue debrox BID through Monday. Will follow up on Monday and attempt to flush bilat ears . 7/10/23 12:37: Patient being seen today for follow up on excessive ear wax, difficulty hearing . Under Assessment/Plans/Orders there was nothing mentioned regarding excessive ear wax, next steps or the Debrox ear drops being utilized for longer than ordered. 7/25/2023 15:06: SW picked up hearing aids from (Hearing Aide Store) as they were reprogramming, recharging, and replacing filters. SW took hearing aids back to (Resident #4's) room, showed them to her, reminded her to let them charge another 4 hours on the charger, per audiologist's recommendation, and then try them again . 8/21/23 11:28: No mention ear assessment 9/15/23 11:57: No mention ear assessment 9/29/23 12:13: No mention ear assessment 10/6/23 11:02: No mention ear assessment 10/11/23 14:04: No mention ear assessment 10/16/23 11:39: No mention ear assessment 10/23/23 13:13: No mention ear assessment 10/25/23 13:17: No mention ear assessment 10/27/23 14:20: No mention ear assessment 10/30/23 12:45: No mention ear assessment 11/1/2023 15:24: No mention ear assessment 11/8/2023 15:39: SW went with Resident #4 to her hearing aide appt .(Resident #4) reported that her hearing aids are not working and wants to be refitted for possible new ones. At appt, (Hearing Aide Professional) advised that (Resident #4) has severely wax compacted ears and that is deterring from her hearing, or from them to complete an accurate hearing test. (Resident #4) returned from the appt and will scheduled one after PCP advises if an ENT appt can be scheduled for a wax removal consultation. 12/1/2023 07:39: .ENT referral for assessment of excess ear wax and inability to remove with use of debrox and irrigation. Patient unable to get hearing aid assessment until resolved . Resident #4 had consistent issues with her bilateral ears with documentation that dated to May 2023. The facility ceased continuous assessment and monitoring of the issue to ensure improvement or make appropriate referrals to resolve the concern timely. The last note regarding this was on 7/25/23 and the next mention was on 11/8/2023 when Resident #4 was taken to an appointment for new hearing aids as she felt her's were no longer working. Resident #4 stated the issue was longstanding and unresolved by the facility and felt a tremendous amount of frustration as is affected her ability to communicate effectively. Resident #38: On 12/3/2023 at approximately 8:45 AM, Resident #38 was observed resting in bed as he awaited breakfast. As we talked, this writer saw what appeared to be a cell phone charging in the corner of his room. When asked if this was his cell phone, he stated it was a device to monitor his heart. Resident #38 shared he had a defibrillator implanted about 4-5 months ago and pointed to his left upper chest. On 12/3/2023 at approximately 10:15 AM, a review was completed of Resident #38's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Dementia, Heart Disease, Atrial Fibrillation, Aortic Valve Stenosis and Chronic Obstructive Pulmonary Disease. Further review of Resident #38's records yielded the following: Care Plan: Resident #38 does not a have a cardiac care plan that addressed usage of the [NAME] Heart Transmitter nor his implanted ICD (small device placed in the chest that detects and stops irregular heartbeats). Physician Orders: There were no current physician orders regarding Resident #38's [NAME] transmitter or ICD. Progress Notes: 6/12/23 at 07:57: Client out to appointment via wheel chair per one transporter . 6/12/23 at 19:17 Resident returned from procedure a&ox 4 via w/c. Resident stated they would make copies of their discharge papers before giving them to nurse. 6/13/23 at 15:55: post procedure follow up appointment scheduled June 22, 2023 at 0830 at (Cardiology). 6/22/23 at 13:23: pt (patient) returned from appointment at 1107. With orders to have device phone check in 7-10 days. Resident stated my phone is not working right now but will call to set up appointment within time frame. Cardiology Note (not dated) - Device check WNL (within normal limits). Restrictions are lifted. First remote check will be 10-30-23. On 12/3/2023 at 12:10 PM, Resident #38 was listening to music to in room. This writer observed the phone still plugged into the charger and when unlocked it displayed [NAME] Pulse. Resident #38 asserted his defibrillator was implanted 4-5 months and stated his daughter brought in the [NAME] device, but he does not remember when that was. On 12/3/2023 at 12:20 PM, Nurse H was queried if she was aware Resident #38 had a [NAME] Transmitter in his room and the nurse stated she was aware. We reviewed Resident #38's orders for anything regarding this and did not locate anything. There were no other current orders, care plans, tasks associated with assessment and monitoring of this area, details of next transmittal, ensuring phone is plugged in and within an appropriate distance to the resident. A note was located from the Cardiologist that stated the next remote check was on 10/30/23. Nurse H stated she was not sure if this check occurred or what the facility's responsibility in this is. On 12/4/2023 at 2:00 PM, an interview was conducted with Unit Manager A regarding the facility's knowledge of Resident #38's [NAME] transmitter and his defibrillator. Manager A started the resident reported to them upon questioning that the device was delivered to his daughter's home, and she brought it to the facility. The facility reached out to his daughter but have not received a response back yet. Manager A continued after review of Resident #38's chart they found his ICD was implanted on 6/12/2023. She was asked what their expectation of staff was when a device is implanted. She stated there should be a progress note detailing when it was implanted with follow up care instructions. With the transmitter they should have know it was at the facility and when the remote checks are being completed. On 12/4/2023 at 2:25 PM, an interview was conducted with MDS Coordinator I regarding Resident #38 now updated care plan to reflect his [NAME] Transmitter and ICD. Coordinator I stated a facility nurse reported a concern from a surveyor regarding cardiac monitoring for Resident #38 and they began to track it to see how it was missed. IDT (Interdisciplinary Team) discussed yesterday what was placed (ICD or Loop Recorder) when Resident #38 went for his outpatient procedure on 6/12/2023. Coordinator I stated upon his return there was no interventions for cardiac monitoring added to his care plan, no progress note detailing the procedure/follow-up care or skin assessment. She reported the facility transported him to the Cardiologist where the device was checked in office on 10/30/23 and from there the transmitter was mailed to his daughter's home. Coordinator I stated they are unable to care plan appropriately if they are unaware and added facility nurses needed more thorough follow through. Resident #38 had limited documentation regarding his ICD was during the timeframe that it was implanted in June 2023. Once the initial monitoring ceased in July 2023 there was no other assessment, monitoring or care planned interventions related to his ICD. Furthermore, it is unknown when the [NAME] Transmitter was placed at the facility as this, too, was not documented or care planned. The facility lacked appropriate documentation, timely interventions, and effective facility communication regarding his cardiac status. A review of the facility policy entitled, Care Plans, Comprehensive Person- Centered, reviewed 2/2021. The policy stated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Observation, interview and record review, the facility failed to monitor weight fluctuations and offer cueing with meals for two resident (Residents #31, Resident #32), resulting in weight loss and likelihood for further weight loss and a decline in overall health and wellbeing. Findings include: Record review of facility provided 'Snack List' undated listed: Oranges, apples, Oatmeal cookies, Sugar-free cookies, [NAME] crackers, Peanut Butter crackers, Potato chips, Fritos, reduced fat Cheeto puffs, Chex mix, Applesauce, Fruit cups, Uncrustable peanut butter and jelly sandwiches. (Very few protein snacks noted on list). Record review of the facility 'Frequency of Meals' policy dated 2/2023 revealed that each resident shall receive at least three meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests, and plan of care. The facility will serve at least three meals or their equivalent daily at scheduled times. There will not be more than fourteen (14) hours span between the evening meal and breakfast. Resident #31: Record review of Resident #31's quarterly Minimum Data Set (MDS) dated [DATE] noted an elderly resident with Brief Interview of Mental status (BIMS) score of 3 out of 15, severe cognitive impairment. Section K: Nutrition noted a weight of 138 pounds. Resident #31 was assessed at a loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Yes, not on a physician-prescribed weight loss regimen. Medical diagnosis included: coronary heart disease, hypertension, cerebral vascular accident (CVA), hemiparesis, and depression. Observation on 12/03/23 at 08:57 AM revealed that Resident #31 was seated up at edge of bed with over bed tray table pulled up to side of bed in the dark. Observation of the bedside tray table revealed a styro foam clam-shell container with a fried egg and sausages, with a bowl of cereal. Beverages were in styro-foam cups also. Resident #31 was attempting to cut the fried egg with a plastic knife and gave up and began to eat the egg and sausage links with her hands while in the dark. Resident #31 stated that they (staff) don't help do anything, it's all cold (food). Record review on 12/03/23 at 12:15 PM of Resident #31's medical records revealed possible weight loss. Record review of the electronic medical record wight log revealed on 6/30/2023 Resident #31 weight was 138.2 pounds and on 9/20/2023 was at 129.8 pounds. The record revealed a three (3) month weight loss is 6.01%. An interview on 12/04/23 at 10:51 AM with the Certified Dietary Manager (CDM) C revealed that there was a Register Dietitian (RD) contracted services, and that the RD works remote. The CDM C stated that she has not ever seen the RD but communicate through text and email. The CMD C revealed that she does a weekly report of weight loss/gains on residents, then emails the report to all department heads, nursing, activities and to the RD. Discussion on Resident #31 the CDM C gave indications of diuretic and why a fluctuation decreased oral intake and Resident #31 was on supplements and refused, she use to have table mate that only ate hotdogs and then Resident #31 stated to eat only hotdogs that was a couple months ago. Now Resident #31 does not come out to the dining room, staff are to encourage snacks and fluids throughout the day and we off alternatives. The state surveyor discussed the observed breakfast on 12/3/23 of cold cereal and sausage links and an egg, in styro foam clam shell, resident stated the egg was cold. The CDM C revealed that if she has a specific issue with a resident the RD will go and look at the record for recommendations. Surveyor requested snack documents and snack lists from the CMD at this time. Record review of Resident #31's 'nutritional' care plan- The resident has nutritional problem or potential nutrition problem related to: diverticulosis of large intestine, dysphagia, malignant neoplasm of the kidney, depression, hearing loss and retention of urine. Goals: significant weight loss triggered during the review 7/14/2023, continue to offer Resident #31 snacks/fluids throughout the day. Interventions: convey a willingness to provide acceptable foods, approach in a non-judgmental manner, collaborate with Registered Dietitian and staff as needed (PRN) . Record review of Resident #31's Tasks: Amount eaten for a 30 day look back revealed from 11/5/2023 through 12/3/2023 was 29 days, with 3 meals a day equaling 87 meals and out of the 87 meals Resident #31 was documented to have eaten 45 meals at 50% or less. (45 meals eaten/87 total meals X 100%= 51% of meals received were eaten at 50% or less, resulting in likelihood for weight loss. Resident #32: Record review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed an elderly resident with Brief Interview of Mental status (BIMS) score of 8 out of 15, moderate cognitive impairment, decisions poor, cues/supervision required. Section I: Active diagnosis included: coronary artery disease, hypertension, renal insufficiency, pneumonia, diabetes, cerebrovascular accident (CVA), Non-Alzheimer's dementia, hemiplegia/hemiparesis, malnutrition, depression, and supra-pubic urinary opening. Section K: Nutritional status assessed Resident #32 at 145 pounds with loss of 5% or more in the last month or loss of 10% or more in the last 6 months, yes not on a physician-prescribed weight-loss regimen. Observation of Resident #32 during the annual survey from 12/3/2023 through 12/5/2023, revealed that Resident #32 took his meals in the dining room with meal setup. There was no cueing or supervision with the meal noted during observations. Record review on 12/04/23 at 10:47 AM of Resident #32's weight log revealed on 8/8/23 a weight of 153.4 pounds, and on 11/15/2023 a weight of 145.2 pound, that was a 5.34% weight loss in three months. An interview on 12/04/23 at 11:01 AM with the Certified Dietary Manager (CDM) C revealed that Resident #32's weight has bounced from being in 150 pounds to 145 pounds and would call that the residents base line. CDM C revealed that the registered Dietitian has full time job and is contracted with the facility. During Resident Council on 12/4/2023 at 11:30 AM, residents were asked if they are offered nighttime snacks. One resident stated there is a cart in the common area by the nurse's station with snacks that are accessible to residents. But the majority of resident reported they are not offered snacks and were not aware of the snack cart as they do not have the physical capabilities to access the cart for an evening snack. Record review of the facility provided 'Snack Cart Sign-Out Sheets' dated from October through November 2023 noted 12 sheets some without dates, were reviewed by the state surveyor. Record review of the 12 sheets provided noted that Resident #31 only received snacks four (4) different times and that Resident #32 had received no snack at all.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that water flush tubing was utilized within a 24 hour period and maintain the head of bed (HOB) at 45 degrees per care plan for one resident (Resident #9), resulting in decreased elevation of the HOB and old water flush tubing with the likelihood of aspiration and infection. Findings include: Resident #9: On 12/03/23, at 7:53 AM, Resident #9 was lying in their bed. Their Jevity 1.5 tube feeding solution was hooked to them and running. The water flush bag was dated 12-1 1930 (7:30 PM). On 12/04/23, at 9:00 AM, a record review of Resident #9's electronic medical record revealed a readmission on [DATE] with diagnoses that included Unspecified fracture of right femur, stroke and Alzheimer's. Resident #9 required extensive assistance with all Activities of Daily Living and had severely impaired cognition. A review of the Focus (the resident) is NPO (nothing by mouth) and requires PEG tube feeding . r/t (related to): Dysphagia . Interventions The resident needs the HOB elevated to 45 degrees during and thirty minutes after tube feed . On 12/04/23, at 10:00 AM, Resident #9 was lying in their bed with their tube food solution hooked to them and running. The head of bed (HOB) was elevated although appeared low. Nurse H was asked to measure the angle of the HOB. On 12/04/23, at 10:13 AM, Therapy Director (TD) P entered the resident's room and measured the angle of the HOB which revealed 30 degrees. TD P was asked what the angle of the HOB was and TD P stated, it reads 30 degrees. On 12/04/23, at 10:20 AM, Nurse H was asked what the HOB should be elevated to for Resident #9 and Nurse H stated, they would have to check the order.

Based on observation, interview and record review, the facility failed to ensure pharmacy services that included acquisition and provision of medications as ordered by a physician were provided to two residents (Resident #19, Resident #24) reviewed for pharmacy services, resulting in multiple missed doses of ordered medications and likelihood for prolonged illness. Findings include: Record review of facility 'Pharmacy Services Agreement' dated 1/30/2023 revealed pharmacy services shall supply to the facility and its resident with FDA approved pharmaceuticals, IV medications, and supplies as ordered by residents' physicians, under the terms and conditions of this agreement and in compliance with all federal and state law and/or regulations. Record review of the facility 'Facility Assessment' annul review date 1/2023 revealed a facility that had a total of 55 licensed beds. The facility resident profile included common diagnosis/conditions of psychiatric/Mood with impaired cognition, depression, anxiety disorder, behaviors that need interventions. Facility assessment on acuity/special treatments and conditions section revealed mental health/behavioral health needs was assessed as number/average or range of residents as approximately 35% of the resident population. Part 2: Services and care offered based on residents' needs- Mental health and behavioral: Manage the medical conditions and medications-related issues causing psychiatric symptoms and behaviors, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, and other psychiatric diagnosis, intellectual or developmental disabilities. Resident #19: In an interview on 12/4/2023 at 11:30 AM, Resident #19 shared concerns with consistent availability of her medications. the resident stated the facility had run out of her sleeping medications four times and its typically on a Friday and she will go a few days without it. The nurses will inform her the medications has been ordered but she does not understand why they wait until her medication is depleted to reorder. Resident #19 stated the medications that have not been ordered was Nortriptyline and a sinus/cough medication. Record review of Resident #19's Medication Administration Record (MAR) for September 2023 from 9/18/2023 through 9/30/2023 noted that medications: Glipizide 5mg one tablet by mouth each morning related to hypertension, Mucinex Sinus-Max nasal solution 2 sprays in both nostrils at bedtime, Nortriptyline HCL 75mg (antidepressant) by mouth at bedtime. were noted to have chart codes of the number 9- other/see progress notes. Record review of Resident #19's progress notes from 9/18/2023 through 9/30/2023 noted that the medications were on order from pharmacy, or a partial dose was administered. In an interview on 12/04/23 at 01:15 PM with Registered Nurse/Unit Manager O record review of Resident #19's September 2023 Medication Administration Record (MAR) revealed that the Mucinex nasal spray is not something we carry in back up and has to be ordered from the pharmacy, the nortriptyline antidepressant is 50mg in the back-up supply in the building and we don't carry the 75mg dose. The resident went out to the hospital on 9/15/2023 and came back on 9/18/2023 and that is when her medications are removed from the medication cart and returned/dispose. Resident #24: Record review of Resident #24's medical diagnosis list from the electronic medical record revealed diagnosis included glaucoma. Observation, interview, and record review on 12/03/23 at 08:07 AM with licensed Practical Nurse (LPN) F during medication administration and medication cart review noted that Resident # 24 eye drop Latanoprost at bedtime for glaucoma 0.005% box was empty in the cart. LPN F revealed that the medication has been out of stock for the last 2 nights. Record review of Resident #24's Medication Administration Record on the computer revealed that Resident #24 had missed two nights of the medications. LPN F stated that the medication would be ordered again from the pharmacy. Record review on 12/04/23 at 09:24 AM of Resident #24's December 2023 Medication Administration Record (MAR) revealed that from 12/1/2023 through 12/4/2023 four nights of missed Glaucoma medication Latanoprost 0.005% eye drops. Record review of Resident #24's progress notes from 12/1/2023 through 12/4/2023 noted Latanoprost Ophthalmic solution 0.005% instill 1 drop in both eyes at bedtime for glaucoma note awaiting pharmacy delivery. Not available in back up. In an interview on 12/04/23 at 12:28 PM, Registered Nurse/Unit Manager (RN/UM) O regarding Resident #24's glaucoma eye drops Latanoprost used at bedtime, RN/UM O had called the pharmacy about that eye drop medication and the pharmacy was out of stock as of Friday and they will send it today or tomorrow.

Based on observation, interview and record review, the facility failed to administer medications timely for one resident (Residents #24), resulting in missed medication administrations resulting in 3 errors during medication administration reviews with a medication error rate of 10%. Findings include: Record review of facility 'Pharmacy Services Agreement' dated 1/30/2023 revealed pharmacy services shall supply to the facility and its resident with FDA approved pharmaceuticals, IV medications, and supplies as ordered by residents' physicians, under the terms and conditions of this agreement and in compliance with all federal and state law and/or regulations. Record review of the facility 'Facility Assessment' annul review date 1/2023 revealed a facility that had a total of 55 licensed beds. The facility resident profile included common diagnosis/conditions of psychiatric/Mood with impaired cognition, depression, anxiety disorder, behaviors that need interventions. Facility assessment on acuity/special treatments and conditions section revealed mental health/behavioral health needs was assessed as number/average or range of residents as approximately 35% of the resident population. Part 2: Services and care offered based on residents' needs- Mental health and behavioral: Manage the medical conditions and medications-related issues causing psychiatric symptoms and behaviors, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, and other psychiatric diagnosis, intellectual or developmental disabilities. Medication Administration Task: During the annual survey dated 12/3/2023 through 12/5/2023 medication administration of 30 administrations and record reviewed residents past Medication Administration Record (MAR). Resident #24: Record review of Resident #24's medical diagnosis list from the electronic medical record revealed diagnosis included glaucoma. Observation, interview, and record review on 12/03/23 at 08:07 AM with Licensed Practical Nurse (LPN) F during medication administration and medication cart review noted that Resident # 24 eye drop Latanoprost at bedtime for glaucoma 0.005% box was empty in the cart. LPN F revealed that the medication has been out of stock for the last 2 nights. Record review of Resident #24's Medication Administration Record on the computer revealed that Resident #24 had missed two nights of the medications. LPN F stated that the medication would be ordered again from the pharmacy. Record review on 12/04/23 at 09:24 AM of Resident #24's December 2023 Medication Administration Record (MAR) revealed that from 12/1/2023 through 12/4/2023 four nights of missed Glaucoma medication Latanoprost 0.005% eye drops. Record review of Resident #24's progress notes from 12/1/2023 through 12/4/2023 noted Latanoprost Ophthalmic solution 0.005% instill 1 drop in both eyes at bedtime for glaucoma note awaiting pharmacy delivery. Not available in back up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent a significant medication error for one resident (Resident #4), resulting in Resident #4 receiving an additional 43 doses of Debrox (ear wax removal treatment) when the practitioner prescribed for five days. Findings Include: Resident #4: On 12/2/2023 during initial tour, Resident #4 was observed taking a nap in her wheelchair and was not able to be aroused. Her hearing aides were observed charging on the dresser. During Resident Council on 12/4/2023 at 11:30 AM, Resident #4 expressed frustration with being unable to hear what was being said and was going to leave the meeting. This writer was able position themselves next to the resident and repeat the questions to ensure inclusion and that her concerns were voiced. Resident #4 shared her hearing aides had been checked multiple times and are working but she is still unable to hear because her ears are full of wax. She continued she does not know why there is so much build up nor does she know when she is supposed to see a physician to have it rectified. Resident #4 reported this had been going on for some time and does not what the holdup is. On 12/4/2023 at approximately 1:00 PM, a review was completed of Resident #4's medical record and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Chronic Kidney Disease, Diabetes, Hypertension, Depression, Atrial Fibrillation and Unspecified Bilateral Hearing Loss. On 12/4/2023 at 3:16 PM, an interview was conducted with Unit Manager A regarding Resident 4's hearing loss. She reported the concern appeared to originate around June 2023 as that is when Debrox Ear Drops were ordered by their Nurse Practitioner. She reported the order was for 5 days but was administered from 6/28/23 to 8/8/23. As when the order was inputted there was no stop date added by nursing. Manager A was queried how long the ear drops should be administered for according to the medication insert and she stated 5 days. Further review was completed of Resident #4's chart and it yielded the following: Physician's Orders: Debrox Otic Solution- Instill 5 drops in both ears two times a day for buildup wax - Ordered on 6/28/23 and ended on 8/8/2023 MAR (Medication Administration Record): - Resident #4's MAR from June 2023 to August 2023 was reviewed and it revealed she received Debrox ear drops from June 28th 2023 until August 8, 2023 when the practitioner ordered the medication for only five days. the resident received an additional 43 doses. Debrox Prescription Insert: .Stop use an ask if a doctor if: You need to use for more than four days .Use twice daily for up to four days if needed or as directed by a doctor . Progress Notes: 6/28/23 10:05: .Patient being seen today for follow up on excessive ear wax, difficulty hearing . Staff concerns with excess ear wax that continues to plug up hearing aids, has had to send out multiple times to have fixed/cleaned. Excess cerumen noted to bilateral ears, unable to visualize TM's. Ear wax removal not attempted due to hardness of wax and pain with mobility of wax. Will start debrox BID for 4 days and re evaluate on Friday with attempts to remove . 6/30/23 11:45: .Patient being seen today for follow up on excessive ear wax, difficulty hearing . Staff has been administering debrox twice daily with some softening of wax. Able to remove small amounts from bilateral ears with tool. Continue debrox BID through Monday. Will follow up on Monday and attempt to flush bilat ears .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that 3 out of 4 medication carts contained medications with no labels of resident names and/or the date that medications were opened in the 100/200/400 Hall Medication Carts and the facility failed to label back up stock insulin in a multi-dose bottle, resulting in the likelihood of cross contamination and ineffective medications. Findings include: Record review of facility 'Medication Labeling and Storage' policy, dated 10/2023, revealed medication storage: (1.) Medications and biologicals are stored in the packaging containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Medication labeling: (2.) The medication label includes, at a minimum: (a.) medication name (generic and/or brand). (b.) prescribed dose. (c.) strength. (d.) expiration date, when applicable. (e.) resident's name. (f.) route of administration. (g.) appropriate instructions and precautions. (#5.) Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. (#8.) If medication containers have missing, incomplete, improper, or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying their items. (#11.) Medications may not be transferred between containers. Medication Storage Task: Observation on 12/03/23 at 08:28 AM of the 100-hallway medication cart reviewed with Licensed Practical Nurse (LPN) H revealed that unsampled Resident in room [ROOM NUMBER] was noted to have an Albuterol Sulfate inhalation powder 108 MCG 2 puffs device, which was not dated. The inhaler device had been used. Observation, interview, and record review on 12/03/23 at 08:07 AM with Licensed Practical Nurse (LPN) F during medication administration and 200 hallway medication cart review noted that Resident # 24's eye drop, Latanoprost (at bedtime for glaucoma 0.005%) box was empty in the cart. LPN F revealed that the medication has been out of stock for the last 2 nights. Record review of Resident #24's Medication Administration Record on the computer revealed that Resident #24 had missed two nights of the medications. LPN F stated that the medication would be ordered again from the pharmacy. Observation of the 200-hallway medication cart reviewed with licensed Practical Nurse (LPN) F revealed that insulin Lispro 10ml bottle with no box, no resident names and opened (with puncture marks noted and was located in the top drawer of the cart). Observation and interview on 12/04/23 at 12:06 PM of the only Medication room with Licensed Practical Nurse (LPN) D of the back-up stock medications dispensed by pharmacy services noted an empty box labeled Lispro insulin 10ml. The box only has manufacturer's instructions, where is the bottle? There should be a 10ml bottle per box label. Observation of the insulin box found in the refrigerator noted no Lispro insulin available in the back up. Record review of the list of medications found in the insulin refrigerator back up box noted Lispro 10ml should be in the box, but none was found. LPN D stated that the Unit Manager nurse might know. Observation and interview on 12/04/23 12:19 PM with Registered Nurse/Unit Manager (RN/UM) O reviewed the back-up medications and medication room. RN O was notified by Licensed Practical Nurse (LPN) D that she and the state surveyor just went through medication room and there was a Lispro 10 ml box with no medication in the box. RN/UM O stated that the insulin medication may have been used and the person who got the medication from the medication room should have reordered the medication. The State surveyor and RN/UM O went to the 200-hallway med cart to review the Lispro insulin 10ml bottle with no label from pharmacy located in no box from pharmacy. The insulin vial was a Reusable multi-dose insulin bottle of 10ml, with no label. RN/UM O stated that she would have to reorder the medication. There is problem with back up medication Lispro is not being reordered. Record review of the facility-provided 'Lispro Removal' noted that on 12/2/2023 at 3:10 PM insulin Lispro 100 units/ML vial was removed by Licensed Practical Nurse (LPN) F.

Based on observation, interview and record review, the facility failed to care plan and provide documented collaborated visits with Hospice Service for one resident (Resident #7), resulting in the likelihood of unmet needs and confusion as to what services hospice provided. Findings include: Resident #7: On 12/4/23, at 10:00 AM, a record review of Resident #7 revealed an admission to hospice services on 12/28/2022 with diagnoses that included altered mental status, congestive heart failure and Diabetes Mellitus. A review of the miscellaneous tab revealed the last HOSPICE NURSE NOTE was for 11/27/23. A review of the Hospice care plan revealed no schedule nor services hospice provided. On 12/04/23, at 1:25 PM, Unit Manager (UM) E was asked how the facility communicated with Resident #7's hospice group and UM E stated, the nurse usually meets with the floor nurse for order changes etc. UM E was asked regarding Resident #7's recent injury to their leg and where the hospice nurse documented that they have assessed it and UM E I know they needed to stitch it up and would assist if finding the hospice notes. On 12/04/23, at 1:35 PM, an observation of the nurse desk revealed numerous hospice binders but not one for Resident #7. On 12/05/23, at 8:51 AM, a further record review of Resident #7's electronic medical revealed numerous hospice notes had been uploaded for review on 12/4/2023. There was no schedule as to hospice visits, no aide, no Chaplin and no social worker visit notes. On 12/05/23, at 8:53 AM, the Director of Nursing (DON) was interviewed regarding the lack of hospice notes for Resident #7 and the DON stated, we don't have a hospice book and any orders will be in the electronic record. The DON further explained that if the hospice nurse changed any orders they would tell the facility nurse and the order would be placed by them. The DON was asked if Resident #7 received social worker, chaplain and aide visits and the DON stated, they have all visited. The DON was asked to provide the last month of all hospice notes for Resident #7 for all visits. Upon exit, the facility had not provided social worker, aide or Chaplin visits for Resident #7.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely complete a mental health evaluation for one resident (Resident #26) reviewed and eight unsampled residents, reviewed for screening of mental and intellectual disabilities, after surpassing the 30-day exemption period, resulting in the likelihood for missed specialized behavior health services from the local Community Mental Health Organization. Findings include: Record review of the facility 'Facility Assessment' annul review date 1/2023 revealed a facility that had a total of 55 licensed beds. The facility resident profile included common diagnosis/conditions of psychiatric/Mood with impaired cognition, depression, anxiety disorder, behaviors that need interventions. Facility assessment on acuity/special treatments and conditions section revealed mental health/behavioral health needs was assessed as number/average or range of residents as approximately 35% of the resident population. Part 2: Services and care offered based on residents' needs- Mental health and behavioral: Manage the medical conditions and medications-related issues causing psychiatric symptoms and behaviors, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, and other psychiatric diagnosis, intellectual or developmental disabilities. Resident #26: Record review of Resident #26's admission Minimum Data Set (MDS), dated [DATE], revealed an elderly resident with an admission date of 1/2/2023 from the community. Section D: Mood assessment identified Resident #26 as feeling tired or having little energy, poor appetite, trouble concentrating on things. Section I: Active diagnosis included- anemia, Atrial Fibrillation, coronary artery disease, heart failure, hypertension, renal insufficiency, diabetes, anxiety disorder, depression, bipolar disorder, respiratory failure, scoliosis, and repeated falls. Section N: Medications received included antipsychotic, antianxiety and antidepressant. Record review on 12/4/2023 of Resident #26's electronic medical record revealed that there was no 30-day screening for PASSAR found in the medical records. admission dated of 1/2/2023, there should have been a February 2023 Level II screening assessment performed and submitted to the state agency. The state surveyor requested the Level II PASSAR form from social services designee B and did not receive the form that day. An interview on 12/05/23 at 10:45 AM with the social services designee (SWD) B revealed that she could not do the OBRA assessments, because she is not a licensed social worker. The SWD B revealed that the Director of Nursing (DON) was in charge of the OBRA assessments and Resident #26 was due in February 2023 when the 30-days exemption period ended, and it was not done until yesterday 12/4/2023 when the surveyor requested the form. SWD B stated that Yes, it was done on 12/4/2023 almost a year late, and that an OBRA person did come into the building because several were due, and they wanted to give SWD the list of OBRA residents not submitted. They did talk about the late submissions and that they would assist in getting the facility caught up. An interview on 12/05/23 at 10:50 AM with the Director of nursing (DON) revealed that Yes, Resident #26's OBRA assessment form was submitted yesterday on 12/4/2023, and that the OBRA assessments are done by the DON. The state surveyor inquired about how many OBRA assessments are late. The DON stated that she, did not know how many OBRA assessment are late. The DON revealed that a OBRA person did come into the facility week or so ago, to introduce new people, and a discussion of late OBRA assessments. Resident #26 was supposed to be done in February 2023 but not done until yesterday (12/4/2023). The DON revealed that she had been on a leave of absence for 3 months and came back in the middle of March 2023 and had a lot of work to get caught up on. The DON stated that the facility did an audit yesterday (12/4/2023) and a bunch of OBRA assessments identified that there were eight (8) other PASSAR's that were late and were submitted on November 21,2023, but Resident #26's was missed. Record review of Resident #26's DCH-3877 form, dated 12/4/2023, revealed Section I: a change of condition. Section II: Screening criteria- Resident has current diagnosis of mental illness, has received treatment for mental illness, has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. There was presenting evidence of mental illness or dementia, including significant disturbances in thought, conduct, emotions, or judgement. Presenting evidence may include, but not limited to, suicidal ideations, hallucinations, delusions, serious difficulty completing tasks, or serious difficulty interacting with others. Diagnosis of bipolar, depression and anxiety were noted with medications of Trazadone, Zoloft, Seroquel, and Xanax.

Based on observation, interview and record review, the facility failed to post in a prominent location for public viewing the actual hours worked by categories of nursing staffing and the census for each day resulting in the public and the 49 residents of the facility being unaware of the nursing staff available to care for residents. Findings include: Record review of the facility 'Staffing' policy dated 2/2023 revealed that the facility provides adequate staffing to meet needed care and services for the resident population. (4.) The facility furnishes information from payroll records as required by Payroll Based Journal or determine the numbers of staffing personnel per shift on a daily basis as required by state guidelines. In addition, this information is posted daily for public viewing at the central nurses' station. FACILITY: Observation on 12/03/23 at 09:46 AM the state surveyor Observation of clear plastic upward standing document holder on the far west end of the nursing station noted posted staffing of daily staffing sheets dated Friday 12/1/2023 and on the back side was Thursday 11/30/2023 census of 49. On 12/03/23 at 09:49 AM the state surveyor requested Licensed Practical Nurse (LPN) D to make copies of the daily staffing posting, dated Thursday 11/30/23 and Friday 12/1/2023. LPN D revealed that the Registered Nurse (RN) nurse manager E who use to be the Director of Nursing and now is the unit manager. RN E must have had the weekend off. It's RN E's job to post the staffing. In an interview on 12/03/23 at 09:52 AM with the Director of Nursing (DON) reviewed the staffing posted on the nursing desk for the resident and public review. The DON stated that Yes, these are Thursday 11/30/2023 and Fridays 12/1/2023 postings. It is usually done by the Unit Manager on the night shift and posted before leaving in the morning. The unit managers don't work the weekends. the state surveyor asked if the facility was posting on the weekends. The DON stated that I assume we are posting the weekends. In an interview and record review on 12/03/23 at 12:03 PM with Registered Nurse (RN)/Unit manager E of the staff posting record review of the Thursday 11/30/2023, and Friday 12/1/2023 that those were the only posting to public. RN E stated Yes, today I was called in because you guys (state) are here. I do work the night shift and I wasn't here on Saturday night, so nothing was posted for the weekend staffing levels. I work every other Sunday night and when I am not here no one does the posting. I am the only one that does it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain sufficient dietary staff to provide dietary services consistently for residents consuming foods from the kitchen, resulting in low dietary staffing, meals being served in Styrofoam containers with plastic utensils, and complaints of cold food. Findings include: On 12/3/2023 at 7:50 AM, the initial tour of the kitchen was completed and at the time of the tour there were only two dietary staff working in the facility. CDM (Certified Dietary Manager) C was cooking, and Dietary Aide J was plating and serving residents in the dining room and passing resident room trays. There were multiple undated and expired food found during the tour in the refrigerator, dry storage area and walk in cooler. During initial tour Dietary Aide J was observed passing meal trays on 300 and 400 halls. Aide J stated she was the only Dietary Aide in the facility and was responsible for completing meal service in the dining room and passing room trays. She explained they utilized Styrofoam containers and plastic silverware to decrease the number of dishes that had to be completed during meal service. Given its just two of them they would not have enough to time to complete all required tasks in preparation for lunch service. Aide 'J shared she is working a double today due to staffing shortages and works doubles often to meet the needs of the residents. The trays were being delivered on an open metal rack that was covered by a thin sheet of plastic. There were no other facility staff assisting Dietary Aide J with passing meal trays to the four halls. During initial screening on facility residents on 12/3/2023 they reported the following concerns regarding their meals: room [ROOM NUMBER]: Resident reported many times his food is cold by the time it is received as he is one of the last one on the hall. room [ROOM NUMBER]: Resident stated the food is ice cold all the time and has been in Styrofoam containers. room [ROOM NUMBER]: Resident reported the many foods is good but its cold. They have grown accustomed to their meals being cold upon delivery. room [ROOM NUMBER]: Resident reported they enjoy their meals but the temperature of the food has been an issue. room [ROOM NUMBER]: Resident shared by the time their breakfast is received its typically cold. During Resident Council on 12/4/2023 at 11:30 AM, the seven residents in attendance concurred that if they eat in their rooms the food is cold by the time it arrives, and they have been serving their meals on Styrofoam containers with plastic silverware. They stated this is a normal occurrence and they have become use to their food being cold by the time it is received. On 12/4/2023 at approximately 1:10 PM, a review was completed of Resident Council Minutes and following can be noted: - 11/7/2023: .Trays are often late & food cold. The note on the side of their concern was that Dietary Manager would follow up. - 6/6/2023: .Hall trays are still cold with coffee with coffee end of hall are coldest . The written on the side of the concern stated the Dietary Manager will follow up at food meeting. On 12/4/2023 at 8:25 AM, an interview was conducted with CDM C regarding dietary staffing. CDM C stated yesterday, their morning relief cook called in which is how she ended up cooking for breakfast. Dietary Aide J was the only aide from 7:00 AM to 4:00 PM but their part time cook came in from 10:30 AM to 6:30 PM. Aide J completed breakfast and lunch meal service alone. For breakfast and lunch Aide J is responsible to set up the dining room for meal service, set place mats with resident's names, obtain their drinks of choice, and deliver their meals plate by plate. Once dining room is completed, they move to the room trays and their food is placed in Styrofoam containers as it cuts back on the time it takes to complete dishes since it was only two of them. CDM C reported they do their best to maintain the temperature of the food but even if they were fully staffed, it would still be one Dietary Aide per hall passing the trays. They have open metal racked carts that they cover with plastic to try and hold the temperature. CDM C stated last month their PM Relief [NAME] quit and a Dietary Aide stepped into that role, so it left another opening in their department. They have been trying to hire staff but they either quit or are terminated. The last set that was hired never made it through the door. There are openings in their schedule regularly and it goes by seniority first to pick up the extra shift, but there are times when no ones picks up and it is only two dietary staff. CDM C was queried if Aide J' typically works doubles, and she stated she does pick up a lot of open shifts. She was asked is it common for only two staff to work the kitchen with their current census and she stated last month was difficult and about 40% of the month there were only two dietary staff completing meal service for the facility. CDM C stated Human Resources and Upper Management are aware. CDM and this writer agreed that it would take approximately 2-3 minutes per resident meal delivery and tray set up. That is not accounting for some residents that may take longer due to extra needs. If there are 14 residents on the hall that is 28-42 minutes to pass trays on one hall. It logical to recognize that the temperature of food would drop if you are toward the back of the hall. CDM C was asked if dietary aides received any assistance from floor staff with passing trays and she stated to her knowledge they do not. It's just her one dietary aide passing trays for each unit alone. We spoke about the expired items found in the kitchen during tour and CDM C explained daily they are supposed to discard of expired items. But those tasks have not taken precedence as their main priority is meal service for their residents.

On 12/4/23 at 10:18 AM, encrusted food debris was observed on the digital probe thermometer. At this time, the thermometer was in it's sheath and food debris was observed in the sheath. CDM C proceeded to instruct staff to clean the thermometer and sheath. According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 12/4/23 at 10:20 AM, a container of raw hamburger patties were observed to be dated 11/28 to 12/3. At this time, [NAME] L was observed to pull out a burger and place it in a cooking pan. During an interview, [NAME] L stated that they intended on cooking the burger. [NAME] L was then informed of the expiration date on the container and stated that they won't cook it. On 12/4/23 at 10:30 AM, individual portioned ice cream cups were observed to be stored in the walk-in cooler. At this time, CDM C stated that they keep the ice cream cups in the cooler because the freezer freezes the cups too hard, which makes it difficult for the residents to eat. The ice cream cups were not dated for 7 days for cold holding at refrigeration temperatures of 41 degrees. On 12/4/23 at 1:12 PM, [NAME] K, while entering the kitchen, was observed to use hand sanitizer instead of washing hands at the hand sink. According to the 2017 FDA Food Code Section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands.P Based on observation and interview the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive meal services. Findings include: On 12/3/2023 at 7:50 AM, the initial tour of the kitchen was completed and at the time of the tour there were only two dietary staff CDM (Certified Dietary Manager) C and Dietary Aide J completing meal service for facility residents. The following was found to be expired in the refrigerator: - Quart of Tomato Soup- expired 11/29/203 - 6 pieces of Jack's Hickory Sticks- expired 11/16/2023 - ¼ contained of grapes- expired 12/1/2023 - Quart of Potato Soup- expired 11/28/2023 - Opened bag of 8-9 Hot dogs- expired 11/29/2023 - Ham slices in storage container- expired 11/22/2023 Also found in refrigerator was a 11-ounce box of Fruity Pebbles and CDM C was asked was it typical to store cereal in the refrigerator and she stated it was a dietary staff's cereal not a resident. Packet of Honey Ham was observed stored on the middle shelf with liquid dripping down to lower shelves with other food stored. There was signage on the outside of the refrigerator that read No resident or staff food. CDM C was queried if expired foods should still be in the refrigerator, and she stated they should not. As the tour continued the following things were observed: - Ice scoop was stored inside the ice bin - Inside the spouts of the cereal dispensers, had a white film of an unknown substance. Walk in Cooler: - 7 pieces of puree toast - expired 12/2/2023 - 15+ chocolate magic cups- stored in a large bin together with many of them busted open and the contents visible. Dry Storage: - Mini Butterscotch Chips- No use by date - Package of Spaghetti Noodles- Expired 12/1/2023 - 2- Large packs of Elbow Macaroni with hole one of the bags- no open or use by date - ¼ bag of Rotini Noodles- no expiration date - 2- XL bag of Mini Seashell Pasta- no open or use by date - ½ bag of Ziti Noodle with two holes in the bag- no open or use by date - ½ bag of Elbow Macaroni- Expired 10/30/2023 - 320 oz cardboard box of Fettuccine Noodles- box was not secured with no expiration date On 12/4/2023 at 8:25 AM, an interview was conducted with CDM C regarding the initial tour of the kitchen. CDM C shared they keep a date binder in the kitchen if staff ever have questions they can verify in the binder. Any food item that is opened, should have an opened and use by date on it. CDM C was asked if it was acceptable to have holes in their pasta bags that were stored, and she stated it was not. She stated she instructs staff that if there is a hole in the original packaging to place it in a sealed container and then store it. CDM C reported expired foods should be discarded appropriately and staff should not have their personal items in the refrigerator. She added the ham should not be store on upper shelves and dripping onto the lower ones. Review of U.S. Public Health Service Food Code, as adopted by the Michigan Food Law, effective October 1, 2012, Chapter 6-403.11 Designated Areas directs that: (A) Areas designated for EMPLOYEES to eat, drink, and use tobacco shall be located so that FOOD, EQUIPMENT, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES are protected from contamination. Review of U.S. Public Health Service Food Code, as adopted by the Michigan Food Law, effective October 1, 2012, Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Pf

Based on interview and record review, the facility failed to ensure the facility's Second Quarter 2023 third party payroll services submitted Payroll-Based Journal (PBJ) data timely, resulting in the second quarter (April/May/June) 2023 payroll submission to trigger by CMS for staffing concerns with the likelihood to affect all residents residing within the facility. Findings include: Record review of the facility 'Staffing' policy, dated 2/2023, revealed that the facility provides adequate staffing to meet needed care and services for the resident population. (4.) The facility furnishes information from payroll records as required by Payroll-Based Journal to determine the numbers of staffing personnel per shift on a daily basis as required by state guidelines. In addition, this information is posted daily for public viewing at the central nurses' station. Record review of the Centers for Medicare & Medicaid Services (CMS) PBJ Staffing Data Report FY Quarter 3 2023 (April 1-June 30) run date 11/21/2023 noted: One-star staffing rating: Triggered. Excessively low weekend staffing: data suppressed. No registered nurse (RN) hours: Triggered. Failed to have Licensed Nursing Coverage 24 Hours/day: Triggered An interview on 12/03/23 at 08:39 AM with the Nursing Home Administrator (NHA), during the off hours entrance conference, revealed an entrance census of 49 residents. The NHA stated that the only reason we triggered is the facility goes through a contracted (third party payroll services) and the NHA kept submitting data. The NHA stated that she called them (third party payroll services), and they said they would fix it, they never got it fixed. The NHA stated that during the entire quarter (second quarter) anybody who has a salary position, the NHA had to enter manually and submit. In an interview on 12/03/23 at 08:53 AM, the Nursing Home Administrator (NHA) stated that the facility had a problem with their contracted third-party payroll services and could not submit the Payroll-Based Journal's required data. The NHA revealed that there were emails between the payroll service and NHA. The NHA stated that the issue didn't get it fixed right away. An interview on 12/05/23 at 11:01 AM, with the Nursing Home Administrator (NHA) on the facility Payroll-Based Journal submission via contracted third party payroll service revealed that the therapy services of the facility is a contracted service and the company sends a Zip file that is loaded into the state system. The salaried employees are manually submitted. All employee hours are downloaded as a report and then that report is uploaded into the QIES system for CMS. The NHA stated that when she runs a submission from the system that tells a submission ID and date. Then the NHA was able to run a validation report within 24 hours, and that tells if what is submitted was accepted or not. The NH stated that all the therapy department payroll was accepted. The contracted third-party payroll service for all facility staff, the NHA submitted it at 8/14/2023 at 12:27 PM. The NHA ran the validation report, and the submission was rejected. Then the NHA stated that she did it again on 8/14/2023 at 12:48 PM and it was rejected as well. On 8/14/23 at 4:59 PM it was submitted again and it was accepted and the NHA stated that she noticed that the total staffing hours were only 25 hours for 3 months. It should be in the thousands, so the NHA pulled the validation report which showed staffing hours of 156.30. The NHA called the third-party payroll service again and on 8/14/23 at 1:57 PM the payroll service created a work order and would follow-up with the NHA. The NHA stated that the Payroll-Based Journal (PBJ) was due at midnight on 8/14/2023 for the second quarter (April. May, June 2023) months. The NHA stated that she kept trying to call them, and again tried to run a PBJ submission at 8/14/2023 at 8:22 PM, and it was rejected. A different error was generated on 8/18/23 at 4:10 PM. The NHA stated that she received an email from the third party payroll service (4 days later). The NHA stated that they have had the contracted third-party payroll service for years (5 years) with no problems. The PBJ which was completed for November (2023) was submitted with no issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to issue a beneficiary notice (ABN/Nomnic) for Resident #34 and notify an eligible resident in writing of the items and services which were or were not covered under Medicaid or of the facility's per diem rate, including the cost of those items and services: resulting in the likelihood for financial hardship. Findings include: Record review of the facility 'Advanced Beneficiary Notice of Noncoverage' (ABN), dated 02/2022, revealed that an Advanced Beneficiary Notice of Noncoverage will be given to the resident/responsible party by the Financial Manager or designee. Resident #34: Observation and interview on 09/12/22 at 10:36 AM with Resident #34 revealed that he gets Tylenol for pain and has arthritis. Resident #34 revealed that he had burned his left leg when he was [AGE] years old. Observed Resident #34 up in wheelchair and that he was able to self-propel about facility. Record review of Resident #34's social worker progress notes, dated 7/6/2022, revealed that the social worker spoke to services of a referral for waiver services for transition to the community which been canceled per the resident's request. Waiver referral has been discontinued at this time. Social Worker (SW) notes on 8/31/2022 at 12:48 PM revealed that the social worker met with resident's family member who was upset in residents' room with several questions/concerns. The SW documented she reviewed all concerns and discussed in length with family about resident's wishes, choices that he made, and options that were presented to him, regarding therapy, placement etc. Resident was happy with his decisions, and he is his own decision maker. The family thanked the SW for resolving their concerns and were satisfied with residents' placement at the facility and his care. Beneficiary Task: The surveyor chose three random residents from the beneficiary notices lists provided by the facility. Interview and record review on 09/14/22 at 09:19 AM with Biller Y of Resident #34's beneficiary notice forms revealed that the facility was not able to find ABN/NOMNIC forms, not in therapy department documents and not in the Social Workers pink NOMNIC binder. In an interview and record review on 09/14/22 at 09:11 AM, Licensed Practical Nurse (LPN/MDS) T revealed that the facility Social Worker was off on medical leave. LPN T review of Beneficiary notices stated that she thought it was lost in communications, Resident #34 was Part A Medicare. The facility was working on placement, when he chose to stay. There should have been a form for him, but the facility cannot find it. Surveyor requested policy for ABN/Nomnic for facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #18: On 9/13/22 at approximately 8:45 AM, Resident #18 was observed in his room, laying in bed. He did not appear to be in any distress. On 9/13/22 at approximately 10:30 AM, a review was completed of Resident #18's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Dementia, Atrial Fibrillation, Hyperlipidemia, Anxiety Disorder and Major Depressive Disorder. His cognition is impaired and required assistance with his ADL's. Further review of Resident #18's medical record yielded the following: Physician Orders: - Cleanse open area on right gluteal fold with normal saline, cover with foam. Change every three days and PRN (as needed). Every day shift every 3 days for wound care treat until resolved. Start date 8/26/22- End date: 9/1/2022 - Cleanse Open area on right gluteal fold with normal saline, cover with foam. Change every three days and if soiled or missing. Every day shift every 3 days for wound care treat until resolved. Start date 9/2/2022 TAR (Treatment Administration Record): Review was completed of Resident #18's TAR and the facility failed to complete ordered wound care treatment on 9/5/2022 and 9/8/2022. Care Plan: There was nothing mentioned in his care plan regarding the wound to his gluteal fold. Physician Notes: There were no physician notes located regarding Resident #18's facility acquired pressure ulcer and it is unclear if the physician was aware of it. Skin Assessments: 8/14/22: .Coccyx blanchable . 8/17/22: .Coccyx and heels clean and intact. 8/21/22: Red area between buttocks. 8/24/22: Right gluteal fold-open area 00.5 x 1 cm (centimeter) . 8/28/22: .Skin intact heels blanchable and intact coccyx intact. 8/31/22: .Coccyx blanchable. Open area in left gluteal fold, treatment in pace. Periwound area darker in color and blanchable . Skin and Wound Assessment 8/31/22: The assessment was blank under the type of wound, location of wound, in house or acquired wound, date wound opened, stage of wound. The measurements were listed as 0.8 x 1.2 x 0.9. It can be noted Resident #18's facility acquired wound opened on 8/24/22. His wound treatment order was placed two days later, there were no care planned interventions and two wound care treatments were missed. On 9/14/22 at 2:30 AM, an interview was conducted with Nurse Q regarding her assessment of Resident #18's wound on 8/31/22. Nurse Q reported the DON alerted her to the residents wound and requested she assess the area and take pictures. Nurse Q reported she is not wound certified and was not comfortable with staging the wound, indicating if it was community or facility acquired and dating the wound and informed the DON of this before assessing the wound. Nurse Q stated they had a wound nurse, but she resigned in June 2022 and on 8/31/22 she completed wound assessments for 5 or 6 residents. Nurse Q reported she was unaware if Resident #18's wound was evaluated by the physician or Nurse Practitioner. Nurse Q reported on 8/31/22 she completed wound assessments on 5-6 residents. On 9/15/22 at 11:30 AM, an interview was conducted with Unit Manager K regarding Resident #18's coccyx wound. Manager K stated their wound nurse left in June and now the nurses are responsible for their own assessments and treatments. If a new skin impairment is found there is a form they complete and provide it to the DON. Manager K stated she is not wound certified and does not stage wounds. She continued while she does not stage wounds based on the information in his chart his wound be considered facility acquired as he has not left the facility. Manager K added when the wound was identified on 8/24/22 a treatment should have been put in place that day. Manager K was asked the last time he was assessed by the physician for his wound. It was reported he was last seen on 8/17/22 and his wound was not opened yet and Physician O rounded today on Resident #18, but his wound was not assessed. On 9/19/22 at 9:25 AM, an interview was conducted with the DON regarding Resident #18's wound. The DON reported the facility has been actively searching for a wound nurse but have not secured one. She reported his wound did develop at the facility. She was informed of the delay in placing a treatment order and missed wound treatments. Review was completed of their wound policy and based on their staging protocols it was determined Resident #18's wound was a Stage 2. Based on observation, interview, and record review, the facility failed to prevent development of Pressure Ulcers (wound caused by pressure) for two residents (Resident#18 and Resident #28), resulting in facility-acquired pressure ulcers for Resident #18 and Resident #28 developed unstageable and/or Stage II pressure ulcers, unnecessary pain, and the likelihood for infection and decline in overall health status. Findings include: Record review of the facility 'Pressure Ulcer/Injuries Overview' policy dated 2/2022, revealed that a pressure ulcer (PU) or Pressure Injury (PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear . Avoidable- means that the resident developed a pressure ulcer/injury . Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color; and may appear scab like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound . Stage I Pressure Injury: Non-blanchable erythema of intact skin, Stage 2 Pressure injury: Partial-thickness skin loss with exposed dermis. Stage 3 Pressure injury: Full thickness skin loss. Stage 4 Pressure injury: Full thickness skin and tissue loss, Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss, Deep Tissue Injury (DTI): Persistent non-blanchable deep red, maroon or purple discoloration. Resident #28: Observation on 09/12/22 at 10:01 AM of Resident #28 in resident room revealed green and black heel/feet poofo boots noted in wheelchair at bedside, not on while in bed, will check care plan . Air mattress noted to bed, resident is laying on her back in bed. In an interview on 09/14/22 at 01:25 PM with Licensed Practical Nurse (LPN) R revealed that the bunny boots (green/black booties) were to be on when in bed. In an interview and record review on 09/14/22 at 02:07 PM with Registered Nurse (RN) Q of Resident #28's electronic medical record revealed on 8/12/2022 note of skin assessment, with dark heel with scab, a scab is open wound. Bunny boots should have been on at all times because of heel wound. There were no photos of the wounds until 8/31/2022 that she (RN Q) did for the Director of Nursing. Registered Nurse Q stated that she was not wound certified, and that the facility had a wound care nurse that had left in June 2022, and the photos stopped at that time until I took them at the end of August. Record review on 09/14/22 at 03:16 PM of Resident #28's care plans of skin care plan had no mention of bunny boots to be worn. In an interview and record review on 09/15/22 at 08:57 AM with the Director of Nursing (DON) about Resident #28's electronic medical records skin assessments for heels, scabbed area would be staged at DTI, or unstageable, Bunny boots may have come back from the hospital, and we did not put an order in for them. Not on care plans, heels would need to be bridged or off the mattress. The DON was asked for the last education on skin/pressure ulcers- we do one if there was something going on. Usually at annual last April or May 2021. Wound care nurse left in June 2022, no photos of [NAME] wounds, admitted [DATE], no photos until 8/31/22, taken by Registered Nurse Q not a wound nurse. Management has been working the floor since May 2022 up until 2 weeks ago, agency had no one to send us. Wound care program does need fixed, we are aware. In an interview and record reviews on 09/15/22 at 12:26 PM with Licensed Practical Nurse (LPN/MDS) T, of Resident #28's care plans for left heel wound and interventions may have been missed. Bunny boots/heel protectors if ordered should be on the care plan and when to wear them. The heels should at least be bridged with pillows to elevate the heels. in an interview and record review on 09/19/22 at 09:00 AM with the Director of Nursing (DON) on Resident #28's Skin assessment on 8/12/2022 record reviewed, left heel with dark area and scab in place, this would be a Deep Tissue Injury. Record review of the care plan revealed that there were no interventions added for heels until 8/31/2022 when she came back from the hospital. Record review of the August Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed a skin prep treatment but was not added to the care plans. On 8/31/2022 off-loading the heels was added to care plans. Skin assessments are done on shower days of the resident. Record review on 09/19/22 at 09:49 AM of Resident #28's hospital Discharge summary dated [DATE] revealed coccyx stage III, Left heel stage III and right heel unstageable all on admission to hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide catheter care according to professional standards of care for 2 residents (Resident #28, Resident #31) of 2 residents reviewed for catheter care, resulting in Resident #28's catheter bag, tubing and urometer being found on the floor, and Resident #31 not having a catheter leg strap in place with likelihood for increased potential of infections, and prolonged illness. Findings include: Record review of the facility 'Catheter Care, Urinary' policy dated 2/2022, revealed that the purpose of the policy was to prevent catheter associated urinary tract infections. Infection control: (1.b.) Be sure the catheter tubing and drainage bag are kept off the floor. (2.) 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.) Resident #28: Observation on 09/12/22 at 09:58 AM of Resident #28 was lying in bed with a urinary Catheter hanging at bedside, bed in low position, with bag on the floor, tubing and spout on floor, urine barometer also laying on the floor, no privacy bag in place able to visualize from doorway. Resident asleep. Bed in low position with catheter bag squished between bed and floor. Observation on 09/12/22 at 10:03 AM the urinary Catheter bag and tubing on the floor, with no privacy bag noted. On 09/13/22 at 8:43 AM the surveyor was notified that resident passed away last night. In an interview on 09/15/22 at 08:47 AM with the Director of Nursing was notified of urinary catheters without privacy bags, leg straps, catheter bags and tubing being on the floor. The DON stated that the catheters should not be on the floor because it's an infection control issues due to germs, and urinary tract infections. The DON stated that the last staff education on catheter care is annually April or May 2021. Interview and record review on 09/19/22 at 10:05 AM with the Director of Nursing of Resident #28's record review of the hospital Discharge summary dated [DATE] revealed Urinary Tract Infection (UTI) with Klebsiellas due to indwelling catheter. Resident #31: Observation on 09/12/22 at 09:44 AM of Resident #31 was awake and lying-in bed, observed a Catheter bag hanging at bedside with no privacy bag or cover noted, orange urine noted. Resident #31 pulled back covers to show that there was no leg strap in place when asked. Observation on 09/14/22 at 11:45 AM with hospice Certified Nursing Assistants (CNA's) revealed that they do the bed baths two times a week. Observed brief change and catheter without a catheter strap secure device. Catheter hanging out of brief on the left side and down the side of the bed. Catheter bag without privacy cover. Observation on 09/15/22 at 08:34 AM of Resident #31's left thigh revealed that a catheter strap was placed, [NAME] stated that the nurses came in here yesterday evening and put that on. No, I didn't have one before, it's kind of nice. It stays still. In an interview and record review on 09/15/22 at 12:58 PM with Licensed practical Nurse (LPN/MDS) T revealed that she corrected the Foley catheter care plan to add leg strap.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure post dialysis assessments were completed for one resident (Resident #40) upon their return from dialysis, resulting in, the facility being unaware of pertinent resident assessment information and the potential for being unprepared for a decline in residents' conditions, due to adverse effects of dialysis. Findings Include: Resident #40: During initial tour on 9/12/22, Resident #40 was observed after returning from dialysis. Resident #40 was queried if facility staffed completed vitals on him prior to dialysis and upon his return. He reported they complete vitals before he leaves and multiple times during dialysis. He was not able to recall if vitals were completed and his port assessed upon his return to the facility. On 9/15/ 22 at approximately 8:15 AM, a review was completed of Resident #40's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included, End Stage Renal Disease, Anemia, Respiratory Failure and Diabetes. Resident #40 is cognitively intact but does require some staff assistance with his ADL (Activities of Daily Living)'s. Further review of his records indicated the following: Care Plan: Focus: (Resident #40) needs hemodialysis three times a weekly at (dialysis facility), chair time 9:30 AM, Mon, Wed, Fri r/t (related to) renal failure, ERSD (End Stage Renal Disease). Intervention/Tasks: .Vital signs per policy and as needed . Monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock . Physician Orders: - Observe dialysis site to R chest for thrombosis, bleeding, stenosis, SEAL syndrome or aneurysm. every shift. It can be noted this order was not specific to when the resident returned from dialysis on his specified days. Dialysis Communication: Review was completed of Resident #40's Dialysis Communication sheets for pre-dialysis assessments and subsequent progress note documentation for post dialysis assessments. It was found there were four post dialysis assessments that were not completed for the resident. 9/2/2022: Post dialysis assessment was not completed upon the resident's return. There was the following progress note at 15:18, Resident returned from dialysis. No post dialysis weight or vitals written on paper from dialysis center . 9/5/2022: Post dialysis assessment was not completed upon the resident's return nor was there a progress note. 9/7/2022: Post dialysis assessment was not completed upon the resident's return. There was the following progress note at 14:34 stated, Resident LOA for dialysis. Dialysis communication form completed and sent with resident. Resident left facility at 07:45 via facility transport. Resident returned to facility vial (via) facility transport at 14:00, dialysis communication form not completed by dialysis. Resident assisted to room and eating lunch. 9/9/2022: Post dialysis assessment was not completed upon the resident's return. There was the following progress note at 15:13 stated, Resident returned from dialysis. Post dialysis weight and vitals not completed on from. Resident resting in bed with call light in reach. On 9/15/22 at 11:40 AM, an interview was conducted with Unit Manager K regarding the facility's expectations for dialysis communication forms and pre/post dialysis assessments. Manager K reported they expect staff to complete pre and post vitals and pre/post assessment of the resident's dialysis site. Manager K stated there is not a spot on their communication form for post assessment, but staff should be documenting their complete post dialysis assessment in the progress notes. Manager K explained there is an order for Resident #40 regarding assessment of this site. This writer and Manager K reviewed the order saw it was ordered as daily and was not specific to his dialysis days. Its unclear if this assessments are being completed prior to him leaving or upon his return from dialysis. Manager K was also informed there were missing post assessments for the resident. On 9/19/22 at 9:25 AM, an interview was conducted with the DON (Director of Nursing) regarding expectation for pre/post- dialysis assessments. The DON reported prior the resident leaving for dialysis vitals and assessment of their access site should be completed and documented on the dialysis communication form. Upon their return, they should complete vitals and assess the access site again and complete a progress note detailing their assessment. The DON was informed this process was not consistently completed for Resident #40 and the DON expressed understanding of the concern. On 9/14/22 at 11:00 AM, a review was completed of the facility policy entitled, Hemodialysis Access Care,revised 2/200. The policy stated, The general medical nurse should document in the resident's medical record every shift as follows: 1. Location of catheter; 2. Condition of dressing (interventions if needed); 3. If dialysis was done during shift. 4. Any part of report from dialysis nurse post-dialysis given. 5. Observations post-dialysis .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #18: On 9/13/22 at approximately 8:45 AM, Resident #18 was observed in his room, laying in bed. He did not appear to be in any distress. On 9/13/22 at approximately 10:30 AM, a review was completed of Resident #18's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Dementia, Atrial Fibrillation, Hyperlipidemia, Anxiety Disorder and Major Depressive Disorder. His cognition is impaired and required assistance with his ADL's. Further review of Resident #18's medical record yielded the following: Physician Orders: - Cleanse open area on right gluteal fold with normal saline, cover with foam. Change every three days and PRN (as needed). Every day shift every 3 days for wound care treat until resolved. Start date 8/26/22- End date: 9/1/2022 - Cleanse Open area on right gluteal fold with normal saline, cover with foam. Change every three days and if soiled or missing. Every day shift every 3 days for wound care treat until resolved. Start date 9/2/2022 Care Plan: There was nothing mentioned in his care plan regarding the wound to his gluteal fold. Physician Notes: There were no physician notes located regarding Resident #18's facility acquired pressure ulcer and it is unclear if the physician was aware of it. On 9/14/22 at 2:30 AM, an interview was conducted with Nurse Q regarding her assessment of Resident #18's wound on 8/31/22. Nurse Q reported the DON alerted her to the residents wound and requested she assess the area and take pictures. Nurse Q reported she is not wound certified and was not comfortable with staging the wound, indicating if it was community or facility acquired and dating the wound and informed the DON of this before assessing the wound. Nurse Q stated they had a wound nurse, but she resigned in June 2022 and on 8/31/22 she completed wound assessments for 5 or 6 residents. Nurse Q reported she was unaware if Resident #18's wound was evaluated by the physician or Nurse Practitioner. Nurse Q reported on 8/31/22 she completed wound assessments on 5-6 residents. On 9/15/22 at 11:30 AM, an interview was conducted with Unit Manager K regarding Resident #18's coccyx wound. Manager K stated their wound nurse left in June and now the nurses are responsible for their own assessments and treatments. If a new skin impairment is found there is a form they complete and provide it to the DON. Manager K stated she is not wound certified and does not stage wounds. She continued while she does not stage wounds based on the information in his chart his wound be considered facility acquired as he has not left the facility. Manager K added when the wound was identified on 8/24/22 a treatment should have been put in place that day. Manager K was asked the last time he was assessed by the physician for his wound. It was reported he was last seen on 8/17/22 and his wound was not opened yet and Physician O rounded today on Resident #18, but his wound was not assessed. Based on observation, interview and record review, the facility failed to have physicians' assessments of Pressure Ulcers per facility policy for 2 residents (Resident #18, Resident #28), resulting in the lack of documentation of physicians' assessments of pressure ulcers. Findings include: Resident #28: Observation on 09/12/22 at 10:01 AM of Resident #28 in resident room revealed green and black heel/feet proofo boots noted in wheelchair at bedside, not on while in bed, will check care plan . Air mattress noted to bed, resident is laying on her back in bed. In an interview on 09/14/22 at 01:25 PM with Licensed Practical Nurse (LPN) R revealed that the bunny boots (green/black booties) were to be on when in bed. In an interview and record review on 09/14/22 at 02:07 PM with Registered Nurse (RN) Q of Resident #28's electronic medical record revealed on 8/12/2022 note of skin assessment, with dark heel with scab, a scab is open wound. Bunny boots should have been on at all times because of heel wound. There were no photos of the wounds until 8/31/2022 that she (RN Q) did for the Director of Nursing. Registered Nurse Q stated that she was not wound certified, and that the facility had a wound care nurse that had left in June 2022, and the photos stopped at that time until I took them at the end of August. Record review on 09/14/22 at 03:16 PM of Resident #28's care plans of skin care plan had no mention of bunny boots to be worn. In an interview and record review on 09/15/22 at 08:57 AM with the Director of Nursing (DON) about Resident #28's electronic medical records skin assessments for heels, scabbed area would be staged at DTI, or unstageable, Bunny boots may have come back from the hospital, and we did not put an order in for them. Not on care plans, heels would need to be bridged or off the mattress. The DON was asked for the last education on skin/pressure ulcers- we do one if there was something going on. Usually at annual last April or May 2021. Wound care nurse left in June 2022, no photos of [NAME] wounds, admitted [DATE], no photos until 8/31/22, taken by Registered Nurse Q not a wound nurse. Management has been working the floor since May 2022 up until 2 weeks ago, agency had no one to send us. Wound care program does need fixed, we are aware. In an interview and record reviews on 09/15/22 at 12:26 PM with Licensed Practical Nurse (LPN/MDS) T, of Resident #28's care plans for left heel wound and interventions may have been missed. Bunny boots/heel protectors if ordered should be on the care plan and when to wear them. The heels should at least be bridged with pillows to elevate the heels. in an interview and record review on 09/19/22 at 09:00 AM with the Director of Nursing (DON) on Resident #28's Skin assessment on 8/12/2022 record reviewed, left heel with dark area and scab in place, this would be a Deep Tissue Injury. Record review of the care plan revealed that there were no interventions added for heels until 8/31/2022 when she came back from the hospital. Record review of the August Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed a skin prep treatment but was not added to the care plans. On 8/31/2022 off-loading the heels was added to care plans. Skin assessments are done on shower days of the resident. Record review of Resident #28's physician progress notes revealed that there were no assessments or notes related to pressure wounds. Record review on 09/19/22 at 09:49 AM of Resident #28's hospital Discharge summary dated [DATE] revealed coccyx stage III, Left heel stage III and right heel unstageable all on admission to hospital. Record review of the facility 'Pressure Ulcers/Skin Breakdown-Clinical Protocol' policy dated 2/2022, revealed that the physician/wound nurse will assist the staff to determine etiology (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc ) of the skin alteration. Monitoring: (1.) During resident visits the physician will evaluate and document the progress of wound healing.

Based on interview and record review, the facility failed to ensure appropriate antibiotic use for one resident (Resident #33) of 3 residents reviewed for unnecessary medications, resulting in Resident #33 receiving Keflex antibiotic for urinary tract infection without a culture and sensitivity for organisms, with the potential for decline in physical health status and prolonged illness. Findings include: Record review of facility 'Antibiotic Stewardship' policy dated 1/2022, revealed that antibiotic will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. (4.) If an antibiotic is indicated, prescriber will provide complete antibiotic orders . (10.) When a culture and sensitivity (C&S) is ordered lab results and current clinical situation will communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued Resident #33: Record review of Resident #33's Medication Administration Record (MAR) for August 2022, revealed that on 8/9/2022 the resident was started on Keflex 500 mg twice daily for urinary tract infection. Record review of Resident #33's electronic medical record revealed that there was no culture and sensitivity of urine for organism of infection found. In an interview on 09/19/22 at 12:00 PM with Licensed Practical Nurse A Infection Control nurse revealed that Resident #33 was put on Keflex (antibiotic) 500 mg BID (twice daily) for Urinary Tract Infection (UTI), there was no supporting documentation of culture and sensitivity for the abnormal Urine Analysis. Resident #33 was on antibiotics for 7 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to timely obtain a dental referral for Resident #35. Resulting in Resident #35 suffering from severe pain, issues with eating and potential for infection and/or abscess given the extensive tooth decay and restoration required. Findings Include: On 9/12/22 at 10:00 AM, Resident #35 was observed in his room resting. When queried about his time at the facility he expressed he has been dealing with a painful toothache for about a month. He expressed he informed staff of the dental issues and the contracted dentist at the facility assessed him some days later and informed him he needed an outside referral to an agency. He reported since then the facility has not scheduled him a dental appointment to assess his dental concerns and added it is painful to chew on the right side of his mouth. He expressed the [NAME] Clerk stated she had to call back to an office on the 27th but he does not understand why he has to wait such an extended about of time for an appointment when his pain is intensifying. Resident #35 went to the emergency room last night due to the pain. On 9/13/22 at approximately 10:15 AM, a review was completed of Resident #35's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Multiple Sclerosis, Transverse Myelitis, Diabetes, Anxiety and Major Depressive Disorder. Resident #35 is cognitively intact and required 1 person assist for some ADL (Activities of Daily Living)'s. Further review of Resident #35's records revealed the following: Progress Notes: 9/11/2022 at 02:25: Resident has severe toothache in upper right jaw and requests to be taken to Covenant ER. (Physician) made aware of resident's request. Report given to nurse .Emergency Medical Response here to take resident to ER. 8/19/2022 at 14:14: Resident seen by .dental group. Recommendation to schedule for fillings and evaluation of # 3,4,5,6,7,8,9,10,11,12 with general dentist. Dental Group Notes: 8/17/22: Schedule pt (patient) an outside General Dentist office for several fillings and evaluation specifically #3, 4, 5,6,7,8,9,10,11,12, will need extensive restorations. Pt needs sedation for Anxiety for filling appointment .Will need extensive restorations for teeth due to much decay . There was no other documentation found regarding the facility's efforts to refer the resident to a dental office. On 9/13/22 at 8:30 AM, Resident #35 reported his toothache is worse at night and the pain waked him up. He reported he has not been provided on an update regarding the dental work he needs completed. On 9/14/22 at 10:20 AM, an interview was conducted with [NAME] Clerk V regarding Resident #35's dental referral. Clerk V started she has been trying to make an appointment for Resident #35 since the end of August 2022 with one dental office but has been unsuccessful. Clerk V explained this dental office has one day, for one hour when you can make appointments for new patients and the next day to call is on 9/22/22. Clerk V stated she tried to call on a different scheduled day for the office and was unable to get through to make an appointment for Resident #35. Clerk V was queried if any other dental offices were contacted while waiting for 9/22/22 and Clerk V stated she had not contacted any other dental offices. Clerk V had no explanation as to why other alternative dental offices were not contacted when there is great probability an appointment will not be secured on 9/22/22. On 9/15/22 at 11:30 AM, Unit Manager K was informed of the delay regarding Resident #35's dental referral and his complaints of pain. Manager K expressed understanding regarding this writer's concern and stated other options should have been explored. According to the SOM (State Operations Manual), .To ensure that residents obtain needed dental services, including routine dental services; to ensure the facility provides the assistance needed or requested to obtain these services; to ensure the resident is not inappropriately charged for these services; and if a referral does not occur within three business days, documentation of the facility's to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Record review of the facility 'Catheter Care, Urinary' policy dated 2/2022, revealed that the purpose of the policy was to prevent catheter associated urinary tract infections. Infection control: (1.b.) Be sure the catheter tubing and drainage bag are kept off the floor. (2.) 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.) Resident #28: Observation on 09/12/22 at 09:58 AM of Resident #28 was lying in bed with a urinary Catheter hanging at bedside, bed in low position, with bag on the floor, tubing and spout on floor, urine barometer also laying on the floor, no privacy bag in place able to visualize from doorway. Resident asleep. Bed in low position with catheter bag squished between bed and floor. Observation on 09/12/22 at 10:03 AM the urinary Catheter bag and tubing on the floor, with no privacy bag noted. On 09/13/22 at 8:43 AM the surveyor was notified that resident passed away last night. In an interview on 09/15/22 at 08:47 AM with the Director of Nursing was notified of urinary catheters without privacy bags, leg straps, catheter bags and tubing being on the floor. The DON stated that the catheters should not be on the floor because it's an infection control issues due to germs, and urinary tract infections. The DON stated that the last staff education on catheter care is annually April or May 2021. Interview and record review on 09/19/22 at 10:05 AM with the Director of Nursing of Resident #28's record review of the hospital Discharge summary dated [DATE] revealed Urinary Tract Infection (UTI) with Klebsiellas due to indwelling catheter. Based on observation, interview and record review, the facility failed to 1) ensure that hair nets were properly worn in the kitchen, 20 ensure that direct caregivers had appropriate nail length, 3) ensure the Infection Control program analysis resident and staff illnesses, 4) ensure Infection Control department walk-through's were done and 5) ensure proper care of indwelling catheters, resulting in the likelihood for cross contamination regarding catheters and staff to residents illness, high infection rates and skin tears from excessive nail length. Findings Include: Facility Infection Control Program: Review of facility monthly Infection Control data revealed for July 2022, the total infection rate was 32.4%. No documentation of any analysis regarding resident or staff illnesses/infections data was done for the Months of July and August of 2022. The facility Infection Control program had no documentation of complete analysis for resident nor employee infections, antibiotic usage, or of the possibility for cross contamination of resident infections, nor any plan for staff education was documented regarding the infection rate (Urinary Tract Infections and Respiratory Infections). During an interview done on 9/14/22 at 2:24 p.m., Infection Control Nurse, LPN A stated I didn't have time. Infection Control Nurse A said she had worked the floor for several months and did not have time to do Infection Control duties (analysis infections, do walk-through's in all departments and Infection Control staff education). During an interview done on 9/19/22 at 10:50 a.m., Infection Control Nurse, A was asked by this surveyor why she had not done any walk-through's in all departments, and she stated, I didn't have time. Infection Control Nurse A said she had worked the floor for several months and did not have time to do Infection Control duties. Review of the facility Surveillance for Infections policy dated 2/22, stated Analyze the data to identify tends. Compare the rates to previous months in the current year and to the same month in previous years, to identify seasonal trends. Hair Net Usage and Long Nails: Observation was made on 9/14/22 at 8:50 a.m., by this surveyor and the Administrator of Nurse, RN Q feeding a resident in the main dining room with nails over 1 and 1/2 inches in length. During an interview done on 9/14/22 at 8:51 a.m., the Administrator stated We have told them no nails. Observation made on 9/12/22 at approximately 9:20 a.m., of Dietary Aide J having approximately 2 thirds of her hair out of her hair net and nails that were over 1 inch in length with acrylic nails on and several of them had gems glued on them. At this time Dietary Aide J was in the kitchen doing dishes. Observation made on 9/12/22 at approximately 9:20 a.m., Dietary Aide FF had approximately 1/2 of her hair out of her hair net. At this time Dietary Aide FF was in the kitchen cooking. Observation was made on 9/14/22 at 10:04 a.m., of Nursing Assistant/CNA W with acrylic nails that were approximately 1/1/2 inches in length. During an interview done on 9/14/22 at 10:04 a.m., Nursing Assistant/CNA W stated I know we can't have long nails, I am getting them cut down. Review of CNA W's facility education dated 3/8/21, stated It is the facility Infection Control policy that no employee shall have fingernails real or artificial over the length of ½ inch. On March 1st. a reminder of this policy was sent out to all staff through shifts as well as the notification this policy would be strictly enforced beginning March 8, 2021. During an interview done on 9/14/22 at 9:58 a.m., Nurse, RN G stated I did know, we know the inches of what our nails should be, no nail polish, no fake nails and short as possible. During an interview done on 9/12/22 at 11:35 a.m., Infection Control Nurse, A stated They (staff fingernail length) can be 5/8's of an inch long. They can have acrylics and gems at this point; that doesn't mean I agree with it. I think it's disgusting. Review of the facility Nails policy (un-dated) revealed staff (direct care givers) were to have short non-acrylic nails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update care plans in a timely manner for three residents (Resident #12, Resident #28, Resident #31) of 16 residents reviewed, (1.) Resident #12 activity care plan, (2.) Resident #28's Skin/pressure ulcer care plan with (3.) Resident #31's catheter care plan to not have catheter strap intervention, resulting in the likelihood for missed activities or likes, missed heel pressure injuries interventions, and increased catheter discomfort or pain, and review and revise care plans with resident changes, to ensure interventions necessary for care and services were provided. Findings include: Record review of the facility 'Care Plans, Comprehensive Person-Centered' policy dated 2/2022, revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. The interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . (14.) The Interdisciplinary Team (IDT) must review and update the care plans: (a.) When there has been a significant change in the resident's condition; (b.) When the desired outcome is not met; (c.) When the resident has been readmitted to the facility from a hospital stay; and (d.) At least quarterly, in conjunction with the required MDS assessment. Record review of facility provided 'Comprehensive Care Plans-Education Key Points (undated), (2.) Updating Care Plans- Care plans must be updated when there are changes regarding the resident, including but not limited to; changes in residents mental/physical status, New or discontinued physician orders, etc Resident #28: Observation on 09/12/22 at 10:01 AM of Resident #28 in resident room revealed green and black heel/feet poofo boots noted in wheelchair at bedside, not on while in bed, will check care plan. In an interview on 09/14/22 at 01:25 PM with Licensed Practical Nurse (LPN) R revealed that the bunny boots (green/black booties) were to be on when in bed. In an interview and record review on 09/14/22 at 02:07 PM with Registered Nurse (RN) Q of Resident #28's electronic medical record revealed on 8/12/2022 note of skin assessment, with dark heel with scab, a scab is open wound. Bunny boots should have been on at all times because of heel wound. There were no photos of the wounds until 8/31/2022 that she (RN Q) did for the Director of Nursing. Registered Nurse Q stated that she was not wound certified, and that the facility had a wound care nurse that had left in June 2022, and the photos stopped at that time until I took them at the end of August. Record review on 09/14/22 at 03:16 PM of Resident #28's care plans of skin care plan had no mention of bunny boots to be worn. In an interview and record reviews on 09/15/22 at 12:26 PM with Licensed Practical Nurse (LPN/MDS) T, of Resident #28's care plans for left heel wound and interventions may have been missed. Bunny boots/heel protectors if ordered should be on the care plan and when to wear them. The heels should at least be bridged with pillows to elevate the heels. in an interview and record review on 09/19/22 at 09:00 AM with the Director of Nursing (DON) on Resident #28's Skin assessment on 8/12/2022 record reviewed, left heel with dark area and scab in place, this would be a Deep Tissue Injury. Record review of the care plan revealed that there were no interventions added for heels until 8/31/2022 when she came back from the hospital. Record review of the August Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed a skin prep treatment but was not added to the care plans. On 8/31/2022 off-loading the heels was added to care plans. Skin assessments are done on shower days of the resident. Record review on 09/19/22 at 09:49 AM of Resident #28's hospital Discharge summary dated [DATE] revealed coccyx stage III, Left heel stage III and right heel unstageable all on admission to hospital. Resident #31: Observation on 09/12/22 at 09:44 AM with Resident #31 was lying in bed with a Catheter bag hanging at bedside with no privacy bag or cover noted, orange urine noted, resident was able to pull the blankets back to expose no catheter strap in place to hold catheter tubing. Record review of Resident #31's care plans pages 1- 29, revealed that there are no interventions to apply or not apply a catheter strap Care Plan Record review and interview on 09/15/22 at 12:20 PM with Licensed Practical Nurse [NAME] (LPN/MDS) T revealed that she went and corrected the catheter care plan to include a catheter strap and that it should be changed weekly or if it becomes loose or soiled. Gave surveyor the revised copy. Resident #12: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 9/15/22, Nursing and Physician progress notes dated 921 to 9/15/22, and care plan s dated 9/21, revealed Resident #12 was 80 years-old, was alert, dependent on staff for all Activities of Daily Living (ADL), and interviewable and admitted to the facility on [DATE]. The resident's diagnoses included, physical and mobility disability, heart failure, kidney disease, muscle weakness, abnormalities of gait and mobility, lack of coordination, anxiety, and major depression. The resident was bed bound when not in wheelchair and required staff assistance for toileting. Review of Resident #12's facility Activity Care Plan initiated on 9/23/20, revealed as interventions he enjoys TV, Church and needs assistance to activities; interventions were not tailored toward staff interventions. The last care plan revision was done on 5/6/22 with a target date of 7/8/22. No documentation was found regarding up-dated measurable goals, timetables or if the target date interventions were met or not any later then 5/6/22. The resident's care plan did not reflect any up-dated changes in the resident, nor his care. During an interview done on 9/15/22 at 10:10 a.m., former Activity Director/Nursing Assistant S said he thought Resident #12's Activity care plan was adequate. Activity Director S stated, I would put direction behind each intervention. I would much rather have my staff doing activities; I would rather host an activity then sit and document; yes, the care plan is minimal. Activity Director S said he did not up-date the residents Activity care plan because he would rather do activities with residents, not document, or do care plans. During an interview done on 9/15/22 at 12:18 p.m., MDS Nurse, LPN T stated It's (Resident #12's facility Activity care plan) pretty generic. I do think it should be Activities who up-date the Activity care plans. I have told the Activity Director before, and I mentioned it in morning meeting about up-dating them. Review of the facility Care Plans, Comprehensive Person-Centered policy dated 2/21, stated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to provide sufficient staffing for 48 residents in the facility, resulting in, residents during initial tour and resident council expressing concerns over staffing on nights/weekends, extended response to call lights and feelings of frustration; in addition to nursing management rotating working the floor almost daily due to staffing shortages. Findings Include: During initial tour on 9/12/22 and 9/13/22, multiple residents expressed concern regarding staffing on nights and weekends. The reported they feel there are not enough staff to meet their needs and they are waiting for over 30 minutes for call lights to be answered. They reported staff are doing the best they can with their current staffing levels, but the residents are suffering. During Resident Council on 9/14/22 at 11:00 AM, the residents reported there has been a lot of turn over with CNA (Certified Nursing Assistant)'s and they are short staffed, but the weekends are the worst. The residents stated the last couple of nights they have been receiving their medications at 10/10:30 PM which is very late for them. They reported there have been times they were left on the toilet for 45 minutes or more as no one came back when they had finished using the restroom. The residents reported the constant low staffing is affecting the quality of care they are being provided. On 9/14/2022 at approximately 9:00 AM, the Administrator reported her nursing management has been working the floor since the beginning of the year due to staffing shortages. The Administrator reported it was more important to ensure their residents were taken care of versus other administrative tasks. On 9/15/22 at 11:05 AM, an interview was conducted with Unit Manager K regarding facility staffing. Manager K stated the facility is actively hiring but they have struggled to hire as they are not receiving that many applicants. During the summer management worked the floor during night shift 2-3 days a week to ensure coverage. Manager K staffing issues have been ongoing since January but worsened in the summer. She continued the DON (Director of Nursing), Infection Control Nurse and herself rotated working the night shift and they were each working 2-3 nights a week which left maybe one day for them to fulfill their current job duties. Manager K reported there were some weeks where they did not fulfill any of their job duties as they were working night shift. Manager K reported for the last three weeks they have been working there in their hired positions but have still not caught up with all their job responsibilities. On 9/15/22 at approximately 12:15 PM, a review was completed of the facility's Daily Schedule for the majority of July 2022 and August 2022. It was found there were a multitude of times nursing management worked the floor to ensure patient care, but with their efforts they were not able to fulfill their job duties which led to deficiencies in other areas. July 2022: Nursing Management (to include MDS Nurse T) worked the floor 22 times with most of the shifts being on nights. On 7/3/22, 7/4/22 and 7/11/22 two management staff worked the same shift to account for their staff shortages. August 2022: The staffing schedule was reviewed from August 1, 2022, to August 18, 2022, and nursing management worked the floor 11 times. On two occasions there were two management staff working the floor at the same time. On 9/19/22 at 9:25 AM, an interview was conducted with the DON regarding facility staffing. The DON reported nursing management has been working in their designated positions for the last four weeks. The DON explained from May 2022 to last month, they (DON, Unit Manager K and Infection Control A) have rotated working the floor 2-3 times a week on night shift. She stated there were time when it was two management staff working at the same shift and one of them were there almost every night working the floor. The DON reported they attempted to utilize agency staff but were unsuccessful as they wanted long term contracts or agency staff were scheduled and did not show up. The DON stated they were actively hiring, setting up interviews and completing orientation but some would not show up for orientation, resign after working one shift or simply not answer when Human Resources would call to provide an offer. The DON reported the Administrator became jack of all trades as nursing management were maybe working in their roles twice a week or less depending on their staffing needs. On 9/19/22 at approximately 12:10 PM, an interview was conducted with the Administrator regarding staffing. The Administrator reported staffing has been a PIP (Performance Improvement Plan) for 2.5 years and over the summer nursing management were consistently working the floor to account for their shortages. The Administrator reported they are actively hiring and offering sign on bonuses but cannot get any night nurses. She stated their nursing management staff worked in their designated positions one to two times a week as they were working the floor two to three nights of the week. She further reported they were trying to stay afloat and nursing management day to day duties were not getting fulfilled as they prioritized patient care. On 9/20/22 at 10:00 AM, a review was completed of the facility policy entitled, Staffing, reviewed 4/2022. The policy stated, Our facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5% when five residents (#6 unsampled, #7, #17, #18, #292) on the 400-hallway received late medications received a total of 46 late medications. This deficient practice resulted the potential for risk of adverse medication effects and decreased medications efficiency. Findings include: Record review of the facility 'Administrating Medications' policy dated 1/2021, revealed medications shall be administered in a safe and timely manner, and as prescribed. (2.) The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. (3.) Medications must be administered in accordance with the orders, including any required time frame. (4.) Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. Medication Administration Task: Observation on 09/13/22 at 08:32 AM with licensed Practical nurse (LPN) BB on 400/100 halls has been here 2 months. Before med pass began, LPN BB was called to room [ROOM NUMBER] for a fall. Observed Resident #142 on floor in room with wheelchair behind her. Unit manager K was in the room. The surveyor left LPN BB to continue medication pass with another nurse. Observation on 09/13/22 at 08:37 AM with Registered Nurse (RN) Q on the 200/300 halls. RN Q stated that she was covering 2 halls today, yes, we seem to be short staffed on both nurses and CNA's. Observation on 09/13/22 at 08:51 AM during the medication pass task revealed that Registered Nurse Q was called to room [ROOM NUMBER], for resident vomiting. RN Q asked resident did go to dialysis yesterday, nausea started during the evening, and has continued. Night shift nurse gave Zofran this morning. Observation on 09/13/22 at 09:22 AM with licensed Practical nurse (LPN) BB observed prepping one medication in hallway for Resident #146. LPN BB walked to residents' room and administered. Resident #146 was upset, she is not comfortable, wants a shower and her polar ice chest is not working, touch of the water flow pad was not cold. LPN BB left the room without hand washing and went back to the medication cart. Observation on 09/13/22 at 10:03 AM with licensed Practical nurse (LPN) BB prepped medication pass for Resident #143, nurse BB went to the resident's room and resident is at therapy. LPN BB waiting for resident return. LPN BB Called therapy department will be another 10 minutes before returns. LPN BB went to therapy department and administered medications. In an interview on 09/13/22 at 10:13 AM with licensed Practical nurse (LPN) BB was asked how many more residents that he need to pass meds on? LPN BB stated that he had two more residents on 100 hallway to pass morning medications on, and all 14 residents on 400 hallway yet. Licensed Practical nurse (LPN) BB also stated that there was an admission coming at noon. Observation and interview on 09/13/22 at 10:30 AM with Resident #7 on the 400 hallway was seated up in wheelchair in resident room. Resident #7 asked about her medications, the surveyor explained they were not a facility employee, and the Resident #7 stated that she did not yet get her morning medications, and stated the medications are running late today. In an interview on 09/13/22 at 10:35 AM unsampled Resident in room [ROOM NUMBER] revealed that she did not yet get her medication today. Observation and interview on 09/13/22 at 10:37 AM with Resident #17 in resident room. Resident was seated up in wheelchair in room, resident #17 was inquiring about nursing and getting medications. Surveyor inquired if medications were given? Resident #17 stated she did not have any meds yet this morning. Resident #17 usually medications are given before now. Its 10:38 AM, and she did get her two (2) pills from the night shift nurse and nothing since, that was around 6 AM. They run short staffed; it takes them a while to get here. 09/13/22 10:41 AM No nurse noted on the hallway during interviews. 14 of 14 residents on the 400 hallway have not received the morning 7 AM to 10 AM, medication pass. Observation on 09/14/22 at 07:38 AM with licensed Practical nurse (LPN) R with surveyor of Medication room review, and Medication room refrigerator. Observation and interview on 09/14/22 at 07:48 AM with licensed Practical nurse (LPN) R of unsampled resident in room [ROOM NUMBER] of antibiotic intravenous (IV) to Left upper arm Peripheral Inserted Central Catheter (PICC) line with dressing dated 9/14/2022. The resident stated she was up late, they (staff) changed the dressing after mid night last night. Observation on 09/14/22 at 07:56 AM the surveyor walked into resident room to find licensed Practical nurse (LPN) BB, performing wound vac dressing change on Resident #292, wound vacuum sponges placed over stapes to midline back, bottom lower third of incision area with infection, area was cleansed and covered with black line of sponge and clear optic dressing applied. Observation and interview on 09/14/22 at 08:26 AM with licensed Practical nurse (LPN) BB, of 400 hallway medication cart revealed Basaglar insulin pen for Resident #38 was opened and used, but not dated. Review of the medication drawers with loose tablet of Zofran 4 mg loose table found in cart. Licensed Practical nurse (LPN) BB stated that yesterday was a long day, LPN BB revealed did continue with the medication pass on 100 hall and then went to do the 400-hallway medication pass. Observation on 09/14/22 at 08:34 AM with licensed Practical nurse (LPN) R, of the 200-hallway medication cart reviewed. in an interview on 09/14/22 at 09:26 AM with licensed Practical nurse (LPN) BB revealed that Yesterday (9/13/2022) LPN BB finished up medication pass at 11:00 AM to 11:30 AM, stating It's a lot of residents to cover. In an interview on 09/14/22 at 01:00 PM with the Director of Nursing RN/DON was asked if licensed Practical nurse (LPN) BB was running late yesterday 9/13/2022 were you aware? The DON stated that she was not aware that LPN BB medication pass were running so late. We are trying to print the Medication Administration Records (MAR) you requested with the administration times printed. IN an interview on 09/14/22 at 01:09 PM with the Registered Nurse (RN) K, Unit manager- was asked if she knew medication pass was running late yesterday 9/13/2022 for licensed Practical nurse (LPN) BB? RN K stated that No, LPN BB did not say anything or tell her about his medication pass. RN K was not aware the morning medication pass was still going at 11:30 AM. LPN BB had an admission come in at noon to room [ROOM NUMBER] also. All the meds on the 400 hallway were late. Record review of facility provided 'Medication Admin Audit Report' dated on 9/14/2022 for the medication administrated on 9/13/2022 for five Resident's: #6 (unsampled), #7, #17, #18, #292. Resident #6 (unsampled): Escitalopram Oxalate (anti-depressant) 10 mg oral scheduled 9:00 AM, administered at 12:47 PM. Lasix (diuretic) 20 mg oral scheduled at 9:00 AM, administered at 12:47 PM. Amlodipine HCI (calcium channel blocker/antihypertensive/angina) 5 mg oral scheduled at 9:00 AM, administered at 12:47 PM. Amiodarone (antiarrhythmic) 200 mg oral scheduled at 9:00 AM, administered at 12:47 PM. Resident #7: Propranolol HCI (beta blocker/antihypertensive/angina) 20 mg oral scheduled at 9:00 AM, administered at 12:50 PM. levetiracetam (anti-seizure) 750 mg oral scheduled at 9:00 AM, administered at 12:49 PM. Apixaban (anticoagulant/cardiovascular) 5 mg oral scheduled at 9:00 AM, administered at 12:49 PM. Sertraline HCI (selective serotonin reuptake inhibitor SSRI/depression/anxiety) 100 mg oral scheduled 9:00 AM, administered at 12:50 PM. Resident #17: Wellbutrin XL (antidepressant) 150 mg oral scheduled 9:00 AM, administered at 11:58 AM. Aspirin (heart health) 81 mg oral scheduled 9:00 AM, administered at 11:59 AM. Lasix (diuretic) 40 mg oral scheduled at 9:00 AM, administered at 11:57 AM. Famotidine (antihistamine/antacid) 20 mg oral scheduled at 9:00 AM, administered at 11:59 AM. Potassium Chloride ER (mineral supplement) 20 meq oral scheduled at 9:00 AM, administered at 11:58 AM. lorazepam (benzodiazepine/anxiety) 1 mg oral scheduled at 9:00 AM, administered at 12:00 PM. Macrobid (antibiotic ) 100 mg twice daily oral scheduled at 9:00 AM, administered at 11:57 AM. Resident #18: Depakote (anticonvulsant) 250 mg twice daily oral scheduled at 8:00 AM, administered at 11:31 AM. Aspirin (antiplatelet therapy) 81 mg oral scheduled 8:00 AM, administered at 11:30 AM. Metoprolol (beta blocker/antihypertensive/angina) 50 mg oral scheduled at 9:00 AM, administered at 11:31 AM. Lasix (diuretic) 20 mg oral scheduled at 9:00 AM, administered at 11:31 AM. Klor-con (mineral supplement) 10 meq, 3 tablets Lasix (diuretic) 20 mg oral scheduled at 9:00 AM, administered at 11:31 AM. Prozac ((selective serotonin reuptake inhibitor SSRI/depression/anxiety) 40 mg oral scheduled at 9:00 AM, administered at 11:31 AM. Resident #292: Metoprolol (beta blocker/antihypertensive/angina) 25 mg oral scheduled at 8:00 AM, administered at 11:37 AM. Sertraline HCI (selective serotonin reuptake inhibitor SSRI/depression/anxiety) 25 mg oral scheduled at 9:00 AM, administered at 11:41 AM. Rybelsus (antidiabetic) 3 mg oral scheduled at 9:00 AM, administered at 11:41 AM. Lasix (diuretic) 40 mg oral scheduled at 9:00 AM, administered at 11:38 AM. Tamsulosin HCI (alpha blocker/urinary retention) 0.4 mg oral scheduled at 9:00 AM, administered at 11:41 AM. Magnesium oxide (supplement) 400 mg oral scheduled at 9:00 AM, administered at 11:41 AM. Bethanechol chloride (urinary retention) 25 mg oral scheduled at 9:00 AM, administered at 11:37 AM. Apixaban (anticoagulant/cardiovascular) 2.5 mg twice daily oral scheduled at 9:00 AM, administered at 11:37 AM. Aspirin (antiplatelet therapy) 81 mg oral scheduled 9:00 AM, administered at 11:42 AM. MS Contin (opioid/pain) 15 mg oral scheduled 9:00 AM, administered at 11:43 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interview and record review, the facility failed to ensure storage, labeling, dating, and disposal of medications per professional standards of practice in one of three carts reviewed, resulting in Resident #38 Basaglar insulin pen being opened and not dated, loose tablets of Zofran 4 mg loose table found in 400 hall medication cart and Resident #8 to have medications found at bedside. Findings include: Record review of facility 'Storage of Medications' policy dated 2/2022, revealed the facility shall store all drugs and biological's in a safe, secure, and orderly manner. (1.) Drugs and biological's shall be stored in the packaging, containers or other dispensing systems in which they are received . (2.) The nursing staff shall be responsible for maintain medication storage and preparation areas in a clean, safe, and sanitary manner . Medication Administration: Observation and interview on 09/14/22 at 08:26 AM with licensed Practical nurse (LPN) BB, of 400 hallway medication cart revealed Basaglar insulin pen for Resident #38 was opened and used, but not dated. Review of the medication drawers with loose tablet of Zofran 4 mg loose table found in cart. Licensed Practical nurse (LPN) BB stated that yesterday was a long day, LPN BB revealed did continue with the medication pass on 100 hall and then went to do the 400-hallway medication pass. Resident #8: Review of the Face Sheet, Minimum Data Set (MDS, dated 3/22), Physician orders dated 3/4/22 and care plans dated 3/22, revealed Resident #8 was 95 years-old, alert and admitted to the facility on [DATE]. The resident's diagnosis included, Acute abdomen, abnormal enzyme labs, Chronic Kidney Disease, Atrial Fibrillation, Heart Disease, history of MI, Dementia and Hypertension. The resident required assist with all Activities of Daily Living (ADLs'). During an interview done on 9/12/22 at 10:53 a.m., Resident #8 stated I do have eye drops in my drawer (she then showed this surveyor her eye drops from her bedside drawer), I put them in 6 times a day. The nurse knows about them she said I could not have them, but I gave her a hard time and she left them. Review of the facility Self-Administration of Medications, policy dated 12/2016, stated Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. During an interview done on 9/19/22 at 12:00 p.m., the Administrator stated, We don't do self-Administration of meds.

Based on observation and record review the facility failed to ensure that residents were provided with the opportunity to vote, resulting in residents not being queried about their right to vote in the Michigan Primary Election and provided with the opportunity to exercise their right as United States' citizens. Findings Include: During Resident Council on 9/14/22 at 11:00 AM, residents were queried about voting during the primary election in August 2022. The residents reported they did not vote, nor do they recall being asked about their preference for voting. About half of the residents reported they would be interested in voting and would like to be provided with the option to do so. On 9/14/22 at approximately 12:00 AM, Activities Director X was asked about residents voting during the primary in August 2022. Activities Director X reported she took over this role a few weeks ago and was not involved with their voting preferences in August. She expressed she is preparing to complete a sweep of the building to verify their voting choices and prepare for the November 2022 Mid-Term elections. On 9/14/22 at approximately 3:00 PM, an interview was conducted with Social Worker Director L, regarding voting rights for the residents. Social Worker L stated she is not over voting at the facility and the Activities Director is responsible for this task. On 9/14/2022 at approximately 3:10 PM, a review was completed of Resident Council Notes for the past 6 months. There was no notation regarding voting for the residents in the upcoming elections. On 9/15/22 at approximately 9:00 AM, an interview was conducted with CNA (Certified Nursing Assistant) S who was the previous Activities Director at the facility. CNA S began as an Activities Director in May 2021 and relinquished his duties on 9/2/2022. He expressed when he began in the position, he was informed by the Activity Director prior to him, that he would receive a reminder card in the mail, regarding beginning the process for voting for facility residents. He reported he was aware he would have to call the different municipalities to request absentee ballots for residents. CNA S stated he did not receive anything in the mail that reminded him to begin the process for voting and the residents were not provided with the opportunity to vote in the primary election in August 2022. CNA S clarified he did not complete a facility audit to ascertain which residents would like to vote for the primary election that passed nor the upcoming mid-term election. On 9/20/22 at 1:45 PM, a review was completed of the facility policy entitled, Voting Rights, reviewed 2/2022. The policy stated, Residents are encouraged to exercise their right to vote in local, state and national elections .The social services department helps resident to vote by: a. assisting with vote registration; b. obtaining and distributing absentee ballots; c. providing writing tools, stamps and assistance with sending mail-in ballots; and or; d. providing transportation to voting sites or ballot drop off boxes . It can be noted the facility policy is not accurate in who is responsible for voting rights for facility residents. Per the Administrator, Activities and Social Services Director the activities department is responsible for assessing the resident right to vote not Social Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed complete assessments to determine the need for bedrails, monitor residents' continued use of bedrails, obtain physicians' orders, implement care plan, and obtain consent prior to use for nine (#20, #27, #18, #30, #95, #24, #21, #6, #17) residents of nine reviewed for entrapment, resulting in resulting in the potential for entrapment, decline in mobility and death. Findings Include: On 9/12/22 at 2:50 PM, Resident #20 was observed to have bilateral enabler bars on his bed and appeared to be in good spirits. On 9/14/22 at 9:40 AM, a review was completed of Resident #20's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Cerebral Infarction, Atrial Fibrillation, Parkinson's Disease and Diabetes. Resident #20 was assessed as having cognitive impairments and required assistance from facility staff for ADL (Activity of Daily Living). Further review of Resident #20's records revealed the following: Bed Rail Assessment: Resident #20 was assessed on 7/30/2019 for bilateral enabler bars to promote independence. There was no other documentation located regarding continued monitoring, physician order's, care plans. On 9/15/22 at 10:05 AM, an interview was conducted with Maintenance Director I regarding facility enabler bars. Director I reported he completed weekly checks on all enabler bars in the facility for usability and damage. Director I provided his weekly audit chart dated 9/8/22 that indicated there 19 residents with enabler bars in the facility. Director I reported the bars are compatible with the beds as they ordered from the supply company and are the same brand as the beds. He stated therapy assessed the residents and he is provide with a request to affix them to the bed. On 9/15/22 at 11:00 AM, the Administrator was queried regarding the frequency of bed rail assessments for residents. It was reported therapy completed the initial assessment and then quarterly thereafter. On 9/15/22 at 3:12 PM, an interview was conducted with Occupational Therapist DD regarding bed rail assessment. Therapist DD explained their therapy company began their contract with the facility on March 1, 2022. He reported when they complete their initial therapy evaluation if they observe residents requiring extra assistance with bed mobility, if they ask or if they are attempting to stimulate their home environment, they will complete an assessment for the resident's usage of the enabler bars. Therapist DD explained they only complete an evaluation and ongoing monitoring for residents on their caseloads with enabler bars, they do not complete the evaluations and monitoring for the entire facility. On 9/15/22 at approximately 3:30 PM, this writer and Maintenance Director I completed a tour of all residents on 400 Unit with enable bars. The following nine residents have enabler bars on 400 Hall: - Resident #27 - Resident #18 - Resident 30 - Resident #95 - Resident #24 - Resident #21 - Resident #6 - Resident #17 - Resident #20 On 9/15/22 at 3:55 PM, a review was completed of below eight residents' medical records, and it was found none of them have the appropriate monitoring, assessment, and physician order for their enabler bars. If the resident did have an assessment, they were over three years old. Resident #27 admitted to the facility on [DATE] with diagnoses that include Intracerebral Hemorrhage, Hemiplegia and Anemia. She was assessed as cognitively intact, required assistance with her ADL's and had upper and lower extremity impairments on one side. Resident #27 was not assessed for her usage of bedrails nor was there physician order or care plan. It is unknown how long this resident had utilized bilateral bedrails. Resident #18 admitted to the facility on [DATE] with diagnoses that include Parkinson's, Dementia, Atrial Fibrillation, Hyperlipidemia, Anxiety Disorder and Major Depressive Disorder. He was assessed to have impaired cognition and required assistance with his ADS's. Resident #18 had their initial bedrails assessment completed on 7/30/2019 and there was no further monitoring for appropriateness, care plan and physician order. Resident #30 admitted to the facility on [DATE] with diagnoses that include Respiratory Failure, Heart Failure and Hypertension. He was assessed to have impaired cognition and required staff assistance with his ADL's. Resident #30 was not assessed for his usage of bedrails nor was there a physician order or care plan. It is unknown how long this resident had utilized bilateral bedrails or if he was deemed safe to have them. Resident #95 admitted to the facility on [DATE] with diagnoses that included Hypertension, Kidney Disease, Dysphagia, Mood Disturbance and Heart Disease. He was assessed as having mild impaired cognition and does require assistance as he has right sided weakness. Resident #95 was not assessed for his usage of bedrails, as no assessment was located nor was there a physician order or care plan. Resident #24 admitted to the facility on [DATE], with diagnoses that included Kidney Failure, Dementia, Diabetes and Hypertension. Resident #24 was assessed as being cognitively impaired and requires minimum assistance for his ADL's. Resident #24 was not assessed for his usage of bedrails (resident only had bedrails on one side of his bed), as no assessment was located nor was there a physician order, continued monitoring, or care plan. It is unknown how long this resident had utilized the bedrails. Resident #21 admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Hemiplegia, Heart Disease, Kidney Disease and Aspasia. He does require assistance with this ADL's and has upper and lower extremity impairment on one side. Resident #21 was not assessed for his usage of bedrails, as no assessment was located nor was there a physician order, continued monitoring, or care plan. Resident #6 admitted to the facility on [DATE] with diagnoses that included Atrial Fibrillation, Hypertension, Adjustment Disorder and Spinal Stenosis. Resident #6 as assessed as being cognitively intact and does require some assistance with her ADL's. Resident #6 was not assessed for her usage of bedrails and there was not a physician order, continued monitoring or care plan. Resident #17 admitted to facility on 2/10/2020 with diagnoses that included Compression Fracture, Osteoporosis, Dysphagia, Bipolar Disorder and Major Depressive Disorder. Resident #17 was assessed as cognitively intact and does require assistance for her ADL's. Resident #17 had their initial bedrails assessment completed on 7/30/2019 and there was no further monitoring for appropriateness nor physician order. It can be noted there are at least 19 residents within the facility that had bedrails. The nine residents on 400 unit had not been assessed appropriately for entrapment, physician order obtained, risk/benefits reviewed nor was consent obtained from the resident or resident representative. On 9/19/22 at 8:00 AM, an interview was conducted with Therapy Director CC regarding bed rail assessments for facility residents. Director CC reported therapy department was only completing assessments for residents actively in therapy. She explained they would assess the resident and then put in a request to Maintenance Director I to install the bed rails. Director CC explained there was no formal assessment they completed for appropriates of the rails. Director CC stated the Assist Rail Use Assessment Form, was provided to her by the Administrator on 9/15/2022. She continued there is now a process in place and once they complete the assessments, they provide them to the Administrator or DON (Director of Nursing) so they can request physician authorization. Director CC clarified they are still only completing the assessments for residents that are on therapy and have bed rails which is seven residents. She reported the two residents on 400 hall are, Resident #95 and #17, she continued Resident #17 already had the bilateral assist bars prior to being back on therapy. Director CC was asked what the frequency of the assessment after the initial one would be, and she stated she did know the frequency of them yet. On 9/19/22 at 9:25 AM, an interview was conducted with the DON regarding enabler bars. The DON reported therapy previously completed all enabler bar assessments for residents. In March 2022 they switched to a new therapy company and it unclear if this process is occurring with the new company. The DON reported their therapy department does complete the assessment for their residents' receiving therapy services. The DON was asked who was responsible for residents with enabler bars who were not on therapy, and she stated there is currently no person assigned to this task. The DON explained after the initial assessment they would be completed quarterly and scanned into the medical record. The DON was informed of the nine residents reviewed, three had assessment but they were from 2019 and the other six residents have nothing mentioned in their records regarding enabler bars. The DON expressed understanding. On 9/21/22 at 9:00 AM, a review was completed of the facility policy entitled, Use of Bed Rails (Assist Bars), reviewed 2/2022. The policy stated, To ensure the proper and safe use of bed rails in the facility. If the facility is to use a side of bed rail, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements; 1. Assess the resident for risk of entrapment from bed rails prior to installation. 2. Review the risk and benefits of bed rails with the resident or resident representative and obtained informed, written consent. 3. Physician Order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure timely Physician-required visits for a total of 11 skilled care residents (resident's #4, #9, #13, #17, #25, #26, #27, #97, #98, #100, and #143), of 16 residents reviewed for Physician visits, resulting in the high likelihood for mismanaged care, un-treated medical conditions, hospitalization, anger, and disappointment. Findings Include: Resident #4: Review of the Face Sheet, Diagnosis Sheet, and Physician progress notes and orders dated 5/5/22 to 9/14/22, revealed Resident #4 was 91 years-old, was admitted to the facility on [DATE] and required staff assistance for Activities of Daily Living (ADLs'). The resident's diagnosis included, Atrial Fibrillation, Urinary Tract Infection(UTI), Chest Pain, Alzheimer's Disease, Stroke, Dysphagia (difficulty with swallowing), muscle weakness, anxiety and decreased cognitive function (BIMS-cognitive assessment tool, 1 through 15, of 9, not interviewable). Resident #9: Review of the Face Sheet, Diagnosis Sheet, and Physician progress notes and orders dated 8/24/22 to 9/14/22, revealed Resident #9 was 90 years-old, was admitted to the facility on [DATE] and required staff assistance for Activities of Daily Living (ADLs'). The resident's diagnosis included, Acute Respiratory Failure, Pleural Effusion, Heart Failure, Pulmonary Embolism, Hypertension, Pain, Anemia, Elevated [NAME] Blood cells, dependent on oxygen and cognitive communication deficit with a BIMS' of 10, not interviewable. Resident #13: Review of the Face Sheet, Diagnosis Sheet, and Physician progress notes and orders dated 6/15/22 to 9/14/22, revealed Resident #13 was 94 years-old, was admitted to the facility on [DATE] and required staff assistance for Activities of Daily Living (ADLs'). The resident's diagnosis included, Respiratory Failure, Pleural Effusion, Pneumonia, UTI, Heart Disease, Abnormal Coagulation Profile, history of Prostate Cancer, long term use of Anticoagulants, Spinal Stenosis and Hypertension. The resident had a BIMS of 9, non-interviewable. Resident #17: Review of the Face Sheet, Diagnosis Sheet, and Physician progress notes and orders dated 7/6/22 to 9/14/22, revealed Resident #17 was 62 years-old, was admitted to the facility on [DATE] and required staff assistance for Activities of Daily Living (ADLs'). The resident's diagnosis included, Chronic Lung Disease, Compression Fracture, Osteogenesis, Chronic Pain, Parkinson's Disease, Muscle Weakness, Dysphagia, Anxiety, Hallucinations, Bipolar, Malingering (grossly exaggerated medical symptoms), Major Depression. Due to mental health concerns, this resident was not able to be interviewed by surveyor. Resident #25: Review of the Face Sheet, Diagnosis Sheet, and Physician progress notes and orders dated 1/19/21 to 9/14/22, revealed Resident #25 was 74 years-old, was admitted to the facility on [DATE], and required staff assistance for Activities of Daily Living (ADLs'). The resident's diagnosis included, Chronic Lung Disease with oxygen dependency, Respiratory Failure, Pneumonia, Hemiplegia following Stroke, Hypertension, Diverticulitis, Emphysema and Major Depression. The resident was alert and interviewable with a BIMS of 10. During an interview done on 9/14/22 at 9:17 a.m., Resident #25 when asked by this surveyor if she had seen her Physician stated, I haven't seen him since I got here; I would like to see him. Resident #26: Review of the Face Sheet, Diagnosis Sheet, and Physician progress notes and orders dated 8/11/21 to 9/14/22, revealed Resident #26 was 91 years-old, alert, was admitted to the facility on [DATE], and required staff assistance for Activities of Daily Living (ADLs'). The resident's diagnosis included, Respiratory Failure, Shortness of Breath, Vertigo, Muscle Spasms, Skin Infection and Muscle Weakness. Resident #27: Review of the Face Sheet, Diagnosis Sheet, and Physician progress notes and orders dated 4/24/22 to 9/14/22, revealed Resident #27 was 79 years-old, alert, was admitted to the facility on [DATE], and required staff assistance for Activities of Daily Living (ADLs'). The resident's diagnosis included, Stroke, UTI, Hemiplegia of right side, Amputation, Chronic Lung Disease, Anemia, Convulsions, Hypertension, Severe Septic Shock, Dysphagia, and Major Depression. Resident #97: Review of the Face Sheet, Diagnosis Sheet, and Physician progress notes and orders dated 9/6/22 to 9/14/22, revealed Resident #97 was 92 years-old, alert, was admitted to the facility on [DATE], and required staff assistance for Activities of Daily Living (ADLs'). The resident's diagnosis included Osteoporosis, UTI, Malnutrition, Abdominal Wall Abscess, Pain, Aortic Stenosis, Heart Failure, High Blood Pressure, Chronic Kidney Disease, Cardiac Arrhythmia, Stroke, and muscle weakness. During an interview done on 9/14/22 at 8:11 a.m., Resident #97 was asked by this surveyor if they had seen their Physician and Resident #87 stated No, I need to see him. Resident #98: Review of the Face Sheet, Diagnosis Sheet, and Physician progress notes and orders dated 11/6/20 to 9/14/22, revealed Resident #98 was 50 years-old, alert, was admitted to the facility on [DATE], and required staff assistance for Activities of Daily Living (ADLs'). The resident's diagnosis included Demyelinating Disease of the Central Nervous System, UTI, Multiple Sclerosis, Diabetes, Disc Degeneration of Lumbar Region, Chronic Migraine, and muscle weakness. Resident #100: Review of the Face Sheet, Diagnosis Sheet, and Physician progress notes and orders dated 9/6/22 to 9/14/22, revealed Resident #100 was 77 years-old, very confused, was admitted to the facility on [DATE], and required staff assistance for Activities of Daily Living (ADLs'). The resident's diagnosis included Stroke with Aphasia (difficulty with talking) and Hemiplegia of the right side, Falls, Dementia with Behavioral Disturbances, Restlessness and Agitation, Heart Disease, Emphysema and Chronic Lung Disease. The resident had a BIMS of 5 and was unable to be interviewed. Resident #143: Review of the Face Sheet, Diagnosis Sheet, and Physician progress notes and orders dated 9/1/19 to 9/14/22, revealed Resident #143 was 75 years-old, alert, was admitted to the facility on [DATE], and required staff assistance for Activities of Daily Living (ADLs'). The resident's diagnosis Acute Kidney Failure, Shortness of Breath, Anemia, Diabetes, Heart Disease, Hypertension, Old MI, and Dehydration. During an interview done on 9/14/22 at 11:10 a.m., Nurse, RN Q when asked by this surveyor if facility Physician, MD N visited his residents on a regular basis stated, No, they (facility Physician's) aren't here; their Nurse Practitioner's (NP) come. He (Physician N) came here a month ago, filling out something, he didn't see anyone. During an interview done on 9/14/22 at 11:20 a.m., Nurse, LPN R when asked by this surveyor if facility Physician N visited his residents on a regular basis stated, he has come in sporadically, about a month ago. I don't think the Doctors see their residents enough. Nurse R could not recall seeing Physician N seeing any Resident when he last visited the facility. During a phone interview done on 9/14/22 at approximately 3:15 p.m., Physician, MD Medical Director O revealed he had been aware of the concern regarding Physician N not visiting his Residents in a timely manner. During an interview done on 9/14/22 at 3:14 p.m., the Administrator stated, I was aware, he (Physician N) was not coming in to see his patient's. During an interview done on 9/15/22 at approximately 10:00 a.m., Physician N said he was aware he missed required Resident visits; since COVID-19 he fell behind and did not visit his Resident's himself at the facility. Review of the facility Physician Services policy dated 2/20, stated The medical care of each resident is under the supervision of a Licensed Physician. Physician visits, frequency of visits, emergency care of residents, etc , are provided in accordance with current OBRA regulations and facility policy. The Medical Director will identify attending physician qualifications and responsibilities, based on clinical and regulatory requirements and the recommendations of relevant professional associations.

On 9/13/22 at 11:01 AM, Certified Dietary Manager, staff D, was observed entering the kitchen with a metal container of food from the kitchen's exterior exit door. At this time the surveyor inquired with staff D as to the contents of the container to which they replied, spring rolls for today's lunch. On 9/13/22 at 11:02 AM, upon interview with staff D regarding the cooking process of the spring rolls they stated, are kitchen is so small we don't have hood space inside, so we purchased two small fryers and keep them outside. At this time the surveyor asked staff D if they would show them the location of the fryers to which they replied, of course, they are right outside the door. On 9/13/22 at 11:03 AM, the surveyor observed two fryers placed on top of a wheeled plastic cart. Next to this cart was another wheeled plastic cart with a half-filled tray of spring rolls and a pair of metal tongs placed on top of it. At this time the surveyor asked staff D on how the facility could ensure the safety of the food being served to the residents with the food, equipment, and utensils being exposed without protection from the exterior elements to which they responded, we'll just stop doing it. They taste better fried, but we can bake them instead. On 9/13/22 at 11:04 AM, the surveyor asked staff D if they had an opportunity to take temperatures of the spring rolls in the tray this morning to which they replied, not since this morning, but I took them out when they were still partially frozen. We can take the temperature right now if you'd like to which the surveyor responded, please. On 9/13/22 at 11:06 AM, staff D was observed taking a temperature reading via a thermometer probe of the spring rolls revealing a temperature of 38 degrees F and stated, prefect, I'll place them in the walk-in cooler and let the cooks know we have to bake the rest of the tray. I wasn't really sure about doing it this way, but we only use the fryers maybe twice a month. At this time the surveyor asked staff D what their intentions were with the other spring rolls fried outside to which they said, I'll make sure they don't serve anymore. Review of the U.S. Public Health Service 2013 Food Code, Chapter 3-307.11 Miscellaneous Sources of Contamination directs that: FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 -3-306. On 9/13/22 at 11:30 AM, upon interview with Certified Dietary Manager, staff D, on if the facility cooks products in advance and cools them for later use, they replied, no. On 9/13/22 at 11:40 AM, a gallon sized container of chicken noodle soup was observed in the two door reach-in cooler labeled with the dates of, 9-11 - 9-15. At this time the surveyor again asked staff D if the facility cooks products in advance and cools them for later use to which they replied, I guess we do. On 9/13/22 at 11:41 AM, the surveyor asked staff D for a copy of the facility's cooling log to review to confirm the proper cooling of the soup to which staff D replied, we don't have one. We just put it in the walk-in cooler. At this time the surveyor asked staff D how the facility would normally handle food items such as this if they could not verify the foods were properly cooled to ensure the foods safety to which they replied, I see your point, we will throw it out. I guess we will need to start keeping cooling logs. On 9/13/22 between 11:45 AM, and 11:52 AM, upon inspection of the walk-in cooler the surveyor observed two containers of pureed sausage, and one container of scrambled eggs with heavy condensation on the interior of the plastic lids with date marks starting on, 9-13-22. At this time the surveyor asked staff D if these items were prepared this morning to which they responded, yes they were. I guess we do cook and cool something's in advance. On 9/13/22 at 11:53 AM, temperatures taken by staff D via a thermometer probe revealed a temperature of 51 degrees F for the scrambled eggs, 67 degrees F for one container of pureed sausage, and 60 degrees F for the other container of pureed sausage. At this time the surveyor asked staff D if they knew what temperature or time the cooling process started at earlier in the day to which they responded, no, not specifically. We will throw these out and make new. I'll talk to my cooks about this. Review of U.S. Public Health Service Food Code, as adopted by the Michigan Food Law, effective October 1, 2012 Chapter 3-501.15 Cooling Methods, directs that: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; Pf (2) Separating the FOOD into smaller or thinner portions; Pf (3) Using rapid cooling EQUIPMENT; Pf (4) Stirring the FOOD in a container placed in an ice water bath; Pf (5) Using containers that facilitate heat transfer; Pf (6) Adding ice as an ingredient; Pf or (7) Other effective methods. On 9/13/22 at 3:43 PM, upon interview with the Certified Dietary Manager, staff D, as to the location of the kitchen's janitorial closet they stated, we don't have one. At this time the surveyor asked staff D, do you mean there are none in the facility, or not one specifically used by the kitchen? Staff D responded by stating, no, there are some, but we fill our mop bucket up in our dish room, we mop the floor when we are done for the day leading toward our back door and then dump our buckets in a drain outside when we are done. On 9/13/22 at 3:44 PM, the surveyor asked staff D if they could show them the drain outside used for dumping their mop buckets to which they said, sure it's right next to where we had the fryers set up. On 9/13/22 at 3:45 PM, the surveyor reviewed writing on the exterior drain's grate cover stating, drains to waterways dump no waste. Upon observation the surveyor asked staff D if they were aware of the inscription on the drain cover to which they replied, no, I don't think anyone did. We will start using the Environmental Services sink across the hall starting today. Review of U.S. Public Health Service Food Code, as adopted by the Michigan Food Law, effective October 1, 2012 Chapter 5-403.12 Other Liquid Wastes and Rainwater directs that: Condensate drainage and other nonSEWAGE liquids and rainwater shall be drained from point of discharge to disposal according to LAW. Review of U.S. Public Health Service Food Code, as adopted by the Michigan Food Law, effective October 1, 2012 Chapter 6-501.16 Drying Mops directs that: After use, mops shall be placed in a position that allows them to air-dry without soiling walls, EQUIPMENT, or supplies Based on observation, interview and record review, facility failed to 1). ensure safe cooking outdoors, 2). grease was discarded safely (not in driveway drain), 3). ensure food items were appropriately dated, 4). ensure proper cooling of foods, 5). ensure proper cooling verification of foods, 6). ensure foods were cooled at proper holding temperatures based upon when the cooling process started, 7). ensure foods were served and prepared in a non-contaminated environment and/or process, and 8). ensure the proper disposal of soiled mop water (not down an exterior storm drain), resulting in the high likelihood for cross contamination, environmental contamination, possible grease fire and the risk for resident illness with hospitalization. Findings Include: Review of the U.S. Public Health Service 2009 Food Code, as adopted by the Michigan Food Law, effective October 1, 2012, revealed all potentially hazardous foods must have an open and use-by date. During the initial kitchen walk through done on 9/12/22 from 9:00 a.m. to 9:35 a.m., accompanied by Dietary Manager D, the following concerns were observed: -At 9:00 a.m., the large metal can opener was noted to have silver paint chipping off the blade. -At 9:05 a.m., a plastic container was found in the refrigerator with cut-up oranges in it; the container had no dates on it at all (no open or use-by date). During an interview done on 9/12/22 at 9:05 a.m., Dietary Manager D stated It should have dates on it. -A wooden spoon, wooden potato masher and wooden handled knife was found in the kitchen. During an interview done on 9/12/22 at 9:20 a.m., Dietary Manager D said he was not aware the kitchen could not have wooden utensils with the exception of baking equipment. Review of the U.S. Public Health Service 2009 Food Code, as adopted by the Michigan Food Law, effective October 1, 2012, revealed an industrial kitchen was not to have wooden utensils with the exception of baking equipment. [NAME] is porous and harbors bacteria. -At 9:20 a.m., the large mixer that was clean and ready for use was found to have dried food particles and dried batter-like substance on the underside of the mixer on the attachment neck, directly over the mixing bowl. -At 9:30 a.m., in the refrigerator was found an open container of Tarter Sauce dated 8/25 (to) 8/31, the tarter sauce was past the use-by date. During an interview done on 9/12/22 at 9:30 a.m., Dietary Manager D said the tarter sauce should have been discarded because it was past due date. During an interview done on 9/14/22 at approximately 10:45 a.m., Dietary Manager D said the facility did not have check-off kitchen duty sheets; he said he checks to make sure everything is clean, and all foods dated. Review of the facility General Sanitation of Kitchen policy dated 1/22, stated The staff shall maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule; Cleaning and sanitation tasks for the kitchen will be recorded.