**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately record and obtain code status (level of medical interventions that an individual wishes to have enacted in a medical emergency situation) documentation for two residents ( Resident #29 and Resident #35) of three residents reviewed for Advance Directives (legal documentation enabling an individual to specify end-of-life care decisions), resulting in lack of accurate assessment and documentation of code status and the potential for a Resident to receive life sustaining medical treatment against their wishes. Findings include: Resident #29: Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses which included heart failure, anxiety, cognitive communication deficient, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to substantial assistance with bathing and dressing. Review of Resident #29's Electronic Medical Record (EMR) revealed the Resident's code status was DNR. Resident #29 did not have a care plan in place pertaining to code status. A Do Not Resuscitate Order Declarant (Resident) Consent form was noted in Resident #29's EMR. The form was signed by Resident #29 on 4/25/23 and Physician K on 5/1/23. Further review of Resident #29's EMR revealed a Decision Making Determination Form specifying Resident #29 was Uncapable of making decisions regarding medical treatment . based upon . inability to understand the disease process and implication of procedures and treatments, or refusal of treatment . The incompetency determination was signed by Physician L on 8/17/21 and 8/24/21. Resident #35: Record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with left sided paralysis, epilepsy, depression, anxiety, dysphagia (difficulty swallowing). Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required maximum to total assistance for hygiene, toileting, and transferring. Resident #35's EMR indicated Full Resuscitate as the Resident's code status. Review of Resident #35's EMR revealed a Decision Making Determination Form specifying the Resident was not capable of making medical treatment decisions. The form was signed by one Physician on 6/1/23 and a second, supporting Physician on 10/24/23. Additional documentation detailed, Family Member N was Resident #35's Durable Power of Attorney and patient advocate. Further review of Resident #35's EMR revealed a form titled, Advance Directive/Medical Treatment Decisions. Under the Advance Directive section of the form, Do Not Resuscitate was checked and initialed with the date 2/2/24. Another box was checked specifying, I do not choose to formulate or issue any Advance Directives at this time with Full Code written above the statement. The form was signed by Family Member N and a Facility Registered Nurse RN on 2/2/24. An interview was completed with Social Services Designee RN O on 8/21/24 at 8:42 AM. Social Services Designee RN O was asked if a Resident who has been deemed incompetent to make medical decisions is able to sign Advance Directive documentation to be a DNR, Social Services Designee RN O verbalized that if a Resident is deemed incompetent, their DPOA and/or guardian should sign the document. When queried regarding Resident #29's code status, Social Services Designee RN O indicated the Resident was a DNR. Resident #29's Do Not Resuscitate Order Declarant (Resident) Consent form and Decision Making Determination Form were reviewed with Social Services Designee RN O. When why Resident #29 signed the DNR order in 2023 when they were deemed incompetent in 2021 if a Resident who is deemed incompetent is not able to make medical decisions, Social Services Designee RN O confirmed the DNR order should have been signed by the Resident's Representative. Social Services Designee RN O revealed Resident #29 come to the facility from a different facility and stated they accepted the documentation from the other facility. When asked if they checked the documentation for accuracy, Social Services Designee RN O did not provide a direct response but reiterated the documentation was completed at another facility. Resident #35's Advance Directive/Medical Treatment Decisions form was reviewed with Social Services Designee RN O at this time. When queried regarding the form indicating the Resident was both a DNR and full code, Social Services Designee RN O verbalized they could not be. Social Services Designee RN O stated, Think an error on the form. When queried regarding the concern pertaining to the conflicting documentation of the Resident's code status on the form, RN O verbalized understanding. On 8/21/24 at 9:36 AM, an interview was completed with the Director of Nursing (DON). When queried regarding Resident #29 and 35's Advance Directive documentation and Code Status, the DON verified concern and verbalized understanding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure prompt attending physician's review of pharmacy recommendations and documentation of rationale for lack of action related to pharmacy medication irregularity recommendation reports for one resident (Resident #11) of five residents reviewed for unnecessary medications, resulting in Resident #11 receiving double the recommended medication dosage, the potential for Adverse Drug Reactions (ADR), and additional medication errors despite pharmacy oversight. Findings include: Resident #11: Record review revealed Resident #11 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Congestive Heart Failure (CHF), heart attack, anxiety, and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, always continent of bowel and bladder, and was independent with Activities of Daily Living (ADL) with the exception of set-up to supervision for bathing and ambulation. Review of Resident #11's Electronic Medical Record (EMR) revealed Monthly Medication Reviews (MMR) were completed by pharmacy staff in a progress note. Any pharmacy recommendations related to medication regimen abnormalities were documented on a Note to Attending Physician/Provider and scanned into the EMR. Review of Note to Attending Physician/Provider from the pharmacy, dated 7/4/24 revealed Resident #11 was receiving Detrol LA (prescription medication used to treat overactive bladder) Oral Capsule Extended Release (ER) 24-hour 4 mg (milligram) . Give 1 capsule by mouth every day and evening shirt for bladder spasm. The pharmacy recommendation detailed, The maximum for ER caps is 4 mg QD (every day). The maximum for IR (Immediate Release) tablets is 2 mg BID (twice a day). Please review for reduction to Detrol LA (ER 24 hr) 4 mg once daily. The Physician/Prescriber Response on the form detailed, Continue same as ordered with no rationale and was signed by the provider on 8/6/24. On 8/8/24, the pharmacy sent another Note to Attending Physician/Provider pertaining to Resident #11's Detrol LA ER dosage of 4mg BID. The pharmacist added, The current regimen increases anticholinergic burden (associated with poor health outcomes, especially in the elderly, including increased risk of falls, dementia, and death) due to being double the FDA-approved maximum (dose). Please review for reduction to Detrol LA (ER 24 hr) 4 mg once daily. The Physician/Prescriber Response on the form was dated 8/13/24 and detailed, Change to 2 mg BID - IR tablets. An interview was completed with the Director of Nursing (DON) on 8/21/24 at 12:00 PM. When queried regarding Resident #11's Detrol LA order being double the recommended dosage and the Health Care Provider not providing a rationale for not following the pharmacy recommendation to reduce the ordered dosage, the DON did not provide an explanation. When queried regarding the facility policy/procedure related to the length of time providers have to review pharmacy recommendations, the DON indicated they believed they had a month. The DON was then queried regarding the pharmacy recommendation dated 8/8/24 related to the same reduction and asked why the medication was changed at that time but not previously and indicated they did not know as a rationale was not provided for continuing the medication by the provider on the July form. Review of facility policy/procedure entitled, Addressing Medication Regiment Review Irregularities (Reviewed/Revised: 12/28/23) revealed, It is the policy of this facility to provide a Medication Regiment Review (MRR) . to identify irregularities and respond in a timely manner to prevent the occurrence of an adverse drug event . 4. The pharmacist must report any irregularities to the attending physician, the facility's medical director and director of nursing and the reports must be acted upon . d. The Attending physician must document in the resident medical record that the identified irregularity has been reviewed and what, if any action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. e. The pharmacist does not need to document a continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist's recommendation. 5. The report should be submitted to the DON within 10 working days of the review. 6. Timeliness of the notification of irregularities depends on factors including the potential for or present of serious adverse consequences .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate medication administration and storage of insulin for one resident (Resident #139) and two inhalers for one resident (Resident #23), resulting in the likelihood of decreased medication efficacy and side effects such as mouth discomfort and/or mouth infection. Findings include: On 8/21/24, at 7:52 AM, During medication administration task, Nurse I prepared medications for Resident #23 which included Breo Ellipta and Spiriva inhalers. Nurse I entered Resident #23's room and provided one puff of Breo Ellipta inhaler and then provided two puffs of the Spiriva inhaler 15 seconds later. The required one minute during the two inhalers was not provided. Nurse I did not offer to the resident to rinse their mouth after the inhaler use. Nurse I returned to the medication cart and placed the inhalers into their corresponding boxes for storage. On 8/21/24. At 8:11 AM, Nurse H prepared morning medications for Resident #139. Nurse H gathered the Lantus insulin via insulin pen. Nurse H removed the cap, cleaned with an alcohol wipe, attached the pen needle, dialed the pen to 40 units. Nurse H did not dial the pen to 2 units which is required to prime the needle. Nurse H administered the Lantus insulin pen into the center of the deltoid at a 90-degree angle. On 8/21/24, at 2:00 PM, a record review of Resident #139's electronic medical record revealed an admission on [DATE] with diagnoses that included Diabetes, Morbid Obesity and Muscle Weakness. Resident #139 had intact cognition and required assistance with Activities of Daily Living. A review of the Physician orders revealed Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 40 unit subcutaneously . A review of the Lantus pen instructions revealed DO A SAFETY TEST Always perform the safety test before every injection. This removes air bubbles and ensures the pen and needle are working properly 1. Select a dose of 2 units by turning the dosage knob . After your safety test, make sure the dose window reads 0. On 8/21/24, at 2:30 PM, a record review of Resident #23's electronic medical record revealed an admission on [DATE] with diagnoses that included Chronic Respiratory Failure, Heart Failure and Chronic Obstructive Pulmonary Disease. Resident #23 had intact cognition and required assistance with Activities of Daily Living. On 8/21/24, at 3:00 PM, the Director of Nursing (DON) was asked to provide the pharmacy instructions for administration on both the Breo Ellipta and Spriva inhalers. The DON was alerted Nurse I did not provide wait time between the puff of the two different inhalers nor offer to the resident to rinse their mouth. On 8/21/24, at 3:15 PM, Resident #23 was sitting in their room and was asked if they have ever rinsed their mouth after an inhaler and Resident #23 stated, no they never have told me. A review of the facility provided Inhalers - What You Need To Know information sheet revealed . If more than (1) puff is required, (whether the same or different medication), there should be a waiting time of approximately (1) minute between puffs . for steroid inhalers, provide a cup of water for resident to rinse and spit back into the cup . clean mouth piece with water and store following manufacturer's recommendations . A review of a provide email from the pharmacy to the DON revealed . Breo Ellipta - Inhaled corticosteroid . Wait 1 minute between Spiriva Respimat and Breo Ellipta

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident Council: On 8/20/24, at 3:46 PM, During resident council, the entire group complained of the following: no choice for food items the portion sizes are small the menu repeats they give you a time limit on picking an alternative the confetti eggs were awful, it was like wet custard but eggs with red and green sprinkles on top we don't get menus for our room you get what you get we don't get real butter we'd like real creamer for our coffee I want a whole banana; we get banana cut up in a dish we want fresh fruit we're sick of canned fruit we get lots of macaroni unless you look at the menu on the wall, you don't know what you're getting The entire group complained of not having menus and that they must look on the wall as to what is on the menu. They complained they do not have menus in their rooms. The group was asked if they could order from an alternative menu if they didn't like what they were served, and the entire group complained that there was a time cut off for making a second choice. The group was asked to explain what the time limit meant, and they complained that they have to pick by certain times in advance for a second choice. For example, the night before for breakfast. The group was asked if they changed their mind once the meal was served could they get something different and the group quickly responded, NO. They complained that the staff say it's too late for that. On 8/21/24, at 8:09 AM, a breakfast tray observation revealed the following items: 1 small scoop of eggs which appeared to be too moist as they were unable to be forked off the plate; hash brown patty with the center not crispy and slightly soggy; 1 piece of buttered wheat toast; a small bowl of corn flakes, 1 cup of milk, 1 cup of coffee that was luke warm, 2 sugar, 1 jelly and 3 dry creamer packs. There was no salt nor pepper provided. On 8/21/24, at 9:18 AM, Registered Dietician (RD) S was asked to explain food choices for the residents. RD S offered that there is an always menu they can select options from. RD S was asked if there were any rules with the always menu and RD S offered, they can talk to staff but unsure how they ordered from the alternative menu. RD S was alerted the residents would like fresh fruits and that they all complained about the taste and appearance of the confetti eggs. RD S was asked what type of eggs the facility provides and RD S stated, we have fresh and powdered eggs. On 8/21/24, at 1:51 PM, just prior to exit, two residents were in the hallway and were overheard making complaints about the lunch served that day. The overheard complaints were did you eat the lunch today? I didn't and No, it was junk I didn't eat either. On 8/21/24, at 2:30 PM, a record review of the facility provided Lunch and Dinner Alternatives document revealed Lunch requests must be made no later than 8:30 am Dinner requests must be made no later than 2:30 PM If a request is placed after cut off time, a sandwich of cook's choice will be served instead . Please note that depending on demand this menu could be subject to change and sometimes we may be out of a certain product. We strive to make you happy and will re-stock ASAP. A second document revealed Ala Carte Menu Great Alternatives for you to choose from Breakfast: breakfast requests must be in by 7 PM the evening before Hot Cereal- Oatmeal or cream of wheat served with syrup or brown sugar as requested Cold Cereal-Fruit loops, cheerios, or corn flakes Eggs-Scrambled, Hard Boiled or Fried with Toast and Jelly. A review of the recipe for CONFEET EGGS 1 0Z (ounce) . Whole liquid egg . 3 ¼ Quart GREEN PEPPERS, CHOPPED . ¾ Cup DICED SWEET RED PEPPERS . ¾ cup .COMBINE EGG, GREEN PEPPER, AND SWEET RED PEPPER. STIR UNTIL VEGETABLE ARE EVENLY DISTRIBUTED . Portion Size: ¼ CUP . Based on observation, interview and record review, the facility failed to provide palatable and appealing food per preference for one resident (Resident # 35) of two residents reviewed and seven of seven confidential group Residents resulting in feelings of frustration and verbalization of discontentment. Findings include: Resident #35: On 8/19/24 at 2:13 PM, an interview was completed with Resident #35 in their room. When queried regarding the food in the facility, Resident #35 stated, Food is horrible. Resident #35 was asked what is horrible about the food and replied, It's cold and doesn't taste good. Record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with left sided paralysis, epilepsy, depression, anxiety, dysphagia (difficulty swallowing). Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required maximum to total assistance for hygiene, toileting, and transferring.

Based on observation, interview and record review, the facility failed to: 1. Properly label and date food and food products, 2. Dispose of expired food and food products, 3. Thoroughly dry dishes prior to stacking, and 4. Ensure air gap for ice machine drainage pipe, resulting in the potential for cross-contamination and foodborne illness. These deficient practices have the potential to affect 37 residents who receive food from the kitchen. Findings Include: During a tour of the facility kitchen on 8/19/24, beginning at 9:04 AM, the following items were noted: - Kitchen Aid stand mixer was uncovered and not in use. When the mixer was tilted back, chunks of dried food substances were observed. - The floor appeared dirty with a build up of unknown substances and dirt behind the tables, oven, and near the walls. A palpable film of grease was present on the interior lip of the stove/oven hood. Visible cobwebs and dust were observed in various areas of the interior of the oven/stove hood. - Open and Undated bottle of Apple Cider Vinegar. When queried if the product is supposed to be dated by dietary staff, Dietary Staff R indicated it was. Dietary Staff R confirmed the Apple Cider Vinegar was not dated and indicated they would need to discard it. A tour of the tall refrigerator in the main kitchen area was completed with Dietary Manager G. The following items were identified in the refrigerator: - Three open and undated 46-ounce (oz) containers of Thickened Lemon Water. Manager G was asked if the containers of thickened water are supposed to be dated when opened and confirmed they should be. Manager G did not provide further explanation but indicated the product was not able to be used and they would dispose of the product. - A 20 oz container of Apple Butter with Opened: 8/5/24; Expired: 8/12/24 written on the container. When queried if the Apple Butter was expired, Manager G confirmed it was. When asked why the food product was still in the refrigerator, Manager G did not provide an explanation but indicated they would dispose of it. - A gallon of 2% milk with no open date on the container. When queried if milk is supposed to be dated when opened, Manager G verbalized is should be. When asked why it was not dated, an explanation was not provided. A tour of the dry storage area was completed with Dietary Manager G. The following items were identified: - Open 16 oz container of mustard with the date, Use by 7/15/24 on it. - Open 32 oz container of Vanilla with the date, Use by 7/1/24 on it. Dietary Manager G was asked about the mustard and Vanilla and verbalized the food products should have been thrown away on the date indicated on the packages. - A box of bananas was noted on a shelf in the dry storage room. The box had a black substance in it and the peel on one banana was split open. When queried regarding the bananas, Manager G disposed of the banana with the split peel and indicated the facility would be receiving their delivery the following day. The dishwashing and drying area was toured with Dietary Manager G. Cups with visible water and moisture were stacked on top of each other on a rack. When asked, Dietary Manager G revealed the area where the cups were stacked were for clean dishes. When queried regarding the visible water and moisture present in the stacked cups, Dietary Manager G stated, Not okay. Will have to rewash. Under the three-compartment sink, in the main area of the kitchen, the drain cover in the floor was pushed to the side, off the drain hole and a PVC pipe was positioned directly in the drain hole. A second, small piece of PVC pipe was connected to the PVC pipe positioned in the drain with a zip tie. The second piece was pushed to the side and appeared to be a makeshift stand for the drainage pipe. There was no air gap observed. Dietary Manager G was queried what the drainage pipe was for and why the drain cover was not in place over the drainage hole and replied, Not sure. When queried how long the pipe had been like that, Manager G and Staff R revealed it had been that way for quite a while but were unable to provide a specific timeframe. Dietary Manager G proceeded to move the drain cover back in place over the drainage hole. The PVC drainage pipe was then positioned directly on top of the drain cover with no air gap present. When queried what the pipe was for, Director G indicated they were unsure. Further visual inspection of the area under the three-compartment sink revealed multiple cobwebs in the area and in the corner. On 8/19/24 at 12:00 PM, an interview and observation of the kitchen drainage pipe and drain cover was completed with Maintenance Director J. When queried regarding the drainage pipe being positioned directly on top of the drainage grate with no air gap, Maintenance Director J stated, That is from the ice machine. When queried regarding the smaller PVC pipe connected to the drainage pipe with a zip tie, Maintenance Director J moved the smaller piece of PVC pipe around the pipe and stated, I think they put it to the side because it (drainage pipe) started sagging. Maintenance Director J proceeded to point out where the drainage pipe was attached to the wall and was sagging in areas. When queried regarding the drain cover being moved off the hole and the drainage pipe being positioned directly inside the drainage hole and why the drain cover was not secured, Maintenance Director J was unable to provide an explanation. An interview was completed with Maintenance Director J on 8/20/24 at 11:06 AM. Maintenance Director J indicated they worked on the drainage pipe and stated, Resecured it and made sure it has a downslope. It has an air gap now. When asked if the drainage pipe should have an air gap, Maintenance Director J stated, Yes. Maintenance Director J was then asked if they completed rounds in the kitchen and replied, Yes. When asked why the drain cover was moved to the side with drainage pipe was positioned in the drain hole when they are completing rounds in the kitchen, Maintenance Director J replied, Needed to be reattached. No further explanation was provided. An interview was completed with the facility Administrator and Director of Nursing (DON) on 8/20/24 at 4:00 PM. When queried regarding observations in the kitchen of undated/outdated food products, drain cover, drainage pipe/lack of air gap, cobwebs/dirt, grease, and cups stacked with visible water/moisture, the Administrator and DON verbalized understanding of concerns and indicated the concerns would be addressed. Review of facility policy/procedure entitled, Kitchen Sanitation (Reviewed/Revised: 1/1/22) revealed, The food service area shall be maintained in a clean and sanitary manner . 1. Kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish . 2. Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair . Review of facility policy/procedure entitled, Food Receiving and Storage (Reviewed/Revised: 1/1/22) revealed, Foods shall be received and stored in a manner that complies with safe food handling practices . 1. Food Services . will maintain clean food storage areas . 7. Foods stored in the refrigerator or freezer will be covered, labeled and dated ('opened on and 'use by' date). Whole produce will have a received date and freshness will be monitored by texture and appearance and discarded as appropriate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Linen: On 8/19/24, at 12:34 PM, CNA P was observed exiting the linen closet with a pile of clean linen in their right arm. The linen was touching their uniform and was uncovered. CNA P entered into room [ROOM NUMBER] and exited without the linen. CNA P gathered washcloths/clean linen and was asked what they planned to do with the 2 piles of linen they had carried into room [ROOM NUMBER] and CNA P offered, I'm changing her. Enhanced barrier: On 8/20/24, at 11:10 AM, Resident #20 was sitting in their wheelchair in their room which was an enhanced barrier room. They had a urinary catheter. CNA P entered the room to answer their call light. Resident #20 offered they wanted to sit in their recliner. Moments later, CNA P entered the room pushing a Hoyer lift with a bed pad in their right hand that was touching the Hoyer lift. CNA Q entered to assist. CNA Q placed gloves on but no gown. CNA P did not place gloves or a gown. The two CNA's assisted the resident into the recliner with their uniforms touching the bed and also the recliner. Once the resident was sitting in the recliner. CNA P entered the bathroom and placed gloves on, removed the urinary catheter bag and placed onto the recliner. CNA P then entered the bathroom and returned with paper towels and a graduate with the same gloves on. CNA P emptied the urine into the graduate and wiped the catheter bag tubing with a paper towel before they dumped it into the toilet. CNA P still did not place on a gown. On 8/20/24, at 11:45 AM, a record review of Resident #20's electronic medical record revealed an admission on [DATE] with diagnoses that included muscle weakness, Chronic Obstructive Pulmonary Disease and [NAME] Prostactic Hyperplasia. A review of the physician orders revealed Use enhanced barriers while performing high-contact activity with the resident . Order Status Active Order Date 07/18/2024 . On 8/21/24, at 11:00 AM, the Director of Nursing (DON) was alerted of the lack of Personal Protective Equipment (PPE) during care of Resident #20 and the DON offered that they should have had PPE on and that Infection Control Nurse had already started education. Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program encompassing outcome and process surveillance, resulting in a lack of accurate and comprehensive infection control tracking including potential infections, surveillance and data monitoring/analysis, appropriate Personal Protective Equipment (PPE) use, lack of implementation of water management sample recommendations, contamination of linens, and the likelihood for spread of microorganisms and illness to all 37 facility residents. Findings include: An interview and review of facility Infection Control (IC) data was completed with IC Registered Nurse (RN) B and the Director of Nursing (DON) on 8/21/24 at 1:12 PM. When queried regarding process surveillance for January 2024, IC RN B provided six audit forms for hand hygiene as well as Verification Checklist-Therapy Gym Cleaning completed by Therapy Staff and Verification Checklist-Kitchen Observation forms completed by Dietary Manager G. Review of the hand hygiene audit forms revealed two of the audits were completed by Dietary Manager G for Dietary Staff and four audit forms were completed by facility nurses for Certified Nursing Assistants (CNA). When queried what shifts audits were completed, IC RN B revealed all the audits were completed on the day or afternoons shifts. An explanation was not provided when asked why audits were not completed on midnight shift. IC RN B was asked what is one of the most important things that people can do to prevent the spread of infection, IC RN B replied, Washing hands. With further inquiry regarding the facility process/procedure for process surveillance including what audits were completed on a monthly basis, IC RN B revealed they do not do hand hygiene audits every month but do complete surveillance monthly. When asked if laundry was completed in the facility, IC RN B confirmed it was. When queried if they completed process surveillance/audits of laundry facilities/procedures, IC RN B replied they do not do official audits. With further inquiry regarding how they determine if linen is processed, stored, and handled in a manner to prevent contamination and the spread of microorganisms, IC RN B verbalized they go in the laundry room but do not have an official audit. IC RN B was then queried regarding the facility policy/procedure related to Enhanced Barrier Precautions (EBP) and if Personal Protection Equipment (PPE) should be utilized when providing care for an indwelling urinary catheter, and stated, Yes, should. IC RN B then revealed they were aware staff had not worn PPE when providing care to a resident with EBP in place. The facility Outcome Surveillance data for January 2024 was reviewed with IC RN B at this time. IC RN B provided a handwritten form titled, Line Listing of Resident Infections, a printed Order Listing Report for Antibiotic Orders and an infection map. The number of resident infections included on the line list did not match the number of infections indicated on the mapping tool. When queried regarding the discrepancy, IC RN B reviewed the data and indicated they missed marking infections on the map. The line listing for January 2024 did not include any carry over infections from December 2023. However, a review of the December 2023 Line Listing of Resident Infections revealed there was one carry over infection into January 2024. Further review of the January 2024 Line Listing of Resident Infections included six Residents and seven infections including four Healthcare Acquired Infections (HAI). There were no residents with signs/symptoms of infections not receiving antimicrobial treatment included on the tracking/surveillance form. The Order Listing Report included two Residents not included on the Line List of Resident Infections. Per the Order Listing Report, the Residents not listed on the Line List of Resident Infections were receiving nystatin powder (anti-fungal medication) and rifaximin (antibiotic medication used to treat irritable bowel syndrome, travelers' diarrhea, and to reduce the risk of overt hepatic encephalopathy-liver dysfunction) with the indication for liver. When queried how they track and complete surveillance of residents with signs/symptoms of infection for identification and prevention of spread who are not receiving treatment, IC RN B replied, Not tracking signs/symptoms of potential infections. When asked why not, IC RN B indicated they track actual infections that are treated. With further inquiry related to outcome surveillance, IC RN B revealed they do not include residents who have orders for nystatin powder because it is not a real infection. When queried if a fungal infection on the skin is transmittable to others, IC RN B and the DON confirmed it could be. When queried if everyone with the common cold and/or other sign/symptoms of gastrointestinal illness always receives antimicrobial treatment, IC RN B verbalized they do not. When asked, IC RN B and the DON confirmed the pathogens/illnesses are able to be transmitted to others and cause illness. IC RN B and the DON verbalized understanding of the importance of surveillance and tracking of potential illness and signs/symptoms of infection. Review of the Monthly Analysis and Summary/QAPI Committee Infection Prevention/Control Report for January 2024 specified there were three HAI infections. IC RN B was then queried regarding their role in the facility water management plan including monitoring for and preventing the spread of waterborne pathogens including legionella and revealed they were not involved in the water management plan. With further inquiry, IC RN B stated, Maintenance does the water testing and would let know me if we have any issues. IC RN B was asked how frequently water testing is completed and stated, Not sure. The facility water management plan was requested at this time. Maintenance Director J provided the facility Water Management Plan binder. The binder included Legionella water sampling testing results titled, Certificate of Analysis. The collection dates of Legionella testing since the last annual survey were dated: 10/11/23, 4/15/24 and 7/23/24. The results for each date included Pre and Post results from the Central Bathroom. The form did not detail the source of the water from the central bathroom. When queried what pre and post meant, Maintenance Director revealed they obtain samples before and after allowing the water to run. The sample dated as collected 10/11/23 detailed a positive result of 0.4 CFU/mL (Colony-Forming Units/milliliter) of Legionella species was identified and grown in the Post water sample. The Certificate of Analysis testing result form detailed, Action Criteria for Legionella . Detectable, but < 1 . Suggested Remedial Action: Potable Water: 2 . Implement action 1. (Review routine maintenance program recommended by the manufacture of the equipment to ensure that the recommended program is being followed. The present of barely detectable number of Legionella represents a low level of concern.) Conduct follow-up analysis after a few weeks for evidence of further Legionella amplification. The level of Legionella represents little concern, but the detected indicated that the system is a potential amplifier of Legionella . When queried if they were aware of the positive water testing results with Legionella growth, both the DON and IC RN B verbalized they were unaware of the result. When queried what actions were taken and if follow-up analysis of the water was completed, both the DON and IC RN B indicated they did not know. Maintenance Director J was contacted by the DON and returned. When asked about the positive Legionella testing results collected 10/11/23 and actions taken following the results including follow up testing, Maintenance Director J verbalized retesting was not completed beyond routine testing and indicated they did not need to complete follow up testing. When queried regarding the Remedial Actions included on the Certificate of Analysis test results, Maintenance Director J did not provide further explanation. When queried why only the central bathroom was tested and why water samples were not obtained, an explanation was not provided. The DON confirmed remediation actions should have been completed and stated, It's a learning experience. When queried regarding respiratory illness signs and systems and potential Legionella infection, IC RN B and the DON verbalized understanding of the importance of coordination and active involvement of the IC Nurse in the Water Management program. Review of facility provided policy/procedure entitled, Infection Prevention and Control Program (Reviewed/Revised: 12/27/23) revealed, The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases . b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings . 12. Linens . staff shall handle, store, process, and transport linens to prevent spread of infection . 16. Water Management: a. A water management program has been established as part of the overall infection prevention and control program . Review of the facility provided policy/procedure entitled, Water Management Program (no date) detailed, It is the policy of this facility to establish water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems . 1. A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing . 3. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Numbers MI00141220 and MI00141312. Based on interview and record review, the facility failed to honor a resident's right to return to the facility following the hospitalization of one resident (Resident #702) of three residents reviewed for transfer and discharge, resulting in Resident #702 being transferred to the hospital for evaluation and treatment related to mental health, and not being allowed to return to the facility without an alternative placement arrangement, necessitating them to stay in the Emergency Department for six days. Findings include: Resident #702: Review of intake documentation revealed concerns that Resident #702 was taken to the hospital Emergency Department (ED) on [DATE] for a mental health evaluation due to aggressive behaviors. Per the intake, Resident #702 was not allowed to return to the facility after having been evaluated at the hospital and determined not to require inpatient mental health treatment. Per information included on the intake documentation, Resident #702 was collaboratively managed by the area Community Mental Health while at the facility and had been taken to five different Emergency departments since [DATE] for mental health evaluations due to behaviors and hospitalized on ce. Record review revealed Resident #702 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizoaffective disorder, bipolar disorder, anemia, conversion disorder with seizures (mental health condition that causes real, uncontrollable physical symptoms), Traumatic Brain Injury (TBI), and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required limited-to-extensive assistance with dressing, personal hygiene, and toileting. The MDS further detailed the Resident displayed verbal behaviors directed toward others 1-3 days with no other behavioral symptoms. Resident #702 was discharged to the ED on [DATE] and did not return to the facility. Review of Resident #702's Electronic Medical Record (EMR) revealed the following documentation related to their final discharge from the facility: - [DATE] at 1:25 PM: SBAR Communication Form and progress note . The change in condition, symptoms, or signs I am calling about is/are: Resident has physical aggression toward staff x 4 staff. Resident also has a hx (history) of physical aggression toward residents x 2. This started on: [DATE]. Since this started has it gotten: Worse . Things that make the condition or symptom worse are: Triggers unknown, severe issues with impulse control . Things that make the condition or symptom better are: N/A . Treatment for last episode (if applicable): Resident has been sent to ER as well as in patient in [NAME] . Primary Diagnoses: Schizoaffective disorder, bipolar . pertinent history: Depression, Bipolar disorder . Mental Status Changes . New or worsening behavioral symptoms . Resident being physically aggressive toward staff and residents . Nursing Notes: On [DATE] resident was observed attempting to go into another residents room, when 2 staff members had to redirect him back to his room. On [DATE] the NHA and DON went down to the resident's room to discuss why he was attempting to go into another residents room when this resident grabbed the NHA by the neck and hair and threw her onto the bed. The DON and another staff member assisted to get this resident off of the NHA. NHA was observed with hair pulled out and red marks around face/neck and arm. Approximately 10 minutes later, this resident also came out into the hallway and grabbed the CNA who was doing one-on-one by the neck, also leaving red marks on his neck. Police notified. Clinical certifications completed . Scanned documentation in the EMR included Bed Holds for prior transfer/discharges but not the transfer/discharge on [DATE]. On [DATE] at 10:00 AM, an interview was completed with the DON and the facility Administrator. When queried regarding Resident #702's discharge from the facility on [DATE], the DON and Administrator verbalized that Resident #702 had an altercation with the Former Administrator causing injury. When asked, the DON revealed that the Police were called, facility physicians completed certifications for mental health, and the Resident was transferred to the ED. When queried what occurred after Resident #702 was transferred to the ED, the DON replied, They (ED Provider) said (Resident #702) could come back and did not qualify for inpatient mental health. The DON stated, We did not take (Resident #702) back. When queried why they did not take Resident #702 back, the DON revealed the Resident had two previous resident-to-resident altercations and they were concerned about safety. The DON verbalized the facility's corporate lawyers got involved and revealed an involuntary discharge was completed. When queried when the involuntary discharge document was given to the Resident, the DON stated, (CNA B) delivered to the hospital. When queried regarding the Resident's plan of care at the facility and interventions following the resident-to-resident altercations, the DON and Administrator revealed the Resident #702 had a one to one staff member and was seen by the county Community Mental Health (CMH). The DON and Administrator revealed CMH was working with the Resident find an Assisted Living Facility for the Resident to move to but had not found placement at the time of the incident involving the Former Administrator. The DON provided facility investigation documentation related to the incident involving Resident #702 on [DATE]. The provided documentation included: - Witness statements related to the incident involving Resident #702 and the Administrator - Typed Letter, signed by the DON detailing, Date of Notice: [DATE] . Hand Delivered. (Resident #702) Hospital Name (Note: Incorrect Hospital Identified) . Re: Immediate Involuntary Discharge . from (Facility) . This letter is to inform You that you will be immediately discharged on [DATE] . The specific reasons for your discharge are: Safety of other individuals in the facility is endangered due to clinical or behavioral status . - State of Michigan Probate Court, County of Gogebic (not county of facility) . Clinical Certificate . My determination is that the person has mental illness . recommend hospitalization only . Signed by facility Physician D on [DATE] at 3:01 PM. Note: The Clinical Certificate Form was not the most recent version of the form provided by the State of Michigan. - State of Michigan Probate Court, County of Gogebic (not county of facility) . Clinical Certificate . My determination is that the person has mental illness . recommend hospitalization only . Signed by facility Physician E on [DATE] at 3:01 PM. Note: The Clinical Certificate Form was not the most recent version of the form provided by the State of Michigan. - State of Michigan Probate Court (Blank) County . Petition of Mental Health Treatment . I request: the individual be examined at the hospital . I request . hospitalization only . Signed by the DON on [DATE]. - Lined piece of paper with the following written: [DATE] . ED Nurse . (Resident #702) belongings were dropped off by (Facility Name). Signed and dated [DATE] by hospital staff. - Pictures of the Former Administrator showing redness/bruising on face and arm. - Printed phone logs with unknown numbers. - Personal Protection Order (PPO) Application documentation for the Former Administrator against Resident #702 dated [DATE]. The documentation indicated the Former Administrator's statement of their reason for requesting the (PPO). The order was signed by the Judge on [DATE] but the facility premises was excluded from the order. A note on the on the order indicated the PPO was never served to Resident #702. A Police Incident number and business card was included in the documentation, but a Police Report was not provided. A copy of the Police Report was requested from the DON. An interview was completed with CNA B on [DATE]. When asked, CNA B confirmed they recalled Resident #702. When queried regarding the Resident, CNA B revealed they had been involved in a resident-to-resident altercations but then hit (Former Administrator) and was sent to the hospital. CNA B was asked if they were involved when Resident #702 was sent to the hospital and revealed they dropped off the discharge notification to the Resident at the hospital. When queried if Resident #702 signed the form, CNA B stated, No, the legal team had me deliver it. CNA B continued, I went to see (Resident #702) in the hospital and gave it to them. When asked if they said or explained anything when they gave Resident #702 the form, CNA B verbalized they told Resident #702, They wanted me to give this to you and left. CNA B added, Said I am sure you know what it is for. When queried if Resident #702 read and/or understood the form, CNA B revealed they did not know and were only instructed to deliver it. CNA B was asked when they went to the hospital to deliver the notice, CNA B revealed they did not recall. Review of Resident #702's Hospital Documentation revealed the Resident remained in the ED from [DATE] to [DATE]. Documentation included the following: ED Provider Notes: - [DATE] at 5:15 PM: Patient was sent over from (facility) due to violent behavior . hitting people and assaulting staff. When I asked the patient why . doing this says 'I do not know' . unwilling to talk to me further at this time - [DATE] at 11:43 PM: Patient . admits . was upset with the nursing staff at his facility due to the voice . understands that it is wrong for the hands another individual. I did discuss this as well with CMH . patient is not a candidate for mental health hospitalization . ED Notes: - [DATE] at 11:45 PM: Spoke with (nurse) from (facility) who stated . cannot accept this patient back to (Facility). This RN requested to speak to the nursing administrator and is awaiting a call back . - [DATE] at 8:29 PM: Per (Hospital Social Worker), the pet and cert (Mental Health petition and certification) sent by (Facility) is invalid due to being on an expired form . - [DATE] at 11:12 PM: This RN spoke with (Former Administrator) who states . cannot allow this patient to return to (Facility) due to violence that (Resident #702) has inflicted on herself and staff . states . placed a personal protective order on this patient and . has placed a formal complaints to the (County Police) to have this patient charged for assault and that this ED and BH (Behavioral Health) units have better ways to manage this patient. This RN explained to that the patient does not qualify for MH (Mental Health) unit placement per (CMH and Mental Health Provider) . (Former Administrator) stated will not speak with this RN on this matter anymore and that will be in contact with this ED manager in the morning regarding this patient's status at her facility and that the patient should go to jail. This RN offered to allow (Former Administrator) to speak with nursing supervision that was currently on and refused stating 'We will handle this all in the morning'. - [DATE] at 3:14 AM: (Police Dispatch) to infer on whether pt is to be released into Police custody due to reported charges being pressed against pt by (facility) staff. After talking with Deputy, (Resident #702) does not currently have any charges/investigations against them at this time . pt is not to be taken into police custody and the residence concern would be strictly between our ED and the (Facility). Pt will remain in ED . - [DATE] at 5:02 PM: Spoke with telehub (mental health) in regards to patient . doesn't meet criteria for mental health admission . if (Resident #702) is still here on Monday they will call a community meeting. Waiting to see when pt (patient) will be placed in AFC (Adult [NAME] Care) home . - [DATE] at 5:09 PM: Contacted by medical team regarding placement for patient. Reportedly patient is from (Facility) and is unable to return due to behaviors before this admission. (Psychiatric Provider, CMH .) determined patient is not appropriate for inpatient psychiatric care. Coordinated with (Facility admission Director F) regarding patient's return. Patient was sent to ED after choking (Former Administrator) . (CMH) currently seeking placement at AFC . not appropriate for MHU (Mental Health Unit) placement . (Other CMH) also found . that patient does not meet criteria for mental health unit placement. Consulted with (Physician), who agrees with discharge to (Facility). - [DATE] at 5:18 PM: Patient's belongings were dropped off by (Facility). Review of Resident #702's Documentation Survey Report for [DATE] revealed documentation of Resident #702 having a Rapid change in mood once on [DATE] and also stayed in their room several times during the month. Review of Resident #702's Documentation Survey Report for [DATE] revealed the only behavior documented during the month was they stayed in their room several times. Review of Resident #702's Documentation Survey Report for [DATE] revealed documentation that Resident #702 stayed in their room several times. The report further detailed Resident #702 had a rapid change in mood, listened to others' conversations, and acted out on them, and yelled at staff and peers once on [DATE]. Review was conducted of the Arenac County Sheriff's Office Incident Report Sheet dated [DATE] at 10:42 AM. The report was related to an Assault and detailed, Complaint/Victim (Former Administrator) . Information: (Former Administration) stated they came to (Resident #702's) room to talk to them about being in another patient's room. After talking for a minute, (Resident #702) by their hair, pulling them towards their bed. (Former Administrator) stated they yelled for help and (Certified Nursing Assistant [CNA] A) and the Director of Nursing (DON) came in to the (Former Administrator) free. (Former Administrator) stated (Resident #702) yelled, 'Admit me now bitch.' (Former Administrator) stated they left the room and called the Sheriff's Office . Suspect: (Resident #702) . Information: Went into patients; room last night to get cards and had permission. (Resident #702_ stated (Former Administrator) came in telling them they were going to get admitted to mental health facility. (Resident #702) stated (Former Administrator) was yelling at them - being a 'bitch' with a authoritative problem. So, they grabbed (Former Administrator) b their neck and twisted. Once other staff came in and they let go . Witness Info: (CNA A): Walked into (Resident #702) had (Former Administrator) in a head lock and grabbing them by their hair . assisted (Former Administrator) on getting free alone with (DON) . Went in with (Former Administrator) to talk about incident last night. (Resident #702) grabbed a hold of (Former Administrator). (DON) and (CNA A) helped (Former Administrator) get away. (Resident #702) stated 'now admit me bitch.' Action Taken: Took report of assault. Notified Undersheriff of the assault and (Resident #702) mental status being schizoaffective disorder and bipolar. Undersheriff advised would not be taking (Resident #702) to jail. Contacted Centralized Intake . Advised to file mental petition with court and contact (Community Mental Health [CMH] Worker B) about new housing. (Facility) advised they were already in the process to change housing, but the state is taking too long . An interview was completed with the DON on [DATE] at 2:00 PM. When queried why Resident #702 was not allowed to return to the facility from the emergency room after being medically cleared for discharge and not provided an opportunity to appeal the involuntary discharge, the DON revealed it was related to safety concerns and the discharge form was authored and provided to the facility to deliver to Resident #702 by Corporate. An interview was completed with the Former Administrator on [DATE] at 3:08 PM. When queried if they recalled Resident #702, the Former Administrator confirmed they did. The Former Administrator was asked what occurred on [DATE] and stated, I was terrified. I went in to talk to them about going into other resident rooms and (Resident #702) became aggressive. The Former Administrator was asked to explain how Resident #702 became aggressive and what was said. The Former Administrator stated, It was so fast. I can't believe (Resident #702) moved that fast. The Former Administrator revealed the Resident was a 1:1 sitter at the time because of two prior resident-to-resident altercations which had occurred including one in which Resident #702 had hit another resident on their ear. When queried if they were alone in room, the Former Administrator indicated no one was directly in the room but responded quickly when they yelled out. The Former Administrator revealed the Resident pulled their hair and they had multiple areas of bruising on their face and arm. A follow-up interview was conducted with the Former Administrator on [DATE] at 5:12 PM. When queried regarding the PPO, the Administrator replied, It was never served (to Resident #702) because the Police said they couldn't find them. With further inquiry, the Former Administrator revealed they did not know how the Police were unable to locate the Resident and were unsure if the PPO was effective as it had not been served. The Former Administrator verbalized the PPO authorized by the court did not include the facility building/premises which was what they had requested and been most concerned about. When asked, the Former Administrator confirmed criminal charges were not pressed against Resident #702. When queried regarding Resident #702's discharge plan, the Former Administrator verbalized CMH was working with the Resident and the facility to find a different placement and had taken the Resident to visit different Assisted Living Facilities. An interview was conducted with CMH Staff B on [DATE] at 10:14 AM. When queried regarding Resident #702's stay and discharge from the facility, Staff B stated, (Resident #702) and I were going out and looking at AFC's but apparently we weren't moving quick enough. When asked what they meant, Staff B stated, (Former Administrator) was not happy and wanted (Resident #702) moved. (The Former Administrator) let everyone know they were not happy (Resident #702) was there and let it show. CMH Staff B was asked how the Former Administrator let it show that they were unhappy Resident #702 was there, Staff B stated, (The Former Administrator) called me all the time and wanted us to move faster but it takes time to get things going. CMH Staff B elaborated they were working to get Resident #702 set up with the waiver program. CMH Staff B stated, (The Former Administrator) would call me all the time and tell me over and over how much it cost (the facility) to have (Resident #702) on a 1:1 sitter. They did not want (Resident #702) there. When queried if they knew what occurred when the Resident was sent to the ED and did not return to the facility on [DATE], CMH Staff B stated, I wasn't there but they (facility staff) had moved (Resident #702) recently. When asked what they meant, CMH Staff B revealed they moved the Resident to a different room and indicated that was difficult for them due to their mental health diagnoses. CMH Staff B continued, (Resident #702) knew they were basically persona non grata and not wanted there. CMH Staff B revealed they were told Resident #702 had displayed aggressive behaviors toward the Former Administrator and the facility dropped (Resident #702) off in the ED and basically would not take them back. CMH Staff B verbalized they worked with the ED to locate temporary placement for the Resident as the facility would not take Resident #702 back and continue to work with them to find alternative permanent placement. Review of facility provided policy/procedure entitled, Transfer and Discharge (including AMA) (Reviewed/Revised: [DATE]) revealed, It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations . 6. Non-Emergency Transfers or Discharges- initiated by the facility, return not anticipated. a. Document the reasons for the transfer or discharge in the resident's medical record . document the specific resident needs that cannot be met, facility attempts to meet the needs and the service available at the receiving facility to meet the needs . b. At least 30 days before the resident is transferred or discharged , the Social Services Director will notify the resident . in writing in a language and manner they understand . 7. Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident . i. Provide e a notice of the resident's bed hold police to the resident . at the time of transfer . j. Provide transfer notice as soon as practicable to resident and representative .

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess, monitor and follow up on Pacemaker checks and a Pacemaker machine for one resident (Resident #3), resulting in no follow up for 17 months, no documented assessment of Pacemaker function, no Pacemaker machine found with the likelihood of Pacemaker complications going unnoticed. Findings include: Resident #3: On 9/21/23, at 9:34 AM, Resident #3 was sitting in their wheelchair and stated, yes, they had a pacemaker and that it had been a while since it was checked. On 9/21/23, at 4:08 PM, Resident #3 was in their room. CNA G assisted with looking in every drawer and in the closet. There was no pacemaker machine found in the room. On 9/21/23, at 4:13 PM, The Director of Nursing (DON) was asked where Resident #3's pacemaker check machine was and the DON stated, they would look into it. On 9/22/23, at 8:24 AM, the DON was again asked where Resident #3's pacemaker machine was and the DON stated, I will have to call the cardiologist this morning. On 9/22/23, at 11:30 AM, a record review of Resident #3's progress notes revealed 9/22/2023 08:49 Nurses' Note . Call placed to Dr. (cardiologist) to notify office on status of cardiac monitor. Reported that facility did not receive the monitor and we would like to schedule resident for follow up appointment to verify stable cardiac status as reported by facility physicians and to verify remote cardiac monitoring is still required . Appointment scheduled for 10/12/2023 at 8:00 am . On 9/22/23, at 2:00 PM, a record review of Resident #3's electronic medical record (EMR) revealed an admission on [DATE] with diagnoses that included impaired balance, seizure disorder and atrial fibrillation. A review of care plan the resident has a pacemaker r/t (related to) Atrial fibrillation. Date Initiated: 03/12/2022 Revision on: 03/24/2022 Goal The resident will maintain free of s/sx (signs and symptoms) of altered cardiac output through review date Date Initiated: 03/12/2022 Target Date: 12/17/2023 Interventions . Monitor/document/report to MD/Nurse PRN and s/sx of altered cardiac ouptue of pacemaker malfunction: dizziness, syncope, difficulty breathing (Dyspnea), pulse rate lower than programmed rate, lower than baseline B/P/ Date Initiated: 03/24/2022 The resident's Pacemaker information: Manufacture: Medtronic Model: . Serial # . Date implanted: 3/7/2022 . Date initiated: 03/24/2022 Revision on: 03/24/2022There was no information regarding the cardiologist managing the pacemaker. There was no information regarding the need for pacemaker checks. There was no information regarding having an electronic pacemaker machine that would read the pacemaker and ensure its function status. A record review of the miscellaneous tab in the EMR CONSULTATION APPOINTMENT SHEET Date: 4-27-22 revealed Resident #3 had been to the Pacemaker Device Clinic that day. The RESULTS OF EXAMINATION: Device (check) WNL (within normal limits) Remote scheduled 8-2-22. SERVICES RENDERED: Device (check) Please call (with) any questions r/t (related to) home monitor. The number was provided on the document. The consult sheet further read OTHER SUGGESTIONS: Please make sure monitor is connected when arrives. RETURN APPOINTMENT DATE AND TIME: 8-2-22 remote (check)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure ongoing assessment, accurate documentation, and care coordination of pressure ulcer (wounds caused by pressure) wound care for one resident (Resident #2) of one resident reviewed resulting in inaccurate documentation, insufficient facility knowledge of pressure ulcer status, lack of wound status and assessment documentation from external wound care provider and the potential for inappropriate and/or delayed care/treatment, wound progression, and decline in overall health status. Findings include: Resident #2: Review of Resident #2's MDS (Minimum Data Set) Indicators indicated the Resident had a pressure ulcer. At 9:49 AM on 9/21/23, Resident #2 was observed ambulating independently with a walker, without staff assistance in their room. The Resident was walking away from their bed towards a wheelchair positioned near the room door. Resident #2 proceeded to sit in the wheelchair. A wound dressing was noted on the Resident's left lower extremity. The dressing was wrapped from the calf to the foot. The dressing was discernibly loose, and the Resident was observed pulling it upward, towards their knee. An interview was completed at this time. When queried regarding the dressing in place on their left lower leg, Resident #2 stated they had cellulitis and were being treated at the wound clinic. Resident #2 was queried regarding wound care provided by facility nursing staff and indicated facility staff did not address the wound because they were going to the wound care clinic. When asked if they had a pressure ulcer, Resident #2 stated they have never had a pressure ulcer. On 9/21/23 at 10:05 AM, Registered Nurse (RN) I was observed responding to Resident #2's call light. From the hallway, RN I was heard telling Resident #2 the dressing on their leg needed to stay in place. On 9/21/23 10:09 AM, an interview was conducted with Registered Nurse (RN) I. When queried regarding skin alterations and pressure ulcers, RN I replied, No pressure ulcers on 200 unit (Resident #2's unit). When queried regarding the wound dressing observed on Resident #2's left, RN I replied, (Resident #2) has an Unna boot (medicated, compression wrap dressing used to treat slow healing lower extremity wounds). RN I was asked when the dressing was due to be changes and stated, (Resident #2) typically goes once a week to wound care (clinic). When asked if the facility changed the Unna boot dressing, Resident #2 reiterated all their wound care treatments were supposed to be completed at the wound care clinic. When queried what wounds the Unna boots were being used to treat, RN I revealed the Resident had venous ulcers (wounds caused by lack of blood flow) on their legs. When asked if Resident #2 had a pressure ulcer, RN I responded they did not. Review of the facility provided CMS 802-Resident Matrix form detailed Resident #2 had an unstageable pressure ulcer (full thickness skin and tissue loss with unknown depth). Review of Resident #2's Electronic Medical Record (EMR) revealed the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Left Lower Extremity (LLE) cellulitis (bacterial infection of the skin), heart disease, chronic kidney disease, Peripheral Vascular Disease (PVD), diverticulitis with perforation and abscess (inflammation and infection of formed pouches creating a hole in intestines), and colostomy (surgically created opening through the abdomen to allow passage of fecal material). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance with bed mobility, transferring, ambulation, dressing, toileting, and bathing. The MDS further revealed Resident #2 had one stage three pressure ulcer (Full thickness tissue loss with exposed adipose tissue) and five venous/arterial ulcers. Review of Resident #2's current and discontinued care plans in the EMR revealed a care plan entitled, Resident is at risk for altered nutritional status related to . pressure ulcer, altered skin integrity, edema . (Initiated: 8/14/23; Revised: 9/20/23). A second care plan entitled, Resident is at risk for impaired skin integrity related to history of pressure ulcers, history of vascular ulcers . readmitted [DATE] (Initiated: 8/14/23; Revised: 9/19/23) was present in the EMR. This care plan included the following active and discontinued interventions: - Administer medications as ordered (Initiated: 8/14/23) - Complete skin inspection weekly and as needed (Initiated: 8/14/23) - Encourage/assist as needed to elevate heels off the mattress as tolerated (Initiated: 8/14/23) - Labs as ordered (Initiated: 8/14/23) - Complete skin inspection weekly and as needed (Initiated: 8/14/23) - Apply protective barrier cream after incontinent episodes (Initiated: 9/19/23) - RESOLVED: Pressure redistribution mattress to bed (Initiated: 8/14/23; Resolved: 9/19/23) Resident #2 had a third care plan entitled, Resident has impaired skin integrity as evidenced by: admitted with redness to buttocks/sacrum with open unstageable to left heel. Venous/stasis ulcers to left lower extremity. readmitted [DATE]. Unna boot remains in place to left lower extremity. Check placement every shift (Initiated: 9/19/23; Revised: 9/21/23). The care plan included the interventions: - Administer treatment(s) per orders (Initiated: 8/14/23) - Complete wound evaluation to observe the progress of the resident's skin condition (Initiated and Revised: 8/14/23) - Notify nurse of any new areas of skin impairment noted during bathing or daily care (e.g., redness, blisters, bruises, discoloration, impairment related to medical device/tubing) (Initiated: 9/19/23) Review of wound assessment documentation in Resident #2's EMR revealed the following: - 4/25/23 at 2:02 PM: Wound Evaluation . #3 Pressure- Unstageable (Slough and/or eschar) . Left Heel . Present on admission . Wound Bed . Eschar . 100% . Exudate . Light . Serous . Area measuring 0.4 (centimeters [cm]) x 0.4 cm x UTD (Unable to Determine) . - 5/2/23: Wound Evaluation . #3 Pressure- Unstageable . Left Heel . Length: 1.3 cm . Width: 0.52 cm . - 5/15/23: Wound Evaluation . #3 Pressure- Unstageable . Left Heel . - 5/23/23: Wound Evaluation . #3 Pressure- Unstageable . Left Heel . Length: 0.37 cm . Width: 0.3 cm . - 7/17/23 at 2:37 PM: Wound Evaluation . #3 Pressure- Unstageable (Slough and/or eschar) . Left Heel . Resolved . Describe . Pressure . Unstageable Due to Slough and/or eschar . Present on admission . Wound Age: Unknown . Continues to go to weekly wound clinic appointment at this time, weekly unna boot changes that are to stay in place until next appointment. Weekly wound clinic notes will be uploaded to chart . Review of progress note documentation in Resident #2's EMR revealed: - 5/30/23 at 3:30 PM: Nurses' Notes . Unna boot changed, wounds improving. Unna boot changed prior to weekly pictures. Resident request not to remove Unna boot for new pictures . Resident is getting setup with (outpatient wound care clinic), appointment 6/8/23. - 6/7/23 at 3:20 PM: SOC-LACE (Return to hospital risk) .Unna boot and outpatient wound care to left lower extremity . - 6/8/23 at 9:54 PM: Physician Progress Note . Patient seen and evaluated for a routine visit . Patient was seen at wound clinic and placed with [NAME] boot . - 6/21/23 at 11:18 AM: Resident's wound care appointment rescheduled for Friday 6/23/2023, leave Unna boot in place per wound care until appointment Friday. - 6/22/23 at 3:16 PM: SOC-LACE (Return to hospital risk) . weekly Unna boot changes at wound care clinic . patient has left leg ulcer which is healing slowly . Extremities: Edema in right and left distal lower extremities. Left leg compression stocking in place . - 6/29/23 at 12:06 PM: Physician Progress Note . seen and examined . continue wound care . - 7/5/23 at 4:18 PM: Nurses' Notes . Resident has Unna boot on LLE, wound evaluation completed weekly at wound clinic. See uploaded notes. - 7/12/23 at 3:41 PM: Nurses' Notes . Wound assessment completed weekly at wound clinic. Wound clinic sends notes weekly, Unna boot changed weekly at visit. Clinic does not take pictures of wounds weekly, when they do, they will send them to be uploaded into chart. - 7/13/23 at 11:13 AM: Nurses' Notes . returned from wound care clinic at this time. no new orders. - 7/19/23 at 1:14 PM: SOC-Nutrition/Hydration . Altered skin integrity to left lower leg and left heel. Wounds are being managed by outpatient wound clinic. Areas are improving per wound clinic . A review of scanned documentation in Resident #2's EMR revealed the following notes from the wound care clinic: - 6/6/23: Wound Care Clinic . Physician Order Details . Pressure Ulcer of Left Heel . Stage 3 . Wound #7 - Calcaneus (heel) . Left . Cleanser: Soap and water . 1 X Per Week . Primary Dressing: Medihoney . Telfa Non-adherent Dressing . Woven Gauze Sponge . Compression Wrap: CoFlex TLC Calamine Lite 2-layer Compression System (Unna Boot) 1 X Per Week . The scanned documentation did not include wound measurements and/or further description. - 6/13/23: Wound Care Clinic Multi Wound Chart Details . Wound Number: 7 . Left Calcaneus . Pressure Ulcer . Weeks of Treatment: 1 . Wound Status: Open . Measurements: 0.9 (cm) X 0.4 (cm) X 0.1 (cm) . Stage 3 . Exudate: Large . Serosanguineous . red, brown . Necrotic . 67-100 % . Exposed Structures . Fat Layer . Physician Order Details . Cleanser: Soap and water . 1 X Per Week . Primary Dressing: Medihoney . Secondary Dressing: Woven Gauze Sponge . Compression Wrap: CoFlex TLC Calamine Lite 2-layer Compression System 1 X Per Week . The scanned documentation did not include wound measurements and/or further description. - 6/23/23: Wound Care Clinic . Physician Order Details . Pressure Ulcer of Left Heel . Stage 3 . Wound #7 Calcaneus (heel) . Left . Cleanser: Soap and water . 1 X Per Week . Primary Dressing: Medihoney . Secondary Dressing: Woven Gauze Sponge . Compression Wrap: CoFlex TLC Calamine Lite 2-layer Compression System 1 X Per Week . The scanned documentation did not include wound measurements and/or further description. - 6/30/23: Wound Care Clinic . Progress Note Details . History of Present Illness (HPI) . Location . left heel. Severity: Wounds are moderate with exposed structure . 6/30/23: The patient's wounds continue to improve the exception of the anterior inferior ulcers. They continue to be significantly deep without granulation. All wounds are debrided. These 2 wounds are dressed with Medihoney. The remainder are dressed with collagen and a nonstick dressing . patient will continue with regular wound care . Assessment . Pressure Ulcer of left heel, stage 3 . Procedures . Wound #7 . Selective/Open Wound Non-Viable Tissue Debridement . Material removed includes Slough, biofilm, and fibrin/exudate . minimum amount of bleeding . Post Debridement Measurements: 0.8 cm length X 0.7 cm width X 0.1 cm depth . Post debridement . Stage 3 . Plan . Wound #7 - Calcaneus (heel) . Left . Cleanser: Soap and water . 1 X Per Week . Primary Dressing: Prisma (collagen based dressing for moist wound healing) . 1 X Per Week . Telfa Non-adherent Dressing . 1 X Per Week . Woven Gauze Sponge . 1 X Per Week . The fax date/time on the scanned note was 6/30/23 at 3:19 PM. The note also included the following recap of prior wound care clinic appointments/treatments under the History of Present Illness section: 6/23/23 . Heel ulcer appears to be resolved. We will continue with topical Medihoney and lower extremity compression . 6/6/23 . patient currently at (facility) and has had 3 weeks of Unna boot treatment . Stage 3 pressure ulcer of the left heel . Wound #7 . open . stage 3 . pressure ulcer Left Calcaneus . measures 0.8 cm length X 0.7 cm width X 0.1 cm depth . There is fat layer (subcutaneous tissue) exposed . Large amount of serosanguineous drainage . large (67-100%) amount of necrotic tissue with the wound bed including adherent slough . Selective/Open Wound Non-Viable Tissue Debridement performed . Post Debridement Measurements: 0.8 cm length X 0.7 cm width X 0.1 cm depth . Stage 3 . - 7/20/23: Wound Care Clinic . Progress Note Details . History of Present Illness (HPI) . Location . left heel . Wounds are moderate with exposed structure . Patient did mention that Unna boot feels tight sometimes . on the edge of appropriateness for compression. We will switch from the long stretch Coban to a 4-inch sterile which should be a little bit light compression . The note included the same recap of wounds included previously on note dated 6/30/23. No additional scanned documentation were present in Resident #2's EMR. Review of Resident #2's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for September 2023 revealed the following: - Change [NAME] boot dressing per wound care every day shift for 1 Day (Start Date: 9/1/23). Documented as completed on 9/1/23. - Place [NAME] boot to left lower extremity one time only for 1 Day (Start Date: 9/19/23). Documented as completed on 9/19/23. - Left Heel: Wound assessment, Document abnormal's in progress notes . every day shift every Tue for Weekly wound assessment with dressing change. Note site, provide notification and other details in the progress note . (Start Date: 5/30/23; Discontinued: 9/18/23). Documented as completed on 9/5/23 and 9/12/23. - Check placement of Unna boot q (every) shift. Changed weekly at wound care (clinic) . every shift for Wound Care (Start: 6/9/23; Discontinued: 9/18/23; Start: 9/21/23). Review of Resident #2's Healthcare Provider (HCP) orders, related to their left heel pressure ulcer, in the EMR including the following: - Cleanse area to left heel with wound cleanser. Pat dry, and apply skin prep to areas q shift every shift for wound care (Ordered: 4/25/23; Discontinued: 5/4/23, Ordered: 5/13/23; Discontinued: 5/15/23) - Cleanse left heel wound with normal saline, pat dry. Apply piece of Xeroform gauze to area, cover with gauze. Secure with kerlix q (every) night and prn (as needed) every night shift for tx (treatment) (Ordered and Discontinued: 4/21/23, Ordered: 5/3/23; Discontinued: 5/4/23) - Cleanse left heel wound with normal saline, pat dry. Apply piece of Xeroform gauze to area, cover with gauze. Apply A&D ointment all elsewhere to foot. Secure with kerlix q (every) night and prn (as needed) every night shift for tx (treatment) (Ordered: 5/4/23; Discontinued: 5/8/23) - Cleanse area to left heel with normal saline, pat dry and apply xeroform gauze, and wrap with kerlix every night shift. every night shift for wound care (Ordered: 5/15/23; Discontinued: 5/16/23) - Silvadene External Cream 1 % (Silver Sulfadiazine) (topical antibiotic cream). Apply to left heel topically every night shift for wound care Cleanse left heel with normal saline, apply Silvadene cream, cover with gauze and secure with kerlix q night and prn (Ordered: 5/16/23; Discontinued: 5/25/23) - Left Heel: Daily wound assessment, Document abnormals in progress notes. Surrounding Skin: skin Normal = N Abnormal = A Wound Pain: Pain Document level of pain at wound site Drainage/Exudate Present: Drain Yes = Y No = N Odor Present: Odor Yes = Y No - N Necrotic Tissue present: Necro Yes = Y No - N Infection present: Infec Yes = Y No = N every night shift Note site, provide notification and other details in the progress note . (Ordered: 5/15/23; Discontinued: 5/25/23, Ordered: 5/25/23; Discontinued: 9/18/23) - Cleanse left lower extremity below the knee to toes with wound cleanser or normal saline, pat dry with gauze, apply Unna boot to left lower extremity from toes to below the knee, wrap with kerlix and secure with coban. Apply 5/25 to be changed on Tuesday 5/30. Change weekly and PRN after 5/30. One time only for Wound Care for 1 Day (Ordered: 5/25/23) - Cleanse left lower extremity below the knee to toes with wound cleanser or normal saline, pat dry with gauze, apply Unna boot to left lower extremity from toes to below the knee, wrap with kerlix and secure with coban. Change weekly and PRN . (Ordered: 5/25/23; Discontinued: 6/8/23; Ordered: 6/8/23; Discontinued: 6/9/23) - Change Unna boot dressing per wound care. Every day shift for 1 Day (Ordered and Start: 7/28/23; End: 7/29/23) - Change Unna boot dressing per wound care. Every day shift for 1 Day (Ordered: 8/28/23; Start 9/1/23; End: 9/2/23) Note: Facility and treatments orders did not correlate with Wound Care Clinic recommendation/orders. On 9/22/23 at 8:41 AM, an interview was completed with Resident #2 in their room. A wound dressing was visible on the Resident's left lower extremity. When queried if the Unna boot had been applied by facility nursing staff after their return from the hospital, Resident #2 stated, I thought they were going to do it at the wound care clinic. Resident #2 then stated, It gets changed once a week but did not provide a response to the question. An interview was completed with MDS/Wound Care RN J on 9/22/23 at 10:41 AM. RN J was asked if Resident #2 had a pressure ulcer and stated, (Resident #2) came in with an unstageable on their left heel. With further inquiry regarding Resident #2's pressure ulcer, RN J stated, All (Resident #2's) wound are being treated by (external wound care clinic). When asked how often wound measurements are completed, RN J replied, Weekly. When queried why there was not weekly wound measurements and assessments in Resident #2's EMR, RN J indicated they should, unless they were in the hospital/out of the facility and/or refused. RN J proceeded to review the Residents EMR. The Director of Nursing (DON) joined the interview at this time. Review of Resident #2's clinical census with RN J and the DON revealed the Resident was out of the facility, in the hospital, from 5/4/23 to 5/13/23 and from 9/15/23 to 9/19/23. When asked why there was no facility wound assessment documentation from 5/23/23 to 7/17/23, RN J stated, I did not measure anymore when (Resident #2) started going to the wound clinic. When asked why no wound measurement /assessment documentation was completed on 5/30/23, RN J indicated the dressing had been completed prior to the wound pictures being obtained. When asked to elaborate, the DON revealed the floor nurse had removed and reapplied the Unna boot dressing before they went to complete the wound care measurements and treatment. The DON disclosed Resident #2 did not want to have the Unna boot removed for wound pictures as it had just been applied. When queried why as assessment was completed on July 17th if they were no longer measuring the wound, the DON stipulated they resolved the left heel pressure wound and assessment because the wound care clinic was performing all wound care measurements. When asked to clarify if Resident #2's left heel pressure ulcer was resolved because it was healed or because the wound care clinic, and not the facility, were completing the wound measurements/assessments, the DON confirmed it was resolved because the facility was not documenting on it. When asked why there was still a treatment in place on the TAR for assessment of the left heel pressure ulcer if it was not being assessed, the DON and RN J explained that resolving the wound in the assessment discontinued the assessment. The DON and RN J were asked what current pressure ulcers/wounds Resident #2 had and indicated the wound care clinic notes would need to be reviewed. When queried why the most recent wound clinic documentation present in Resident #2's EMR was from 7/20/23, both the DON and RN J revealed there should be more recent documentation from the wound clinic. A review of the scanned documentations in Resident #2's EMR was completed with the DON and RN J at this time. After review, both staff verified the last documentation from the wound care clinic in the EMR was dated 7/20/23. The staff were then asked the facility policy/procedure to ensure communication is maintained between the Wound Care Clinic and the facility, both the DON and RN J revealed the wound care clinic is supposed to send notes back with the Resident and staff member who accompanies them. RN J left the conference room to speak to other staff. Upon their return, RN J stated that another staff member was getting a copy of the wound care clinic documentation. RN J then stated the staff member who accompanies Resident #2 to their appointments asks (for the documentation) but does get them. When queried how they knew what wounds Resident #2 actually had without the documentation, an explanation was not provided. When queried how they knew the wound care orders were the same without documentation from the wound care clinic, both the DON and RN J relayed the clinic would call them if the orders were changed. When asked why the orders in the EMR did not match the orders/plan on the available wound care clinic notes in the EMR, a response was not provided. When queried why the wound care documentation in the EMR indicated the left heel pressure ulcer was healed on 6/23/23 while also specifying the pressure ulcer was debrided on 6/30/23, and lack of clarification documentation in the EMR, RN J indicated they would need to review the documentation. RN J was then asked why the MDS assessment dated [DATE] specified Resident #2 had a left heel pressure ulcer when the facility had not assessed the wound, documentation from the wound care clinic was unclear, and there was no clarification documentation, clarification was not presented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to institute and operationalize policies and procedures to ensure comprehensive Range of Motion (ROM) monitoring, documentation, and implementation of a restorative nursing program for one resident (Resident # 1) of two residents,, resulting in a lack of restorative nursing services to maintain and/or prevent further decline in ROM, lack of quantitative assessment and documentation of ROM limitation, and the likelihood for increased ROM limitations, pain, and decline in independence and quality of life. Findings include: Resident #1: On 9/21/23 at 9:10 AM, Resident #1 was observed in their room, sitting in their bed. The head of the bed was elevated, and they were wearing a hospital style gown. An interview was completed at this time. During the interview, Resident #1 did not move either shoulder. The Resident was noted to only move their arms from the elbow joint. When queried if they were able to move their shoulders and lift their arms, Resident #1 replied, No and revealed they had arthritis. When asked if they were receiving Therapy, Resident #1 stated, No. With further inquiry, Resident #1 revealed they had previously received therapy but not currently. When asked if they were receiving Restorative Nursing to assist with ROM and movement, Resident #1 indicated they were not. With further discussion, Resident #1 indicated they would like to receive therapy and/or Restorative Nursing. Resident #1 verbalized a Restorative Nursing program had not been offered and/or discussed with them. When queried how they transfer and get out of bed, Resident #1 revealed the staff use a Hoyer (mechanical lift to transfer dependent individuals). Record review revealed Resident #1 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included heart failure, cerebral infarction (stroke) with resulting right sided hemiplegia and hemiparalysis (one sided paralysis), dysphagia (difficulty swallowing, and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete all Activities of Daily Living with the exception of eating. The MDS further detailed Resident #1 had no upper or lower extremity ROM limitations. A comparative review of Resident #1's prior MDS assessments for ROM limitations revealed bilateral Upper Extremity (UE) impaired ROM was documented on the MDS assessments dated 9/7/22, 12/8/22, and 12/16/22. One sided Lower Extremity (LE) ROM impairment was documented on the MDS assessments dated 9/7/22, 12/8/22, 12/16/22, and 1/14/23. Review of Resident #1's current and discontinued care plans did not include a care plan related to limited ROM. Review of Resident #1's progress note documentation in the Electronic Medical Record (EMR) included the following: - 4/1/23 at 9:44 PM: Nurses' Notes . At dinner time res stated was having left shoulder pain . in rotator cuff . Resident crying when shoulder palpated lightly - no abnormalities felt. No swelling, discoloration, or injury. Denied recent injury or fall. Resident given Tylenol and gabapentin as ordered, and per resident request . - 4/1/23 at 11:49 PM: Nurses' Notes . Report received from RN at ER . X-ray of shoulder shows severe arthritis . - 8/16/23 at 3:27 PM: Physician Progress Note . Seen and evaluated this afternoon . sitting up in wheelchair and is doing well . is complaining of shoulders hurting with arthritis and is on Norco (narcotic pain medication) TID (three times per day) prn (as needed) . will continue with the present medications and will follow up. No new changes. Review of scanned therapy documentation in Resident #1's EMR revealed: - Occupational Therapy (OT) Evaluation & Plan of Treatment . dates: 6/7/23 -7/6/23 . Musculoskeletal System Assessment . UE ROM . RUE ROM = Impaired; LUE ROM = Impaired . RUE ROM . Shoulder = Impaired . Elbow/Forearm = Impaired . LUE ROM . Shoulder = Impaired . Elbow/Forearm = Impaired . AROM (Active Range of Motion) R Shoulder: Flexion = NA (decreased ROM, unable to obtain measurements secondary to increased fatigue) . - Physical Therapy (PT) Evaluation & Plan of Treatment . dates: 6/8/23 -7/16/23 . Musculoskeletal System Assessment . LE (Lower Extremity) ROM: RLE ROM= WFL (Within Functional Limits); LLE ROM = WFL . Assessment Summary . Barriers . None noted . Exercises Prescription . Purpose of Exercise = Range of Motion, Endurance, Strength . PT and/or OT discharge summary documentation were not noted in Resident #1's EMR. An interview was completed with Restorative RN K on 9/22/23 at 1:33 PM. When queried if Resident #1 had limited ROM in their shoulders, RN K revealed the Resident had arthritis. RN K was asked if the Resident was receiving Restorative Nursing and stated, No. When queried why Resident #1 was not receiving Restorative Nursing, RN K replied they had not received a referral from Therapy services for restorative. When queried regarding the facility process/procedure in which Restorative is initiated, RN K indicated most residents are referred after being discharged from therapy. When queried why Resident #1's therapy discharge documentation was not scanned into their EMR, RN K was unable to provide an explanation. A copy of the discharge documentation was requested at this time. Review of Resident #1's PT Discharge Summary for Dates of Service: 6/8/23 -7/16/23 revealed Therapy services did not recommend a functional maintenance or Restorative Nursing program upon discharge. Review of Resident #1's OT Discharge Summary for Dates of Service: 6/7/23 -7/18/23 revealed Therapy services did not recommend a Restorative Nursing program upon discharge. An interview was conducted with Therapy Manager L on 9/22/23 at 1:43 PM. When queried regarding Resident #1, Manager L confirmed the Resident was no longer receiving therapy services. Manager L was asked if Resident #1 had ROM limitations and confirmed they did. When asked why the Resident was not referred to the facility Restorative Nursing Program following therapy discharge to prevent further limitations and/or maintain current level of functioning, Manager L stated, Because (Resident #1) is non-compliant. When asked why they meant, Manager L stated, (Resident #1) said they will walk with therapy but not with aides. When asked if Therapy Staff worked with the aides to ensure the Resident felt safe when walking with them, Manager L did not provide a response. Manager L then stated, One time (Resident #1) complained of pain in their wrist and said it really, really hurt and indicated the Resident did not want to participate in therapy. When queried if therapy staff typically measure the degree of ROM to determine and identify the level of impairment, Manager L replied, We don't measure unless a specific reason. Manager L was then asked what impaired meant when documented for shoulder ROM and stated, Less than 90 degrees. When queried if less than 90 degrees could be 10 degrees or 80 degrees, Manager L confirmed and stated, It's vague. When asked how the facility determined and identified if a Resident's ROM was decreasing without measurements, Manager L indicated they understood but did not provide further explanation. A follow up interview was completed with RN K on 9/22/23 at 2:11 PM. When queried why the most recent MDS indicated Resident #1 had no limitations in ROM when the last PT/OT evaluations specified the Resident did have limitations, RN K reviewed the MDS and confirmed they had made an error during MDS completion. RN K was then informed of Manager L stating Resident #1 was not referred to Restorative Nursing due to being non-compliant and asked if that was acceptable. RN K verbalized it was not and indicated nursing staff are able to work with Residents in different ways than therapy. Review of facility policy/procedure entitled, Restorative Nursing (Implemented 1/1/21) revealed, The goal (s) of Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a gait belt and walker during a toilet transfer for one resident (Resident #3), resulting in the care plan not being followed and an unsafe transfer. Findings include: Resident #3: On 9/21/23, at 9:24 AM, Resident #3 was sitting in their room in their wheelchair. Resident #3 pushed their call light for assistance. Shortly after, CNA H entered and offered Resident #3 assistance. The resident stated they needed to use the bathroom. CNA H pushed the resident into the bathroom and assisted the resident to stand up and then onto to the toilet. CNA H did not use a gait belt. CNA H left out of the room and came back a short time later. Resident #3 was in the bathroom on the toilet. CNA H assisted the resident out of the bathroom and back to their wheelchair. CNA H was asked why there was a gait belt hanging on a hook on the wall and CNA H stated, she doesn't always let us use it and often will say let me you do it myself. On 9/22/23, at 2:00 PM, a record review of Resident #3's electronic medical record (EMR) revealed an admission on [DATE] with diagnoses that included impaired balance, Limited mobility and seizure disorder. A review of the resident is at risk for falls related to . Date initiated: 03/11/2022 Revision on: 03/24/2022 The resident will be free of falls through the review date . Interventions . Use gait belt for transfers/walking Date Initiated: 03/11/2022 . A review of the the resident needs activities of daily living assistance related to: Activity Intolerance. Cognitive Deficits . Date Initiated: 03/11/2022 Revision on: 01/17/2023 . Interventions . Transfer with 1 assist with gait belt and front wheeled walker Date Initiated: 03/11/2022 Revision on: 04/13/2022 . A review of the the resident has a mood problem . Interventions . Provide care in unhurried manner Date Initiated: 03/24/2023 .

Based on interview and record review, the facility failed to ensure that the Director of Nursing (DON) worked fulltime/40 hours a week in the facility, resulting in the lack of a fulltime DON working 40 hours in the facility and with the likelihood of decreased oversight and management of resident care and assessment. Findings include: On 9/20/23, at 10:32 AM, During entrance conference, the Administrator stated that the Director of Nursing (DON) worked fulltime; 40 hours a week and that there were no nursing waivers. On 9/22/23, at 12:42 PM, The DON was asked if they worked fulltime at the facility and the DON stated, there are two days a week they go to another facility. The DON was asked to explain and the DON explained, they didn't want to be confusing and that they go right to the other facility from home. The DON explained the other facility was under survey so they went there but then had to come to this facility as a survey was being conducted. The DON was asked if there were set days they are at the other facility and the DON stated, usually Tuesdays and Thursdays. The DON was asked if they come in on the weekends to pass medications and the DON stated, No. On 9/22/23, at 3:18 PM, Payroll Benefits Coordinator (PBC) A was interviewed regarding the fulltime DON position and how many hours a week they work. PBC A explained that it varies and depends on how much the other facility needs the DON and that they have to fill out a transfer form so the other facility gets charged for the hours the DON works at their building. PBC A was asked who covers the DON when they are not in the building and PBC A stated, the Administrator has 2 hours a day as interim a day for don allocation. PBC A explained for form as they fill it out, the Administrator signs it and then the transferring facility administrator signs it also. On 9/22/23, at 3:20 PM, a record review of Employee Hours Transfer Form along with PBC A was conducted which revealed Date: Employee Name: Home Facility: Position: Pay Rate: Transfer Location: Number of Days Worked: Total Hours Worked: Home Administrator: Transfer Administrator: The Employee Hours Transfer Form were filled in with the following dates worked at the transferring facility and signed by both Administrator's: Date: 6-1-23 . Number of Days Worked: 5/31, 6/1 . Date: 6-8-2023 . Number of Days Worked: 1 day . Date: 6-15-2023 . Number of Days Worked: 1 day . Date: 6-21-2023 . Number of Days Worked: 1 day 6/21 . Date: 6-30-2023 . Number of Days Worked: 1 day . Date: 7-6-2023 . Number of Days Worked: 1 day . Date: 7-7-2023 . Number of Days Worked: 1 day . Date: 7-13-23 . Number of Days Worked: 1 day 7/13 . Date: 7-18-2023 . Number of Days Worked: 1 day 7/18 . Date: 7-25-2023 . Number of Days Worked: 1 day 7/25 . Date: 7-27-2023 . Number of Days Worked: 1 day 7/27 . Date: 8-1-2023 . Number of Days Worked: 2 days 8/1, 8/4 . Date: 8/8/2023 . Number of Days Worked: 2 days. 8/8, 8/10 . Date: 8/22/2023 . Number of Days Worked: 2 days 8/22, 8/25 . Date: 8-29-2023 .Number of Days Worked: 2 days 8/29, 8/31 . PBC A was asked to clarify the dates the DON transferred to the other facility to work was it for the weekend or during the week and PBC A stated, they are only during the week. A further review of the Employee Hours Transfer Form revealed the following dates the DON was transferred to the other facility: 9/6 9/7 and on 9/18 the DON was transferred to a third facility to work. During exit conference, the facility Administrator and the DON offered that they would provide additional documentation. The facility provided the DON's time sheet and a typed letter from the Administrator three days after survey exit. The letter read Full time Director of Nurses: As you will note, the requirement has been met by having a designated, full-time registered nurse serving as the director of nursing. Additionally, in regards to the guidance for PBJ, as defined by CMS, (see attached). (DON) RN, licensed in the State of Michigan, is the full time DON for (facility) (DON) is available to (facility), 24/7/365. As part of her DON functions and development, she has been assigned to learn from and assist other facilities, AND, consistently remains responsible and accessible to (facility). Additionally, through technology and company equipment, (DON) is able to receive input from and promptly respond to her team and NHA as needed. Her hours of connectedness to her facility well exceeds the minimum 40 hour work week. Please see attached payroll documents. The letter was signed the Administrator and Dated 9-25-2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a clean ice machine, a proper functioning dish machine, a clean process for clean drying dish racks and a clean fan in the main kitchen, resulting in cross contamination of clean dishes and dish racks, a leaking dish machine with the likelihood of dirty dust particles likely to contaminate clean dishes on the dying rack and the likelihood of cross contamination for all residents using dishes in the facility. Findings include: On 9/20/2023, at 12:35 PM, observation of the main ice machine was conducted along with Dietary Manager DM D DM D lifted the lid and 3 orange perpendicular lines were observed as if they had been dripping in the ice. DM D was asked to wipe the bottom of the medal face plate which revealed orange and brown residue onto the white tissue. DM D was asked what color it was and DM D stated, it's brown debris with a bit of orange. DM D was asked who cleans the ice machine and DM D explained, the kitchen staff cleans it. On 9/20/23, at 12:50 PM, Kitchen [NAME] C along with DM D were interviewed at the ice machine. Kitchen [NAME] C explained how they clean the ice machine and that they would wipe down the medal face plate to include the plastic facing. DM D took another white tissue and wiped one of three orange line of debris which made the tissue bright orange in color. This did not appear as rust. DM D stated, I would say it needs to be recleaned. DM D took an additional white tissue and again wiped the bottom of the medal face plate which revealed a large amount of orange and brown residue. Kitchen [NAME] C was asked if they thought the ice machine was clean or dirty and Kitchen [NAME] C stated, it's dirty and we will clean it. On 9/20/23, at 1:17 PM, the Administrator was made aware of the orange and brown residue noted on the ice machine and the Administrator stated, maintenance is cleaning it. The Administrator was asked who's responsible for cleaning the ice machine and the Administrator stated, maintenance and they clean it monthly. The Administrator was asked to provide the cleaning schedule for the ice machine. On 9/22/23, at 1:48 PM, an observation of the dish room, dish machine and the circulating fan over the dry dish rack was conducted along with DM D. The circulating fan was stopped and there was a large amount of dust and debris noted to the fan cover and blades. DM D stated, they would get the fan cleaned. The dish machine had a gross amount of food debris and white residue noted to all corners and seams. DM D was asked to run the dish machine to ensure proper temperature cycle. While the dish machine was running during the washing cycle it was noted to leak water on all sides and onto a hanging pipe and handle to the back wall. The dirty water spurted out onto the drying counter and splashed onto a clean rack of dishes. The dish machine was noted to spurt the water during the rinse cycle onto the clean dishes also. DM D was asked how often the dish machine was cleaned and how long had it been leaking onto the clean dishes and DM D stated, we clean it every couple of days and that the buildup was normal. DM D was asked to explain where the clean dish racks go after cooling off and DM D stated, they get placed on the clean dish rack next to the cooling counter. The clean dish rack was observed to be plastic and have approximate 3 inch slots noted to all the shelves. DM D was asked to have the Administrator come to the dish room. On 9/22/23, at 2:00 PM, the Administrator entered the dish room and was asked if the dish machine was normally dirty and leaking and the Administrator stated, that they could clean the dish machine every day. The Administrator was made aware of the spurting dirty dish water onto the clean dishes and the Administrator stated, that the clean dish rack could be pushed farther down the drying counter, and they lifted an empty dish rack that revealed a large amount of dried food particles underneath the rack. As the Administrator pushed the clean dish rack away from the dish machine the dirty water that had spurted out onto the counter was pushed down farther on the clean drying counter. DM D was asked how they could ensure that the dry dish rack was not contaminated with the dirty dish water and food particles and the DM D did not respond. The Administrator was asked to provide the cleaning schedule and who was responsible for maintaining the dish machine. It was explained that the dish machine was rented and the DM D would contact the representative responsible. DM D was asked to provide the manufacturer recommendations on cleaning and maintenance of the rented dish machine and the facility's cleaning schedule of the kitchen. On 9/22/23, at 3:31 PM, a further observation of the dish machine with DM D was conducted. The dish machine was noted to be clean of food debris and clean of the white residue. DM D stated, that the white residue appeared to be lime buildup and used a lime cleaner to remove it. The pipe to the back wall over top of the dying counter was cleaned of all debris. DM D stated, that the fan was also cleaned and was placed back over top of the clean dish rack. The fan was observed to be clean of all debris. A review of the facility provided Commercial Dishwasher Cleaning Checklist THE ULTIMATE CHECKLIST FOR DAILY CLEANING guideline revealed . the food debris, grease and other dishware impurities don't just magically [NAME]. Some of it gets flushed away, but a significant amount gets stuck inside the dishwasher. Since you can't get clean dishes out of a dirty dishwasher, regularly cleaning it is equally important for prolonging your dish machine's life and having satisfactory cleaning results as providing regular service and maintenance . The facility did not provide the cleaning schedule or the last maintenance assessment of the dishwasher.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete accurate Minimum Data Set (MDS) Assessments for one resident (Resident #38) of 12 residents reviewed for assessment accuracy, resulting in the MDS assessments not accurately reflecting Resident #38's discharge status. Findings include: Resident #38: On 5/2/22 at 8:15 AM, record review was completed of Resident #38's (discharged record) chart and it revealed the resident was admitted to the facility on [DATE] with diagnoses of: Femur fracture, Atrial Fibrillation, Heart Failure, Hypertension and Asthma. Resident #38 was system selected as a discharged record to review for hospitalization. Upon further review of the chart, it showed Resident #38 was discharged home on 3/22/22 rather than to an acute hospital, as indicated within the survey system. On 5/4/22 at 8:30 AM, review was completed of Resident #38's progress notes and discharge MDS (Minimum Data Set) Assessment. The following was shown: Progress Notes: 3/22/22 at 9:15 AM: Discharge to home with home health care services. Reviewed discharge instructions with res. & states understanding. Medications sent home with res. & personnel belongings. Transported by niece. 3/21/22 at 9:17 AM: Seen and evaluated today and note done for her DC home tomorrow. She is resting in bed and denies any needs toady. States her pain is well controlled. she is resting in bed and no complaints today. D/W her the need to f/u with her PCP and I am only allowed to give her 3 days of her pain medications. She verbalized understanding. 3/17/22 at 11:07 AM: discharge: Plans per resident and therapy are for completion of therapy on Monday 3/21/22, and discharge to home on 3/22/22. Resident very eager and feels ready. Discharge MDS Assessment: Under A2100 it indicated Resident #38 was discharged to an Acute Hospital which is not accurate as Resident #38 was discharged home. On 5/4/22 at 8:50 AM, an interview was conducted with MDS Coordinator E regarding Resident #38's discharge assessment. This writer and Coordinator E reviewed the resident's progress notes and agreed the resident was discharged home with home health care and not to a hospital. We then reviewed MDS Section A and the coordinator acknowledged Resident 38's assessment was coded inaccurately. Per the SOM (State Operations Manual), .To assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline . Per the RAI (Resident Assessment Instrument) Manual, .Review the medical record including the discharge plan and discharge orders for documentation of discharge location .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to complete consistent Activities of Daily Living (ADL) Care for six residents (Resident #3, Resident #5, Resident #15, Resident #18, Resident #27 and Resident #31), resulting in Resident #3 not receiving consistent showers, Resident #5, #15, #27 and #31 nail care and/or shaving not being completed and Resident #18's oral care not being completed. Findings Include: Resident #3: On 05/02/22 at 09:17 AM, an interview was conducted with Resident #3. The resident was observed in bed, comfortably watching television. She expressed when she initially arrived at the facility, she wasn't receiving her showers for about two months. When further queried if staff provided a bed bath instead, she started they did not. Resident #3 stated she continued to complain regarding showering, and they finally began to shower her on a regular basis. On 5/3/22 at approximately 11:15 AM, a review was completed of Resident #3's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Spina Bifida, Dysphagia, Dysthymic Disorder, Hyperlipidemia and Hypertension. Further review of the medical records yielded the following: Care Plan: Focus: The resident needs activities of daily living assistance related to: spina bifida, weakness, impaired mobility, muscle weakness . Interventions: .Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Bed Mobility: Extensive with assist of 2 staff members. Dressing: The resident requires extensive assistance with 2 staff members to dress. Review was completed of Resident #3's shower documentation from July 2021 to October 2021. Facility staff documented many refusals from the resident and there was no supporting documentation found regarding the resident's refusals and staff reapproaches. Additionally, staff documented NA on some of the entries which indicated, Not applicable. July 2021: Resident #3 was admitted on [DATE] and did not receive her first shower at the facility until 7/24/2021 (eight days after her admission). August 2021: Resident #3 refused showers on the following days: - 8/4/21, 8/7/21, 8/11/21, 8/14/21, 8/18/21 and 8/21/21. Her first shower in August was on 8/25/21 and there was no supporting documentation located regarding the six refusals, any reapproaches or having management speak to the resident regarding her continued refusals and reasons for them. September 2021: Resident #3 refused showers on the following days: - 9/11/21, 9/15/21, 9/18/21, 9/23/21, 9/25/21 and 9/29/21. There was no supporting documentation located regarding the six refusals. October 2021: Resident #3 refused showers on the following days: - 10/2/21, 10/6/21, 10/21/21 and 10/28/21 Facility staff documented NA on 10/7/2 and 10/16/21. It can be noted Resident #3 does not have a refusal care plan related to showers nor was there any subsequent documentation by staff that showed they offered more than once, offered a bed bath, or alerted their Charge Nurse, DON (Director of Nursing) or Unit Manager to the consistent refusals. There was no further follow-up on this matter by the facility that was documented in the resident's chart. On 5/3/22 at 10:00 AM, an interview was conducted the DON regarding facility practices for showering residents and refusals documentation. The DON expressed she would prefer residents received a shower rather than a bed bath. If they refuse a shower, staff should offer a bed bath and still complete a skin sheet. The DON reported staff should reapproach resident's three times after refusal of any care and document their efforts. The DON and this writer reviewed Resident #3's shower documentation from July 2021 to October 2021. It was pointed out it was documented the resident refused the majority of August 2021 and there and there was no subsequent documentation of this. It was added some of the staff are documenting NA for her showers as well. The DON expressed the resident is care planned to refuse some cares. This writer and DON reviewed the resident's care plan and there was nothing located related to her refusal of showers. The DON was further queried if showers are a consistent refusal has there been a root cause analysis as to why she refuses showers or further discussion and follow up. The DON expressed she reviewed everything and is certain the aides alert the nurses when residents refuse but there is no supporting documentation. Resident #31: During initial tour on 5/2/22 at 9:56 AM, Resident #31 was observed watching television in his room. The resident had an extremely long beard that reached his chest, his mustache covered his lips entirely and met his beard, at the chin. Resident #31 reported his mustache does make it difficult to eat soup as the particles become stuck in his beard. The resident continued he would like to his beard and mustache to be trimmed. When asked when the last time staff offered to cut his beard/mustache he reported it had been a few months since they offered this service. On 5/2/22 at approximately 4:00 PM, a review was completed of Resident # 31's record and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Respiratory Failure, Major Depressive Disorder, Alcoholic Cirrhosis and Chronic Obstructive Pulmonary Disease. Further review was completed of Resident #5's ADL (Activities of Daily Living) charting and it indicated daily, facility staff were completing personal hygiene for the resident that included combing hair, brushing hair, shaving, applying makeup, washing/drying face, and hands. It is unknown how the charting indicated shaving was completed for the resident when she was observed to have chin hairs. Resident #15: During initial tour on 5/2/22, Resident #15 was observed resting in bed and there was multiple long (4-5 inches) and visible chin hairs on the resident. Additionally, underneath Resident #15's fingernails, (on both hands) multiple nails had a black/brown buildup underneath them. Resident #15 stated it has been a while since staff shaved her and cleaned underneath her nails. On 5/2/22 at approximately 3:45 PM, a review was completed of Resident #15's records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, Schizophrenia, Hypertension and Syncope and Collapse. Resident #15 does require assistance with her personal hygiene. Resident #5: During initial tour on 5/2/22, Resident #5 was observed sitting in the Day Room watching television and drinking her coffee. She had multiple gray chin hairs that were 5-6 inches long. When questioned about the chin hairs she reported when her daughter visits, she will shave them. On 5/2/22 at approximately 3:30 PM, a review was completed of Resident #5's medical records and it revealed the resident was admitted to facility 12/4/2020 with diagnoses that included: Diabetes, Schizophrenia, Hypertension and Major Depressive Disorder. Further review was completed of Resident #5's ADL (Activities of Daily Living) charting and it indicated daily, facility staff were completing personal hygiene for the resident that included combing hair, brushing hair, shaving, applying makeup, washing/drying face, and hands. It is unknown how the charting indicated shaving was completed for the resident when she was observed to have chin hairs. Resident #27: During initial tour on 5/22/22, Resident #27, was observed resting in bed. She was observed to have visible chin hairs of varying sizes. When questioned regarding her preference she reported she would like to have them shaved but they have not offered by the staff. On 5/2/22 at 3:37 PM, a review was completed of Resident #27's medical record and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Hemiplegia, Dementia, Atrial Fibrillation, Heart Failure and Anxiety. Resident #27 requires assistance with her personal hygiene. Further review was completed of Resident #5's ADL (Activities of Daily Living) charting and it indicated daily, facility staff were completing personal hygiene for the resident that included combing hair, brushing hair, shaving, applying makeup, washing/drying face, and hands. It is unknown how the charting indicated shaving was completed for the resident when she was observed to have chin hairs. On 05/03/22 at 10:20 AM, this writer and the DON observed all residents with identified nail care and shaving concerns from initial tour the day prior. The following was observed: -Resident #3 was observed in her room and no longer had chin whiskers. The resident reported her daughter shaved her yesterday during her visit. -Resident #31 was observed resting in bed and still had his extremely long beard and mustache. The resident reported to the DON and this writer he would like to his mustache trimmed so he can eat soup and his beard cleaned up on the sides. -Resident #15 was observed in bed and no longer had whiskers, but her fingernails still had the same darkened substance underneath them. -Resident #27 was observed resting comfortably in bed and still had the multiple whiskers and unclean fingernails. After the observations of the residents the DON acknowledged the concern of this writer and shared the observations with the unit staff for them to address the care needs of the residents. On 5/4/22 at 12:53 PM, the DON reported they completed an audit on chin whiskers and nail care and completed the care on residents if needed at the time of the audit. Survey team member reported to the DON during the interview that they observed Resident #21 as she was eating this morning and she had dark brown/black substance underneath her pointer and index fingers. On 05/04/22 at 02:49 PM, this writer informed the Unit Manager E of the observations of the residents (#5, #15, #27 and #31) with unclean nails, unshaven beards, mustaches, and chin whiskers. Unit Manager E reported normally on shower days, nail care and shaving are completed for residents. The Unit Manager acknowledged the concern of this writer. On 5/12/22 at 4:00 PM, a review was completed of the facility policy entitled, Refusal of Treatment, implemented on 1/1/2021. The policy stated, .If a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concern .Should the resident refuse to accept treatment, detailed information related to that refusal must be entered into the residents' medical record . On 5/12/22 at 4:15 PM, a review was completed of the facility policy entitled, Nail Care, implemented 1/1/2021. The policy stated, .Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis . On 5/12/22 at 4:30 PM, a review was completed of the facility policy entitled, Activities of Daily Living (ADLs), revised 10/30/2020. The policy stated, The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain . grooming, and personal and oral hygiene . Resident #18: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool dated 1/22), Care Plans dated 1/22 and Nursing Notes dated 1/22 through 4/22, revealed Resident #18 was 89 years-old, admitted to the facility on [DATE], was alert with confusion, dependent on staff for all Activities of Daily Living/ADL's, had muscle weakness and had his own natural teeth. The residents diagnosis included, conversion disorder with seizures, Parkinson's Disease, Alzheimer's Disease, muscle weakness, Heart Disease, and Dysphagia (difficulty swallowing). Observation and interview of resident #18 was done on 5/4/22 at 12:19 p.m., he was in his room in his wheelchair with a family member with him. The resident stated to this surveyor, I have not brushed my teeth in a long, long time. Observation of the residents oral cavity revealed his teeth were yellow and had a thin shinny coating on them and his tongue was noted to be dry. Observation was made by this surveyor on 5/4/22 at 12:25 p.m., with resident and family permission of his room. This surveyor was unable to locate any toothpaste in the residents room. Three dry bristled toothbrushes in a dry baggie were found sitting in a brown paper box behind the TV. During observation and interview done on 5/4/22 at 12:54 p.m., Nursing Assistant/CNA I stated I didn't get to it today, we don't keep toothettes (soft sponge on a stick for oral care) in room (the residents room). CNA I then went and looked in the residents room for toothpaste and a toothbrush. CNA I found the three dry toothbrushes and was not able to find any toothpaste. During an interview done on 5/4/22 at 12:50 p.m., CNA/Resident Advocate H also looked in the residents room and was only able to find the three dry toothbrushes. CNA H stated I don't think there should be three toothbrushes in there, there should be one and dated and toothpaste. During an interview done on 5/4/22 at 1:00 p.m., CNA J said she had not brushed the residents teeth and stated they (residents) may not get their teeth brushed until after lunch. During record review done on 5/4/22 at 1:02 p.m., CNA H showed this surveyor the daily ADL charting that had already been done (dated 5/4/22 at 11:25 a.m.), revealing Resident #18's oral care had been documented as being completed by CNA I. The oral care box was green (color when completed) and it said yes (indicating completed). CNA I had documented she had completed Resident #18's oral care for the shift. Review of the facility Competency Skills Checklist dated 8/11/21, revealed CNA I had been checked off as competent in oral care. During an interview done on 5/4/22 at 2:30 p.m., the Director of Nursing/DON said the resident was able to answer questions and he was able to brush his own teeth with set-up. The DON stated, the residents teeth should be brushed a minimum of twice a day. Review of the facility Activities of Daily Living (ADL's) policy dated 1/1/21, stated A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview and record review, the facility 1) Failed to ensure that opened and partially used food items had a Use by date, 2) Failed to maintain food preparation equipment in a sanitary condition, and 3) Failed to ensure that clean and ready-for-use kitchen equipment was air dried properly, resulting in an increased potential for food borne illness, potentially affecting 28 of a census of 31 residents who consume oral nutrition from the facility kitchen. Findings Include: Review of the U.S. Public Health Service 2009 Food Code, as adopted by the Michigan Food Law, effective October 1, 2012, directs those physical facilities shall be cleaned as often as necessary to keep them clean, food equipment was to be dried in a manner that leaves no water left inside prior to storage, and ready-to-eat foods shall be clearly marked at the time the original container is open if held for more than 24 hours. During the initial tour of the facility kitchen done on 5/2/22 from 9:15 a.m., through 9:50 a.m., accompanied by staff member G (Kitchen Supervisor), the following observations were made: -At 9:17 a.m., the large metal can opener was observed to have silver chipping off paint and dried food particles on the blade. -At 9:19 a.m., the resident microwave was found to have dried food on the right inside and top. During an interview done on 5/2/22 at 9:18 a.m., staff member G said staff should have cleaned the microwave after they used it; second shift was responsible to clean it. -At 9:19 a.m., the small white freezer was observed to have food stuck to the sides and approximately 2 inches of ice build-up on all sides and the top. -At 9:20 a.m., in the refrigerator was found a can of open and partly used chocolate frosting with no opened or use-by date on it. During an interview done on 5/2/22 at 9:20 a.m., staff member G stated I just ordered use-by stickers; there needs to be use-by dates. -At 9:23 a.m., in the refrigerator was found two gallon milks (chocolate and white milk), open and approximately half used without a use-by date on either. -At 9:25 a.m., two clean and ready for use half silver metal pans were stacked on one another and found to be wet inside of both. This increased the likelihood of bacterial growth. -At 9:30 a.m., the clean and ready for use Robot Coupe (food processor) was found to have the top on with water found inside under the blade. -At 9:35 a.m., in a second refrigerator was found: -A partly used large container of French Dressing with an open date of 4/19/22, with no use-by date on it. -A partly used large container of Ranch Dressing with an open date of 4/22/22, with no use-by date on it. -A partly used container of Strawberry Jam with an open date of 4/27/22, with no use-by date on it. During an interview done on 5/2/22 at 9:40 a.m., staff member G stated I just hired all new people. Review of the facility Kitchen Quick Rounds dated 4/25/22, revealed a check mark indicating no concern for food labeling and dating. Review of the facility Facts in Fifteen meeting education (used for staff meeting on 4/13/22 and 4/20/22), stated In addition to labeling, dating items requires special attention. All foods that require time and temperature control (TCS) should be labeled with the following: Common name of the food, Date the food was made (includes open for perishable foods) (and) use by date. Review of the facility Infection Prevention job description stated, Establish facility-wide systems for the prevention, identification, reporting, investigation and control of infections and communicable disease of residents, staff, and visitors control. Review of the facility Supervisor Dietary job description stated, Provides training, direction, and guidance for the dietary staff (and) schedules and supervises the cleaning and maintenance of equipment.