Based on interview and record review, the facility failed to obtain consent for an antipsychotic medication prior to initiation for one Resident #324 (R324) of five residents reviewed for antipsychotic medications. This deficient practice resulted in R324 not giving consent prior to initiation of medication. Findings include: Resident #324 (R324) Review of the Electronic Medical Record (EMR) revealed admission to the facility on 4/28/25 with active diagnoses that included bipolar disorder, type 2 diabetes mellitus, and unsteadiness on feet. R324 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition. A review of physician orders included Haloperidol (antipsychotic) 10 mg . Give 1 tablet by mouth one time a day every Monday, Wednesday and Friday for bipolar diagnosis. Review of the Medication Administration Record (MAR) for April 2025 revealed R324 had received the antipsychotic medication on 4/30/25. Review of the MAR for May of 2025 revealed R324 received the antipsychotic medication on 5/2/25, 5/5/25, and 5/7/25. Review of the EMR revealed R324 did not sign a consent for the antipsychotic medication. During an interview on 5/8/25 at 9:47 a.m., Social Services Director (SSD) E reported she completes consents with residents on admission or when the medication is ordered. SSD E reviewed the EMR for R324 and reported the consent had not been completed. During an interview on 5/8/25 at 9:52 a.m., the Director of Nursing (DON) acknowledged the consent for the antipsychotic medication was not in the EMR and had not been completed. Review of document titled Use of Anti-psychotic Medications read in part, .the resident, family, and or surrogate decision maker must be educated (verbal and or written information according to facility protocol) about the use of antipsychotic drugs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the correct therapeutic diet was prescribed for 4 Residents (#36, #43, #321, & #325) of 10 residents reviewed for nutritional concerns. This deficient practice resulted in the potential for unmet nutritional needs and the potential for health complications. Findings include: Resident #36 (R36) R36 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, chronic kidney disease and history of a stroke. On 5/6/25 at 12:26 PM, the lunch tray for R36 was observed and included a tray card which read in part, Diet Order: Regular Texture, Consistent Carbohydrate, No Added Salt, Fluids thin. The tray included a packet of salt. Resident #43 (R43) R43 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, atrial fibrillation, and chronic obstructive pulmonary disease. The physician orders included a diet order dated 7/19/24 of No Added Salt (NAS), regular texture, *Thin consistency, double protein portions. On 5/6/25 at 12:27 PM, the lunch tray for R43 was observed with Certified Nurse Aide (CNA) F. The tray card indicated a Diet Order: Regular Texture, No Added Salt, Fluids thin. The tray included a packet of salt. Resident #321 (R321) R321 was admitted to the facility on [DATE] with physician orders including a diet order of No Added Salt (NAS), Regular texture, Regular Thin liquids consistency. On 5/6/25 at 12:22 PM, the lunch tray for R321 was observed with the Registered Dietitian (RD) G. The tray card indicated a Diet Order: Regular Texture, No Added Salt, Fluids Thin. The tray included a packet of salt. RD G stated, He should not have gotten that (the salt packet). Resident #325 (R325) R325 was admitted to the facility on [DATE] with diagnoses including acute congestive heart disease, acute respiratory failure, and hypertension. R325's physician orders included a diet order written on 4/30/25 of Consistent Carbohydrate/NAS, Regular texture, Regular Thin liquids consistency, double protein portions. On 5/6/25 at 12:23 PM, the lunch tray for R325 was observed with the RD G. The tray card indicated a Diet Order: Regular Texture, Consistent Carbohydrate, No Added Salt, Fluids Thin. The tray included a packet of salt. RD G stated, That is not right, and she removed the salt packet from the tray. RD G said that the dietary department was not following the tray cards and salt should not be on those trays with No Added Salt diets. The Diet Manual titled Dining RD: Diet Manual for Long Term Care 2022 was presented and read in part: No Added Salt Diet Indications for Use: . The diet follows the Regular Diet, avoids adding the use of salt at the table, and avoids sending salt packets on the meal trays served in the rooms.

Based on observation, interview, and record review the facility failed to provide food in a manner that was a palatable (preferable) temperature for 15 of 27 residents interviewed. This deficient practice resulted in frustration with meals and the potential for weight loss and diminished nutrition. Findings include: During an interview on 6/10/24 at 11:22 a.m., CR609 stated Often times the food is cold or cool CR609 stated I do ask them to warm up the food, but some food is rubbery when it gets warmed. During an interview on 6/10/24 at 11:30 a.m., CR610 was asked about the temperature and palatability of the food. CR610 stated the food is cold. During an interview on 6/9/24 at 3:13 p.m., CR614 was asked about the temperature and palatability of the food. CR614 stated the food is cold. During a confidential group interview on 6/10/24 at 2:00 p.m., 12 Resident who remained confidential per request (CR600, CR601, CR602, CR603, CR604, CR605, CR606, CR607, CR608, CR611, CR612, and CR613) of 27 residents agreed the food is not palatable due to cold temperatures of food. CR602 stated the food is cold when the staff bring it to CR602's room as they are served last. CR602 stated the vegetables are over-cooked and mushy. CR600 stated the bread or buns get soggy and mushy when the bread is on a plate near items with water in it. CR601 stated salt and pepper are not available on meal trays. During an interview on 6/11/24 at approximately 12:30 p.m., the NHA (Nursing Home Administrator) acknowledged residents had food temperature concerns that were brought to him from resident council meetings. The NHA stated It is something we have to work on. On 6/09/24 at approximately 3:45 PM, the steam table was observed to have been set up for the evening meal. A full sized pan was observed in one of the steam wells covered with aluminum foil. [NAME] B was asked what was in the pan and was identified as Brussels spouts and had been placed in the steam table about 15 minutes ago. The temperature of the spouts was measured to be 201°F. When asked when the evening meal was to begin, [NAME] B stated it would be in about an hour. The Brussels spouts were observed to be over cooked, mushy lacking full nutritive value.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 76 residents. Findings include: On 6/9/24 between 1:10 PM and 2:00 PM, initial observations of the kitchen were made. During this period, two stainless steel pans of sliced ham steaks were observed sitting on a food preparation table. No staff were in the kitchen preparing food. Dietary Assistant (DA) C was in the dish washing room conducting dish washing and was interviewed at this time and asked the whereabouts of kitchen staff. DA C stated they were outside on break. The temperature of the ham steaks was measured with a metal stem digital probe thermometer and found to be between 54°F and 61°F. A pan of ham steaks observed in the walk in refrigerator was found to have a temperature of 48°F. During the same initial observations, a stainless steel pan of tuna salad was observed to have a plastic wrap cover with dates of 6/4 and 6/7. An interview with DA C was conducted at approximately 1:40 PM and learned the product was expired and was subsequently disposed of. The wire rack shelves in both the [NAME] (brand name) and Traulsen (brand name) refrigerators were observed to have the coating worn off and had become rusted and uncleanable. On 6/9/24 between 2:15 PM and 2:30 PM, the pantry refrigerators for Station I and Station II containing residents' food were observed. The station II refrigerator contained six meat and cheese sandwiches had expiration dates of 6/8. Also in the Station II refrigerator was a bag from a local fast food chain with food inside. The bag was lacking any identification related to whom it belonged or any dates of placement or expiration, Station I pantry refrigerator contained a dozen eggs, not procured from an approved source, and were noted to be colored eggs. An interview with nursing staff G revealed the eggs had been brought in by one staff from their chicken farm, for another staff member. The eggs were observed to still have soiled shells in the carton. On 6/9/24 at approximately 4:00 PM, staff were observed to be placing food in the steam table in the main dining room. It was observed there were no hand towels at the only hand sink available to food service staff. Again on 6/10/24 at 7:00 AM the hand towel dispenser was observed to be empty. An interview with [NAME] F was conducted at this time and asked if there were any hand towels who then stated I guess not. At the noon meal at approximately 11:45 AM the dispenser was still empty. This was brought to the attention of Certified Dietary Manager (CDM) A who promptly filled the dispenser. On 6/10/24 between 11:30 AM and 12:00 noon, [NAME] F was observed entering and exiting the door between the kitchen and the dining room where the steam table and food service was conducted. [NAME] F took a pair of gloves out of a box and placed them on her hands without washing her hands. On 6/10/24 at approximately 11:45 AM, the temperature of a container of pureed chicken, as identified by [NAME] F was measured and found to be 115°F. An interview with [NAME] F was conducted at this time and shown the temperature of the chicken, [NAME] F only replied Oh. When asked what the holding temperature was supposed to be, [NAME] F did not reply. At this same time, two ham and cheese sandwiches were observed sitting on a metal cart adjacent to the steam table. The internal temperature of the sandwiches was measured to be 51°F. No attempt at keeping the sandwiches cold was being made. The FDA Food Code 2017 states: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above;P or (2) At 5ºC (41ºF) or less 6-301.12 Hand Drying Provision. Each HANDWASHING SINK or group of adjacent HANDWASHING SINKS shall be provided with: (A) Individual, disposable towels; (B) A continuous towel system that supplies the user with a clean towel; 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (H) Before donning gloves to initiate a task that involves working with FOOD;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intake: MI00141230 Based on interview and record review, the facility failed to implement abuse policies to report and investigate allegations of abuse for one Resident (R2) of three residents reviewed for abuse. This deficient practice resulted in the delay of investigation and the potential for continued abuse for facility residents. Findings include: Review of R2's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnose including depression, weakness, and pain. R2's Annual Minimum Data Set (MDS) assessment revealed she scored a 10/15 on the Brief Interview for Mental Status (BIMS) score indicative of mild cognitive impairment. Review of R2's Activity of Daily Living (ADL) care plan dated 11/17/22 read, in part, .Toileting: Resident required total dependence for toileting, check and change, provide peri-care Date Initiated: 8/23/23. Transfers: Resident requires Total/Hoyer .date initiated 11/17/22 . Review of the complaint filed with the state agency on 11/30/27 read, in part, Complainant states three days ago resident (R2) was sexually abused by resident (R3). Complainant states she went to do a two-hour check on the residents and found that (R2's) brief was open and there was paper towel in her vagina covered with feces. She states she notified two nurses and filed a complaint with the DON (Director of Nursing). The DON told the complainant that the concerns would be turned into the Administrator the next day. Complainant states she still hasn't heard anything back from the Adm. (Administrator) . An interview was conducted with the Nursing Home Administrator (NHA) and DON on 12/5/23 at approximately 10:00 a.m. The NHA and DON stated that they were notified of concerns between R2 and R3, and that R3 was trying to be helpful towards R2 when she begins to holler out for assistance. The NHA and DON stated that they did not believe it was a concern of abuse. An interview was conducted with Certified Nurse Aide (CNA) A on 12/5/23 at 11:57 a.m. CNA A stated that they were working the same hallway as R2 and R3 and was one of two CNAs to discover paper towel with feces in R2's brief on 11/26/23. CNA A stated R2 was completely dependent on staff for assistance with peri-care and could not have performed these actions by herself. CNA A stated that when the paper towel was discovered, they told Registered Nurse (RN) B and RN C immediately and notified the DON by text message. CNA A stated they felt that they were dismissed by the nurses and DON about these findings. CNA A stated that when R2 was asked who did this, she pointed to her roommate (R3). An interview was conducted with RN B on 12/5/23 at 12:15 p.m. When asked if CNA A had reported an allegation of abuse between R2 and R3, RN B stated, Yes, they did. RN B then stated that they were working overtime and attempting to complete their charting before going home and did not follow up with the allegation. RN B stated that she believed CNA A also notified RN C of the allegation and that RN C was responsible for following through. A phone call interview was attempted to RN C on 12/5/23 at 12:22 p.m. There was no return phone call before the exit date on 12/5/23. An interview was conducted with CNA D on 12/5/23 at 12:23 p.m. CNA D confirmed that she was working the same hallway that R2 and R3 lived on and was responsible for their care that evening. CNA C stated that she and CNA A went to do a check and change on R2, as R2 was dependent on two staff members for cares and discovered that her brief had been detached. CNA D stated that she found this suspicious because R2 was no longer able to perform these tasks. CNA D stated that when her and CNA A went to remove the brief from under R2, there was 2-3 paper towels in her brief covered in feces and a wrapped-up paper towel in her vagina. CNA D instructed CNA A to go notify the nurses. CNA D stated that when CNA A returned to continue care for R2, they stated that the nurses would notify the DON. CNA D stated that when asked who did this, R2 pointed to her roommate (R3). CNA D stated that following this incident, she had not been interviewed by any management or the abuse coordinator. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy dated 11/28/17 read, in part, .Investigation: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated . a) Investigation of abuse. When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: who was involved, Residents statements, Resident's roommate statements (if applicable), involved staff and witness statements of events, A description of the resident's behavior and environment at the time of the incident, Injuries present including a resident assessment, Observation of resident and staff behaviors during the investigation, Environmental considerations .All staff must cooperate during the investigation to assure the reside is fully protected .Internal Reporting: Employees must always report any Abuse or suspicion of abuse immediately to the Administrator. The administrator will involve key leadership personnel as necessary to assist with reporting, investigation and follow up. The administrator will report to the Medical Director .

Resident #51 (R51) On 8/22/23 at 1:44 PM, an observation was made of R51's room. A container of nasal spray labeled oxymetazoline hydrochloride 0.05% was observed sitting on top of the bedside table for R51. The directions read 2-3 sprays in each nostril every 10 to 12 hours, do not exceed 2 doses in a 24-hour period. R51 was asked what the spray was for and replied, It is for my nasal congestion. R51 was asked how often he uses it and if he tells anyone he used it and replied, I use it whenever I need it. I usually use it a few times a day. Review of R51's physician order, dated 8/3/23, revealed an order for oxymetazoline HCL (hydrochloride) Nasal Solution one unit in both nostrils every 24 hours as needed for nasal congestion. Review of R51's medication administration record (MAR), dated 8/1/23 through 8/23/23, revealed, only one documented administration for oxymetazoline HCL on 8/13/23 at 1916 (7:16 PM). R51's August MAR lacked any other documented administrations for this medication order. Review of medication package insert for oxymetazoline hydrochloride, read in part, .This medication provides only temporary relief. Do not use more often, use more sprays, or use longer than directed because doing so may increase the risk of side effects. Also, do not use this medication for more than 3 days or it may cause a condition called rebound congestion . Review of R51's electronic medical record (EMR), lacked any assessment or order to self-administer his own medications. Based on observation, interview, and record review the facility failed to perform a resident assessment for the self-administration of medication for 3 residents (R16, R57, and R51) of 18 residents reviewed for self- administration of medication, resulting in the potential for the mismanagement of medication and adverse side effects. Findings included: R16 According to the Minimum Data Set (MDS), 7/14/2023, R16 scored 14/15 (cognitively intact) on her BIMS (Brief Interview Mental Status), required extensive assistance with her ADLs with physical assistance from 1-2 people due to physical limitations to both arms and legs related to her diagnoses of multiple sclerosis and quadriplegia. Observed on 8/23/2023 at 9:40 AM, R16 had 3 bottles of OTC (over-the-counter supplements) on a shelf multi-shelf storage rack. On the next shelf down was a white plastic bin containing 10 OTC bottles of various supplements. R16 stated, Those are my vitamins. I take them every day. Staff give them to me. During an observation and interview on 8/23/2023 at 5:25 PM Director of Nursing (DON) toured R16's room with Surveyor. Family Member (FM) I was feeding resident dinner. DON observed with FM and Surveyor, 3 bottles of OTC supplements on a shelf. FM I stated, I give her (R16) them twice a day. I've been doing this for years. There was a care meeting about this a few years ago. Staff knows this. DON stated, I did not know these were here. I will have to check into this. The DON did not mention the shelf below with a plastic bin containing 10 bottles of OTC supplements. During an observation and interview on 8/24/2023 at 11:30 AM FM I was with R16 feeding her lunch. The 3 bottles of OTC supplements were gone from the room. The basket of 10 OTC supplements were still in a plastic bin on a shelf. FM I stated, We were not asked if they could be taken from the room (referring to the 3 bottles of OTC supplements). No one said anything to us. Those belong to my wife. They should have talked to her about taking them. That pisses me off. R16 stated, That is s*itty, sh*tty, sh*tty. They did not say anything to me. They took them last night. Review of R16's Progress Note dated 3/11/2021 14:50 (2:50 PM) Care Conference Note reported a care conference was held with SW (Social Work), res (resident) and this nurse present as well as husband, and CMH (Community of Mental Health) SW present on the phone. Res (resident) husband would like (resident) to be able to have her vitamins as she wishes. Review of R16's medical records did not report a Self-Administration of Medications evaluation had been conducted. Review of R16's Order Summary did not reveal any OTC supplements had been listed to be self-administered or administered by a nurse. Review of R16's Medication Administration Record/Treatment Administration Record (MAR/TAR) dated 8/1/2023-8/31/2023 did not reveal any OTC supplements had been listed to be self-administered or administered by a nurse. Review of an email sent by the Nursing Home Administrator (NHA) dated 8/23/2023 at 4:15 PM reported there were no residents in the facility that self-administered medications, and this had been confirmed with the DON. R57 According to the Minimum Data Set (MDS), 6/28/2023, R57 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status), required supervision while walking in the facility, with diagnoses that included depression, gastroesophageal reflux disease (GERD), atrial fibrillation, and anemia. During an observation and interview on 8/24/2023 at 10:00 AM, Registered Nurse (RN) L was at a medication cart talking with R57 who was holding a medication (med) cup with various pills. RN L was explaining to the resident she was getting a muscle relaxer and she would put a few medications in applesauce for her. R57 took the medication cup with her and walked away, down the hall, into her room, and shut the door behind her. The RN stated, as she placed a large white pill in a med cup with applesauce, (R57) was given her medications and she brought them back out to me to ask a question. I am putting one of her larger pills in applesauce and taking it to her now. I do not know if she self-administers medications. R57 stated after the RN left her room, The pills were first left in my room, but one pill was too large for me to swallow. I do not want it in pudding. I asked to have some applesauce to take the large one. Review of R57's medical record did not reveal a Self-Administration Medication evaluation had been done. Review of R57's Order Summary did not reveal any medications had been listed to be self-administered or administered by a nurse. Review of R57's Medication Administration Record/Treatment Administration Record (MAR/TAR) dated 8/1/2023-8/31/2023 reported the following medications were administered between the hours of 8:00 AM and 9:12 AM: -Biotin Oral Tablet 10000 mcg .give 1 tablet by mouth one time a day for supplement approved by (Nurse Practitioner) to take-resident supplied. It was noted on the MAR an x had been put under each date from 8/1/2023 to 8/31/2023 indicating the medication was not being administered. -Folic Acid Oral Table 1 mg .give 1 tablet by mouth one time a day for deficiency -Magnesium oxide oral tablet 400 mg .give 1 tablet by mouth one time a day for low magnesium -Spironoclactone oral table 25 mg . give 1 tablet by outh one time a day for edema -Thiamine HCL oral tablet 100 mg . give 1 tablet by mouth one time a day for supplementation -Vitamin D3 oral capsule 1.25 mg (50000 UT) (cholecalciferol) give 1 capsule by mouth one time a day every Thu (Thursday) for supplement -Citracal petites/vitamin D oral table 200-6.25 mg-mcg .give 1 tablet by mouth two times a day for supplement -Metoprolol succinate ER oral tablet extended release 24 hour 25 mg .give 1 table by mouth two times a day for palpitations hold for SBP (systolic blood pressure) <110 DBP (diastolic blood pressure) <60 HR (heart rate) <60 -Multivitamin oral table .give 1 tablet by mouth two times a day for supplement -Omeprazole oral table delayed release 20 mg .**DAW** give 2 tablet by mouth two times a day for GERD for 6 weeks -Gabapentin oral capsule 100 mg .give 2 capsules by mouth three times a day for pain. It was noted this is a controlled substance. May open gabapentin and put in applesauce per preference related to difficulty swallowing capsules every shift for med administration. -Cyclobenzaprine HCL oral tablet 5 mg .give 1 tablet by mouth every 8 hours as needed for muscle spasms -Tylenol Extra Strength oral tablet 500 mg .give 2 tablets by mouth every 8 hours as needed for pain -Ultram oral tablet 50 mg .give 1 tablet by mouth every I hourse as needed for pain give with Tylenol Further review of R57's MAR/TAR 8/1/2023-8/31/2023 did not reveal any medications had been listed to be self-administered. Review of R57's Care Plan revealed, .uses antidepressant medication (Remeron, Trazadone) related to diagnosis of major depressive disorder (6/29/2023). The goal was for the resident to be free from discomfort or adverse reactions related to antidepressant therapy through the review date. To met this goal, interventions were to be implemented including administer antidepressant medications as ordered by physician. Review of R57's Care Plan Dx (diagnosis of alcohol use disorder (6/21/2023). The goal was for the resident to be in a safe environment during her stay at the facility. To meet this goal, one of the interventions to be implemented was educating the resident on potential injury related to ordered medications and interaction with substance abuse. Review of the facility's Preparation and General Guidelines, Medication Administration-General Guidelines dated May 2022, revealed, .Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide oxygen services per standards of practice and per physician orders for one Resident (#52) of one resident reviewed for oxygen services. This deficient practice resulted in the potential for the development of respiratory complications, including infections. Findings include: Resident #52 (R52) Review of the Electronic Medical Record (EMR) revealed R52 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, congestive heart failure, weakness, and anxiety. Review of the 8/10/23 Minimum Data Set (MDS) assessment showed R52 scored a 14/15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated R52 was cognitively intact. R52 was marked as receiving oxygen therapy in the MDS assessment. On 8/22/23 at 12:16 p.m., during an attempted interview, R52 was in the main dining room eating lunch. This Surveyor observed R52's room and noted an oxygen concentrator near the back wall of his room with a nasal cannula attached. The nasal cannula was in R52's recliner chair with no protective covering available to place the cannula when not in use. R52's oxygen tubing was dated 8/21/23. On 8/23/23 at 9:23 a.m., R52 was observed sleeping in his recliner chair, with his oxygen concentrator noted to be in the same location as above and with the same nasal cannula tubing dated 8/21/23 attached. R52's nasal cannula was positioned behind his back in the recliner chair with no protective covering available to place the cannula when not in use. On 8/24/23 at 10:47 a.m., R52 was observed sitting in his recliner chair. R52's nasal cannula was noted to be sitting in his lap, with the oxygen concentrator running. An interview was conducted with R52 who stated that he felt fine and did not want to wear his nasal cannula at that time. When asked if R52 had a place to put his nasal cannula when not in use, he stated no. On 8/24/23 at 11:44 a.m., an observation was made with the Regional Director of Clinical Operations/Staff G of R52's nasal cannula. R52 was playing trivia in the main dining room during this observation. R52's nasal cannula was observed to be sitting in his recliner chair with the oxygen concentrator turned on. Staff G confirmed that R52 did not have a proper storage bag to place his nasal cannula when not in use. Staff G confirmed that R52's nasal cannula should be stored properly to prevent infection. Review of R52's care plans read, in part, The resident has Congestive Heart Failure .Oxygen Settings: O2 (oxygen) via nasal prongs at 2L/M (2 Liters per Minute) to maintain 90% SPO2 (Saturation of Peripheral Oxygen) while sleeping/napping and PRN (as needed). Date Initiated: 8/10/2022 . R52' Care Plan did not instruct staff on where to properly store his nasal cannula when not in use. Review of the facility's Oxygen Administration policy revised October 2010 did not specify where to place oxygen equipment, including a nasal cannula when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure there was consistent communication with the dialysis center for 2 of 2 residents (Resident #19 and Resident #28) reviewed for dialysis and failed to assess dialysis access sites for 1 of 2 residents (Resident #19) for dialysis care needs. This deficient practice resulted in the lack of assessment for a blood clot to develop, narrowing/stenosis to develop, and blocked access resulting in the potential for a blocked access/lifeline. Finding include: Resident #19 (R19) On 8/22/23 at 1:03 PM, an interview was conducted with R19 in his room. R19 was asked about his dialysis, what his schedule was like, and what kind of access he had to receive dialysis and replied, I go Monday, Wednesday, and Friday about ten minutes to eleven and return around four in the afternoon. I had a port in my chest, but they took that out last week and have been using the access in my left upper arm. R19 was asked if nursing assesses his access or if they change the dressing on his left upper chest and replied, No. Dialysis does that. R19 was observed to have a dressing on his left upper chest that was undated and a second dressing to his left upper arm on his fistula. Review of R19's physician orders, revealed a lack of an order addressing the need to assess a second access in R19's left upper arm. R19 had a physician order for monitoring for signs and symptoms of infection in a chest access. (R19 had the chest access removed, but unsure of the exact date). Review of R19's [NAME] (gives a brief overview of each residents needs), date printed 8/24/23, revealed a skin care area, read in part, Updates with PACE North and PACE North team via e-mail. (PACE North is a program of all-inclusive care for the elderly and takes him to dialysis and the facility picks him up from dialysis and brings him back to the facility). On 8/23/23 at 9:35 AM, an observation was made of R19's left upper chest dressing where he used to have an access and the dressing remained undated. Review of R19's progress notes, dated 7/25/23 through 8/24/23, revealed a lack of documentation as to when the chest access had been removed and discontinued. On 8/24/23 at 8:23 AM, an observation was made of R19's left upper chest dressing which remained undated. R19 also had a dressing intact to his left upper arm where his fistula was located, and he indicated that the dressing needed to be removed. On 8/24/23 at 10:19 AM, an interview was conducted with Registered Nurse (RN) L. RN L was asked if she knew what kind of dialysis access R19 had and replied, I am not sure. I would have to check. RN L finished preparing medications and checked the orders for R19 and replied, He has a chest access. We look at it to ensure no signs and symptoms of infection or bleeding, but that is it and dialysis does the rest. RN L was asked if she was aware of any other type of dialysis access and replied, No. Not that I am aware of. On 8/24/23 at 10:27 AM, an interview was conducted with Certified Nurse Aide (CNA) K. CNA K was asked if she knew what kind of dialysis access R19 had and if she would care for him in any special way and replied, I have to double check on a correct answer. CNA K proceeded to seek help to answer this Surveyors question. On 8/24/23 at 10:31 AM, a follow-up interview was conducted with CNA K. CNA K replied, Usually he would require a full set of vital signs and if access on one arm then take a blood pressure on the opposite arm. CNA K was asked which arm R19 had an access in and replied, His right. I think. On 8/24/23 at 10:34 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked if she knew what kind of dialysis access R19 had and replied, He has a perm cath access in his left upper chest. The DON was asked if she knew that R19 had any other type of access and replied, He has a fistula as well. Dialysis tried using it (fistula) a couple of months ago but were unable and so they continue to use the chest access. We don't use the fistula and dialysis does not use the fistula. The DON was asked if she was aware that the chest access had been discontinued and replied, I am not. Dialysis just clamped the cath yesterday for 8/23/23 and there is no date on the form from dialysis. It just has a signature. I would have to look through his notes to see when they pulled out the left chest access. I will get back to you. Review of dialysis communication notes, dated July 3, 2023 through August 23, 2023, revealed the following: a.) 7/3/23 incomplete form post dialysis, b.) 7/5/23 incomplete form post dialysis, c.) 7/14/23 incomplete form post dialysis, d.) 7/17/23 incomplete form post dialysis, e.) 7/19/23 through 7/26/23 dates lacked pre or post dialysis forms, f.) 7/31/23 incomplete form pre and post dialysis, g.) 8/7/23 lacked pre or post dialysis form, h.) 8/9/23 lacked pre or post dialysis form, i.) 8/16/23 lacked pre or post dialysis form, j.) 8/18/23 through 8/23/23 dates lacked pre or post dialysis forms and, k.) five pre and post dialysis forms lacked dates and two of the five had no recorded post weights. Review of facility policy, Dialysis, dated 01/07, read in part, .Education surrounding the care of unique needs of the resident on hemodialysis is also important. Communication between outpatient dialysis and facility should include: Written communication form with review of daily weights, any changes in condition or mood. Pre-Dialysis Protocol: . 5. Communicate/facilitate plan for preventative skin interventions. Post Dialysis Protocol: 1. Review Communication Folder for any pertinent information. 2. Remove fistula/graft-dressing evening of dialysis treatment and/or as directed by the nephrologist. **Check fistula for bruit (listening to fistula) or feel for a thrill (by touching the fistula.) This must be done daily, best after dressing is removed . 5. Observe skin/heels for any pressure areas from extended sitting/lying during dialysis . Daily Fistula/Graft Checks - Check for any signs of infection daily . Documentation on Treatment Sheets Includes: Fistula checks daily: Monitoring for presence of bruit and thrill . No blood pressures are to be taken on the access arm . Daily Checks of Vascular Access - Inspection of Access - Condition of the skin over access - redness. Palpation of Access - Thrill +/- - Heat - Drainage - Swelling - Tenderness. Auscultation of Access - Bruit +/- - Quality/Character . Resident #28 (R28) Review of R28's EMR revealed admission to the facility on 2/9/23 with diagnoses including end stage renal disease. R28's Treatment Administration Record (TAR) for August 2023 read, in part, .Dialysis on Monday, Wednesday, and Friday. A request was made for R28's Dialysis Communication Forms for July and August 2023 by email to the Nursing Home Administrator (NHA) on 8/23/23 at 2:17 p.m. This Surveyor confirmed there would have been 22 appointments for R28 to attend dialysis at the time of the request. On 8/24/23 at 9:43 a.m., an interview was conducted with the DON concerning R28's Dialysis Communication Forms. The DON provided four hard copies of R28's forms dated 7/3/23, 7/5/23, 7/19/23, and 8/14/23. The DON confirmed that R28 did not have any additional communication forms to dialysis, and that the facility's transportation driver was unaware that a communication form needed to be provided when assisting R28 to her dialysis appointments. Review of facility policy, Dialysis, dated 01/07, read in part, .Education surrounding the care of unique needs of the resident on hemodialysis is also important. Communication between outpatient dialysis and facility should include: Written communication form with review of daily weights, any changes in condition or mood. Pre Dialysis Protocol: .5. Communicate/facilitate plan for preventative skin interventions. Post Dialysis Protocol: 1. Review Communication Folder for any pertinent information. 2. Remove fistula/graft-dressing evening of dialysis treatment and / or as directed by the nephrologist. **Check fistula for bruit (listening to fistula) or feel for a thrill (by touching the fistula.) This must be done daily, best after dressing is removed .5. Observe skin/heels for any pressure areas from extended sitting/lying during dialysis .Daily Fistula/Graft Checks - Check for any signs of infection daily .Documentation on Treatment Sheets Includes: Fistula checks daily: Monitoring for presence of bruit and thrill .No blood pressures are to be taken on the access arm .Daily Checks of Vascular Access - Inspection of Access - Condition of the skin over access - redness. Palpation of Access - Thrill +/- - Heat - Drainage - Swelling - Tenderness. Auscultation of Access - Bruit +/- - Quality/Character .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #51 (R51) On 8/22/23 at 1:44 PM, an observation was made of R51's room. R51 stated, The Certified Nurse Aide (CNA) came in my room the other day (unable to state which day) and rearranged my room. Moved my bed up against the wall like this (left side of the bed was up against the wall and the head of the bed). Look at the wall. They (CNA) pushed the bed so tight up against the wall. When you move the head of the bed up and down or the whole bed up or down it rubs right against the wall and is gouging the drywall all up. It looks like cr*p and there are drywall particles on the floor. If that's any indication how they treat the equipment and furniture around here I don't know what you want me to say about the care. Review of R51's census, revealed an admission date of 6/20/23, with room [ROOM NUMBER] assigned. On 7/14/23 R51 had a room change to room [ROOM NUMBER]. Review of R51's Minimum Data Set (MDS), dated [DATE], section C - cognitive pattern, revealed, intact cognition. On 8/22/23 at 12:28 PM, an observation was made of room [ROOM NUMBER]. The bathroom of room [ROOM NUMBER] had a toilet paper roll sitting unwrapped on top of the metal pipe near the flusher (located out of reach and behind the person using the toilet). The toilet paper dispenser holder was loose on the left handle and lacked a toilet paper dowel to hold the toilet paper roll in proper placement. On 8/22/23 at 4:14 PM, an observation was made of room [ROOM NUMBER]. room [ROOM NUMBER]'s night light in the wall left of the bathroom door was open in the back and lacked a cover (located left of the sink where water could splash and break the bulb. There were four extra pillows; two in corner near bed B, one on bed A and one in chair of bed A (the pillows all lacked pillowcases). There were multiple drywall gouges in room [ROOM NUMBER] behind the headboards of bed A and B. Behind bed B their laid particles of drywall on the floor. To the left of the bathroom door there was an indentation that was approximately three feet tall and two foot wide and a piece of the drywall was pealing on the right of the indentation near the bathroom door frame. On the left side of bed A where the side rail was located, the drywall had a plaster patch that was approximately the size of a five gallon bucket circumference. Resident #4 (R4) On 8/23/23 at 4:40 PM, an interview was conducted with R4. R4 stated, The room doesn't look very nice. The wall is really bad behind my bed too. Review of R4's MDS, dated [DATE], section C - cognitive pattern, revealed, intact cognition. On 8/23/23 at 5:20 PM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked if a room readiness checklist was performed on room [ROOM NUMBER] bed A or room [ROOM NUMBER] bed A and replied, Well, we used to do the checklist, but now we go to the room to ensure there is a nice blanket on the bed, the lights work, and the call light system is working properly. There is no formal checklist. Just in the morning we discuss as a team what rooms are ready for an admission. Resident #70 (R70) On 8/24/23 at 7:34 AM, an interview was conducted with R70 in her room. R70 was asked about the condition of the drywall in her room and replied, It was like that when I was admitted . R70 was asked how the room appearance made her feel and replied, I would not leave my home in that condition. I feel some discomfort to the room and am overwhelmed. R70 was asked if she used her bedrails and replied, I use the one on the right to help me get out of bed. I don't use the one on the left and it could be removed so it does not continue to damage the wall. Review of R70's census, revealed an admission date of 8/9/23, with room [ROOM NUMBER] bed A assigned. Review of R70's MDS, dated [DATE], section C - cognitive pattern, revealed, intact cognition. On 8/24/23 at 7:58 AM, an observation was made of room [ROOM NUMBER]. room [ROOM NUMBER] was a semi-private room with bed B occupied and bed A empty. In room [ROOM NUMBER] bed A was inspected for room admit readiness and was found to have the curtain pulled back behind the nightstand to the back of bed A's headboard. The curtain was drawn back and there was an area of approximately two feet wide by two feet tall with multiple wall marring's where the paint had been peeled away and the drywall was exposed. The wall was marked up with brownish colored lines running vertical in various lengths. On 8/24/23 at 8:00 AM, an interview was conducted with the NHA. The NHA was invited into room [ROOM NUMBER] with this Surveyor. The NHA was asked if room [ROOM NUMBER] bed A was considered room ready and replied, Yes. The curtain behind bed A was revealed to the NHA. The NHA then replied, Ninety percent of the rooms are ready for new admits. Not all are ready, but we have to take new residents when they are ready to be admitted and not turn them away. We try our best to have rooms ready and looking good. Before we get a new admission, we perform a room readiness checklist. It cost money to fix and repair rooms. On 8/24/23 at 8:24 AM, an observation was made of room [ROOM NUMBER]. The entrance to room [ROOM NUMBER] lacked a threshold strip to protect the carpeting from lifting between the carpet and wood linoleum. The carpet was slightly lifted exiting the doorway of room [ROOM NUMBER] (potential trip hazard). Review of facility document, Room Readiness Checklist, revealed, a check list for walls; clean visible residue on walls and wipe down all pictures/artwork. Bathroom; clean and sanitize entire bathroom (sink, toilet inside and out, mirrors, fixtures). Bathroom; stock toilet paper and soap. The Room Readiness Checklist lacked any inspection of the appearance of drywall, nightlight fixtures, or toilet dispenser. This citation pertains to intake MI00138612 Based on observation and interview, the facility failed to ensure a homelike environment, in 3 (R25, R16, and R45) of 18 residents reviewed for homelike environment, resulting in the potential for decreased quality of life. Findings include: R25 According to the Minimum Data Set (MDS) 6/29/2023, R25 scored 4/15 on her BIMS (Brief Interview Mental Status), was independent with her ADLs (activities-of-daily living), with diagnoses that included dementia, seizure disorder, and anxiety. During an observation on 8/22/2023 at 2:50 PM of R25's room, a sliding glass door that led out to an enclosed patio area. Outside of the sliding doors was a drainage grate covered with twigs, leaves and debris. Partially covering the grate was a sandbag. Laying waded on top of the sandbag was an old, wet, dirty towel. During an observation and interview on 8/23/2023 at 3:00 PM Maintenance C toured R25's room specifically looking at the outside of the sliding glass door and drainage grate. Maintenance C stated, The grate is covered with a lot of stuff. It should be cleaned up. There is an old towel that is laying on top of the sandbag. It does not look very nice. I do not know how that got there. R16 According to the Minimum Data Set (MDS), 7/14/2023, R16 scored 14/15 (cognitively intact) on her BIMS (Brief Interview Mental Status), required extensive assistance with her ADLs with physical assistance from 1-2 people due to physical limitations to both arms and legs related to her diagnoses of multiple sclerosis and quadriplegia. During an observation and interview on 8/23/2023 at 9:40 AM, R16 was awake in bed with a sliding glass door to the right side of her bed. Outside of the sliding glass doors were 2 sandbags. The drainage grates outside the doors were covered with twigs, leaves, and other debris partially covering the grate. During an observation on 8/24/2023 at 11:30 AM R16 was awake in bed with a sliding glass door to the right side of her bed. Outside of the sliding glass doors were 2 sandbags. The drainage grates outside the doors were covered with twigs, leaves, and other debris partially covering the grate. During an observation and interview on 8/24/2023 at 2:40 PM Maintenance C toured R16's room specifically looking at the outside of the sliding glass door and drainage grate. Maintenance C stated, The grate is covered with a lot of stuff. It should be cleaned up. Those sandbags have been there for a while. During an observation and interview on 8/24/2023 at 5:30 PM R16 was awake visiting with Family Member (FM) I while in bed. A sliding glass door was to the right side of her bed. Outside of the sliding glass doors were 2 sandbags. The drainage grates outside the doors were covered with twigs, leaves, and other debris partially covering the grate. FM I stated, Those bags have been there a long time. They were put there to keep the rain from coming in under the sliding doors. I do not know how the grates drain away water with all the stuff that is piled on top of them. When (name of R16) was living at our house she would never have tolerated having that at the house. R45 According to the Minimum Data Set (MDS) 7/27/2023, R45 scored 15/15 on her BIMS (Brief Interview Mental Status), independent with locomotion in the facility with the use of a wheelchair, with diagnoses that included anxiety and depression. During an observation on 8/23/2023 at 9:45 AM of R45's room, a sliding glass door led out into an enclosed patio area. Outside of the sliding door was a drainage grate covered with twigs, leaves, and sand from a broken sandbag that was lying on top of the grate. Buried upside down in the sand was a glass dinner plate. The plate was dirty with a black grime. During an observation and interview on 8/23/2023 at 2:45 PM Maintenance C toured R45's room specifically looking at the outside of the sliding glass door and drainage grate. Maintenance C stated, The grate is covered with a lot of stuff. That sandbag is broken and spilled sand covering the grate. It should be cleaned up. During an interview on 8/24/2023 at 3:30 PM, R45 stated, I have been working with therapy to start walking again with a walker. I'm hoping I can go out and sit on the patio outside the sliders. But with the sand all over I do not know how I'll get out there with my walker. It does not look very nice. If that had happened at my house when I was younger, I would have cleaned it up right away. Look at that glass plate. What is that doing out there buried in the sand? Why would they (facility) let it look like that and not clean it up?

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess, monitor, document, and provide treatment per professional standards of practice for four Residents (#8, #19, #51 and #67) out of 18 residents reviewed for quality of care. This deficient practice resulted in outcomes/potentials associated with poor diabetes care and colostomy care. Findings include: Resident #8 (R8) An interview was conducted on 8/23/23 at 8:52 AM, with R8 in her room. R8 was asked about her care that was provided to her by facility staff and replied, Aides do not help me with my colostomy bag and said that I do it at home I can do it myself here. I cannot reach the graduated cylinder over there on the bedside nightstand, and I cannot get up without assistance. Review of R8's Minimum Data Set (MDS), dated [DATE], section C - cognitive pattern, revealed, intact cognition, and section G - functional status, revealed, two-person physical assistance for toilet use and extensive assistance. Review of R8's point of care (POC) documentation, dated 7/25/23 through 8/23/23, revealed colostomy care to be completed every shift (three times daily), and lacked colostomy care documentation three times daily on 7/25/23, 7/31/23, 8/4/23, 8/5/23, 8/8/23, 8/9/23, 8/10/23, 8/13/23, 8/14/23, 8/16/23, 8/18/23, and 8/19/23. Resident #19 (R19) An interview was conducted on 8/22/23 at 1:03 PM, with R19 in his room. R19 was asked about his medical diagnosis of diabetes mellitus and if he received evening snacks and replied, Only if I ask for them. The staff does not offer me a snack. Review of R19's task list snack offered, dated 7/27/23 through 8/23/23, revealed R19 was not offered an evening snack on 8/1/23, 8/3/23, 8/4/23, 8/7/23, 8/8/23, 8/12/23, 8/13/23, 8/16/23, 8/17/23, and 8/23/23. Review of R19's [NAME], dated 8/24/23, revealed, Eating/Nutrition: Nutrition - PM/HS (afternoon/evening) Snack. Review of R19's electronic medical record (EMR), blood sugar summary revealed, on 7/31/23 at 05:45 (5:45 AM) 53.0 mg(milligrams)/dL(deciliter), and on 7/31/23 at 06:15 (6:15 AM) 47.0 mg/dL. Review of R19's EMR, progress notes, lacked any documentation regarding intervention, rechecking low blood sugar, or communication to physician. Resident #51 (R51) An interview was conducted on 8/22/23 at 1:44 PM, with R51 in his room. R51 was sitting in his wheelchair and wearing a hospital gown. R51 was asked how he was doing and how his care was and replied, On 8/21/23 no one came to help me empty my colostomy bag when I put my light on at 7:30 PM for two hours. I wheeled out to the hallway, and no one was available. This morning (8/22/23) at 4:30 AM I requested ice water mug, and it took 45 minutes to get that. I asked a male care assistant to help me empty my colostomy bag and he stated he would come back and never did. R51 demonstrated how difficult it was to get into the bathroom by himself. R51's wheelchair had to be exactly fit into the bathroom door frame with no room left on ither side of the wheelchair for his hands to roll the wheels into the bathroom. R51 stated, At my house I have an extra colostomy bag in the bathroom, and it makes things easier to manage. R51 was asked about his medical diagnosis of diabetes mellitus and if he received evening snacks and replied, The staff does not offer me an evening snack. Review of R51's MDS, dated [DATE], section C - cognitive pattern, revealed, intact cognition, and section G - functional status, revealed, one-person physical assistance for toilet use. Review of R51's [NAME] and tasks revealed, no indication he needed/required an evening snack. (Staff were not directed to give R51 an evening snack even though he had a diagnosis of diabetes.) Review of R51's POC documentation, dated 7/25/23 through 8/23/23, revealed colostomy care to be completed every shift (three times daily), and lacked colostomy care documentation three times daily on 7/25/23, 7/30/23, 7/31/23, 8/3/23, 8/4/23, 8/5/23, 8/9/23, 8/10/23, 8/13/23, 8/14/23, 8/18/23, and 8/19/23. The care plan for R51, dated 7/11/23, read in part, The resident has an (sic) colostomy to L (left) lower abdomen .Resident will have no complications with ostomy .monitor stoma site .monitor for changes in consistency .monitor stoma site for signs of bleeding . Resident #67 (R67) An interview was conducted on 8/22/23 at 12:52 PM with R67 in his room. R67 was sitting on his bed and was eating lunch. R67 was asked about his medical diagnosis of diabetes mellitus and if he was offered an evening snack and replied, No snacks are offered to me in the evenings. Review of R67's MDS, dated [DATE], section C - cognitive patterns, revealed, intact cognition. On 8/24/23 at 12:00 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked what her expectations were for offering diabetic residents evening snacks and responded, All residents that are diabetic should be offered an evening snack every evening and this should be documented in the task as completed. The DON confirmed that blood sugars that fall below normal range (>70.0 mg/dL) should be communicated with the physician, interventions, and a recheck on the blood sugar should all be documented in the EMR. The DON was asked if residents with colostomy bags should be assisted by staff in emptying and care and responded, Yes. The care assistant should be assisting with this task and documenting every shift on the POC. Review of facility policy, Quick Resource Tool: Meal HS Snacks, dated 9/1/21, read in part, Standard: Snacks and beverages will be provided as identified in the individuals plans of care. Bedtime (a.k.a. HS) snacks will be provided for all residents .Guidelines: .6. Nursing Services is responsible for delivering the individual snacks to the identified residents and offering evening snacks to all other residents . Review of facility policy, Diabetes Management, dated 6/29/17, read in part, .Nursing Evaluation / Symptoms. Blood glucose monitoring: Ideal range is 70 - 100 mg/dl, results <70 or >400 indicate hypo pr hyperglycemia require immediate follow up, determine with the physician . Review of facility policy, Colostomy, Urostomy or Ileostomy Care, dated 6/29/21, read in part, .Patient Centered Care .A resident that does not have the ability secondary to cognitive or limiting functional deficits should have a plan of care developed for the evaluated determined support and assistance .

Based on observation, interview, and record review, the facility failed to properly monitor resident refrigerators and follow protocol for 3 residents (R33, R16, and R25) of 4 residents reviewed to ensure food brought into the facility and stored in resident refrigerators was labeled and dated with an expiration date, resulting in the potential for food born illness. R33 According to the Minimum Data Set (MDS) 7/6/1023, R33 scored 15/15 (cognitively intact) on his BIMS (Brief Interview Mental Status), he was independent with his ADLs (Activities of Daily Living), with diagnoses that included dementia. During an observation an interview on 8/23/2023 at 8:10 AM, R33 had a personal refrigerator in his room. The refrigerator had food in paper bags and clear plastic bags that were not dated or labeled. During an interview on 8/23/2023 at 8:15 AM Certified Nursing Assistant (CNA) J stated, I believe housekeeping and nurses are to look at the resident's refrigerators. During an interview on 8/23/2023 at 8:25 AM, Nursing Home Administrator (NHA) stated, There is no specific policy for personal refrigerators. The refrigerators would be under the Infection Control policy. If there is a problem with a resident's refrigerator, the IP (Infection Preventionist) is notified, and she does a Risk v. Benefit with the resident. During an observation and interview on 8/23/23 at 8:31 AM, NHA stated, (R33) is probably a high risk for storing open foods in his refrigerator. Observed the refrigerator with the NHA who stated, This frig is stuffed. Observed a clear plastic bag to contain per NHA some kind of meat, bread wrapped in a paper napkin, and cake with frosting in a red plastic cup inside a clear plastic bag. NHA stated, Housekeeping makes rounds every week and spot cleans personal refrigerators. They look for expiration dates on food. If the food is not dated, it is thrown away and the resident is notified. Nursing documents in the TAR (Treatment admission Record) refrigerator temperature daily. If housekeeping continues to notice reoccurring food not dated, resident not cooperating, or cleaning issues, they contact the IP who will then complete a Risk v. Benefit document with the resident. A care plan should be completed for a resident who has a personal refrigerator. Review of R33's Risk V. Benefit reported on 5/1/2023 a concern regarding personal refrigerator temperature. Review of R33's Order Summary revealed there was no order for daily temperature checks for a personal refrigerator checked by nursing. Review of R33's Medication Administration Record/Treatment Administration Record (MAR/TAR) dated 8/1/2023-8/31/2023 revealed there was no order for daily temperature checks for a personal refrigerator to be documented by nursing. Review of R33's Care Plan did not have a resident-specific treatment plan for his personal refrigerator. R16 According to the Minimum Data Set (MDS), 7/14/2023, R16 scored 14/15 (cognitively intact) on her BIMS (Brief Interview Mental Status), required extensive assistance with her ADLs with physical assistance from 1-2 people due to physical limitations to both arms and legs related to her diagnoses of multiple sclerosis and quadriplegia. During an observation and interview on 8/23/2023 at 9:40 AM, R16 had a personal refrigerator in her room. Observed inside of the refrigerator was a partial stick of butter in a clear plastic bag that was not dated. Multiple bottles of condiments including pickles that were opened with no dates or labels. R16 stated, My husband puts food in there for me. I do not know if anyone cleans it or checks the temperature. During an interview on 8/23/2023 at 2:35 PM Housekeeping Supervisor (HSKG) D stated, Maintenance and housekeeping used to do audits on resident refrigerators but we do not do them as regularly as we used to. If a resident asks to have their refrigerator looked at housekeeping will do it, but it is not done all the time. Some residents do not want their stuff touched. If asked by (names of NHA or DON) housekeeping will check on the refrigerators. A Risk v. Benefit form has to be signed by the resident that has refrigerator. During an interview on 8/23/2023 at 2:40 PM Maintenance C stated, (HSKG D) had to do audits once in a while on resident refrigerators. This was put on us to do by administration. Residents had to sign a paper to have a refrigerator. We do not do the audits now. Review of R16's Care Plan did not have a resident-specific treatment plan for a personal refrigerator. R25 According to the Minimum Data Set (MDS) 6/29/2023, R25 scored 4/15 on her BIMS (Brief Interview Mental Status), was independent with her ADLs, with diagnoses that included dementia, seizure disorder, and anxiety. Review of R25's medical record did not reveal a Risk v Benefit form had been documented. Review of R25's MAR TAR August 2023 did not have an order for monitoring the temperature of resident's personal refrigerator prior to the start of the survey on 8/22/2023. Review of R25's Care Plan did not have a resident-specific treatment plan for a personal refrigerator. Observed on 8/22/2023 at 3:22 PM R25's personal refrigerator had 3 glasses partially filled with milk each with a paper lid from the dining room. None of the glasses were dated or labeled. Observed on 8/23/2023 at 9:55 AM R25's personal refrigerator had 3 glasses partially filled with milk each with a paper lid from the dining room. None of the glasses were dated or labeled. During an observation and interview on 8/24/2023 at 11:40 AM R25's personal refrigerator had 3 glasses partially filled with milk each with a paper lid from the dining room. The milk in the glasses had started to separate. None of the glasses were dated or labeled. R25 stated, I drink it when I remember. I do not know if anyone checks it or not. Review of facility policy, FOOD BROUGHT IN BY FAMILY OR VISITORS PERSONAL REFRIGERATORS 2017, reported food or beverages brought in by family or visitors may be stored in the client's personal refrigerator. Refrigerators are cleaned regularly to maintain a safe and sanitary environment for food storage. Refrigerated foods that have been opened or left-over foods stored in the refrigerator will be marked with use-by date. The use-by date is six days from the day the food was opened or the day the left-over food was put in the refrigerator. Perishable foods are discarded on the sixth day after preparation/opening or on the expiration date. Review of facility policy, Food Safety Requirements Guideline effective date 11/28/17, revealed, .b. Educate and Inform .4. Proper labeling and dating of each item 5. Leftover foods will be used with 3 days or discarded .c. Monitor i. Facility staff will be appointed to check resident refrigerators for proper temperatures, food containment, and quality, and disposal of items per facility guideline. ii. Facility staff will be appointed to check resident rooms through daily housekeeping process for food and beverage items for safe and sanitary storage and handling. d. Foods requiring refrigeration will be received by the facility designee (activity department, food and nutrition department, charge nurse, etc.) for proper and immediate storage including labeling and dating .e. Staff will examine food for quality (smell, packaging, appearance) to identify potential concerns .D. Refrigeration . b. Document the temperature of external and internal refrigerator gauges .

Based on observation, interview and record review, the facility failed to employ a dietary manger with the appropriate skills to carry out the food and nutrition services, as evidenced by the lack of having the proper credentials of a certified Dietary Manager (CDM) and being able to demonstrate adequate knowledge related to the operations of the kitchen. This deficient practice has the potential to create unsanitary conditions in the kitchen and result in menus which are inadequate for the dietary requirements of all 71 residents. Findings include: On 8/22/23 at approximately 10:30 AM, during the initial tour, Kitchen Manager (KM) A was interviewed related to certification as a dietary manager. KM A stated he was not a Certified Dietary Manager (CDM) but had recently taken the Serve Safe class. The following observations and interviews were made regarding determining KM As competency of the facility's kitchen manager: On 8/23/23 at approximately 11:41 AM Kitchen Manager (KM) A was observed as he entered the kitchen from the dining room, wearing gloves, then lifted the lid to a large 30 gallon garbage can and replaced the lid. KM A then walked into the dish room and began handling clean cups and glasses to be taken into the dining room for the noon meal service. KM A failed to wash his hands following the handling of the garbage can lid and the clean meal service wares. An interview was conducted at this same time with KMA, who was asked if he was aware of what he did wrong. KM A was unaware that he had failed to wash his hands. On 8/22/23 at approximately 10:15 AM, during the initial tour of the kitchen, it was observed the facility utilized a high temperature dish machine for the washing, rinsing and sanitizing of the food service equipment. Dietary Aide (DA) H was observed operating the dish machine and asked how the machine was monitored or tested to ensure proper sanitizing of food contact surfaces. DA H stated they simply read the gauges on the machine and record the readings. When asked if there were any devices, such as an irreversible thermometer or strips available to test the sanitizing cycle, DA H stated he was not aware of any. An interview was conducted immediately with KM A related to the testing of the dish machine and the availability of testing devices. KM A stated the facility did not have anything to test the machine with. When asked to demonstrate the last time the machine had been tested and shown to properly sanitize food contact surfaces, KM A was unable to find any documentation. KM A stated the facility had not had any since he arrived, and had been over two months. On 8/23/23 at approximately 8:15 AM, observations were made of the walk in cooler. Observed were: A large (greater than two gallons) stainless steel pan, labeled refried beans with a date of 8/22; A large stainless steel pan with no label (appeared to be ground beef) with a date of 8/22; and a stainless steel pan of pulled pork dated 8/20. The temperature of the refried beans was measured, using a steel probe digital thermometer and found to be 45°F; the ground beef was measured to be 43°F, and the pulled pork was 41°F. An interview with KM A was conducted at this time and was learned the ground beef was taco meat and was prepared on 8/22, as were the refried beans. KM A stated the containers were supposed to be labeled with an expiration date. Documentation of proper cooling was requested from KM A, who then reviewed the production sheets and reported no cooling documentation had been conducted for the refried beans, taco meat or the pulled pork. A review of the production sheets for the individual days identified on the pans was conducted and verified there was no documentation for any of the three products. KM A stated he would dispose of the products. On 8/23/23 at approximately 9:05 AM KM A approached this surveyor, in the presence of the Nursing Home Administrator (NHA) in the corridor and stated he had located the cooling log for the pulled pork. At approximately 9:10 AM, a document titled <food vendor company name and logo> Cooling Log was reviewed. The document contained a single entry dated 8/22, and identified the pulled pork being cooled. No time was or temperature was entered to show the product had reached 41°F in the required time frame. Further, the date on the pulled pork container in the walk in cooler was dated 8/20, and the cooling log indicated the date of the cooling process entry was 8/22. When this was brought to the attention of KM A and asked to reconcile the discrepancy, no explanation was offered. On 8/22/23 at approximately 2:00 PM, an interview was conducted with KM A related to the testing of sanitizing chemicals used in the three compartment sink and buckets for the wiping clothes. When asked how the solutions were tested, KM A stated We use strips. When asked how it was tested, and the product being used, KM A stated, parts per million.' KM A could not identify the chemical being used. KM A then pulled out QT _40 strips, used for testing Quaternary products, then produced chlorine test strips. When asked again which test strips were used and what the chemical being tested was, KM A walked to the three compartment sink, pointed to the container on the floor and stated That. We measure for that. The container was reviewed with KM A and shown the product contained Lactic Acid as the sanitizing chemical. KM A stated I didn't know that. When asked why directions for measuring and testing Quaternary (quat) solutions was posted over the sink, and a dispenser containing quat test strips was adjacent to the sink. KM A did not respond.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure staff person washed their hands after being potentially contaminated. 2. Failing to ensure the high temperature dish machine was being tested for proper sanitization of food contact surfaces. 3. Failing to properly cool potentially hazardous foods after cooking and before being served. 4. Failing to properly clean the exterior rind of melons prior to cutting and serving. 5. Failing to maintain kitchen/food service equipment in a sanitary manner. 6. Failing to ensure food brought in from outside the facility, for residents, was labeled and safe for consumption. 7. Failing to ensure the person in charge (PIC) was knowledgeable about food service sanitation issues in the kitchen. These deficient practices have the potential to result in food borne illness among any and all 71 residents of the facility. Findings include: 1. On 8/23/23 at approximately 11:41 AM Kitchen Manager (KM) A was observed as he entered the kitchen from the dining room, wearing gloves, then lifted the lid to a large 30 gallon garbage can and replaced the lid. KM A then walked into the dish room and began handling clean cups and glasses to be taken into the dining room for the noon meal service. KM A failed to wash his hands following the handling of the garbage can lid and the clean meal service wares. An interview was conducted at this same time with KMA, who was asked if he was aware of what he did wrong. KM A was unaware that he had failed to wash his hands. FDA Food Code 2017 states: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; 2. On 8/22/23 at approximately 10:15 AM, during the initial tour of the kitchen, it was observed the facility utilized a high temperature dish machine for the washing, rinsing and sanitizing of the food service equipment. Dietary Aide (DA) H was observed operating the dish machine and asked how the machine was monitored or tested to ensure proper sanitizing of food contact surfaces. DA H stated they simply read the gauges on the machine and record the readings. When asked if there were any devices, such as an irreversible thermometer or strips available to test the sanitizing cycle, DA H stated he was not aware of any. An interview was conducted immediately with KM A related to the testing of the dish machine and the availability of testing devices. KM A stated the facility did not have anything to test the machine with. When asked to demonstrate the last time the machine had been tested and shown to properly sanitize food contact surfaces, KM A was unable to find any documentation. KM A stated the facility had not had any since he arrived, and had been over two months. FDA Food Code 2017 states: 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing. (A) In manual WAREWASHING operations, a TEMPERATURE MEASURING DEVICE shall be provided and readily accessible for frequently measuring the washing and SANITIZING temperatures (B) In hot water mechanical WAREWASHING operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL surface temperature. 3. On 8/23/23 at approximately 8:15 AM, observations were made of the walk in cooler. Observed were: A large (greater than two gallons) stainless steel pan, labeled refried beans with a date of 8/22; A large stainless steel pan with no label (appeared to be ground beef) with a date of 8/22; and a stainless steel pan of pulled pork dated 8/20. The temperature of the refried beans was measured, using a steel probe digital thermometer and found to be 45°F; the ground beef was measured to be 43°F, and the pulled pork was 41°F. An interview with KM A was conducted at this time and was learned the ground beef was taco meat and was prepared on 8/22, as were the refried beans. KM A stated the containers were supposed to be labeled with an expiration date. Documentation of proper cooling was requested from KM A, who then reviewed the production sheets and reported no cooling documentation had been conducted for the refried beans, taco meat or the pulled pork. A review of the production sheets for the individual days identified on the pans was conducted and verified there was no documentation for any of the three products. KM A stated he would dispose of the products. On 8/23/23 at approximately 9:05 AM KM A approached this surveyor, in the presence of the Nursing Home Administrator (NHA) in the corridor and stated he had located the cooling log for the pulled pork. At approximately 9:10 AM, a document titled <food vendor company name and logo> Cooling Log was reviewed. The document contained a single entry dated 8/22, and identified the pulled pork being cooled. No time was or temperature was entered to show the product had reached 41°F in the required time frame. Further, the date on the pulled pork container in the walk in cooler was dated 8/20, and the cooling log indicated the date of the cooling process entry was 8/22. When this was brought to the attention of KM A and asked to reconcile the discrepancy, no explanation was offered. FDA Food Code 2017 states: 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less 4. On 8/22/23 at approximately 11:25 AM, cook F was observed cutting up slices of watermelon and cantaloupe. An interview was conducted at this time with F to learn the process of cleaning the exterior of the melons prior to slicing. F stated the melons were simply put under some running water before slicing. F acknowledged the facility did not have a process to ensure the exterior rind had been properly cleaned, using a brush and/or a disinfecting solution, prior to pushing the knife through the rind and into the fruit center. FDA Food Code 2017 states: 3-302.15 Washing Fruits and Vegetables. (A) Except as specified in ¶ (B) of this section and except for whole, raw fruits and vegetables that are intended for washing by the CONSUMER before consumption, raw fruits and vegetables shall be thoroughly washed in water to remove soil and other contaminants before being cut, combined with other ingredients, cooked, served, or offered for human consumption in READY-TO-EAT form 5. On 8/22-23/23 observations of the kitchen equipment were made. The walk in cooler and walk in freezers were observed to have a silver seam tape hanging from the ceiling throughout both units. The gaskets on the [NAME] single door refrigerator, adjacent to the cooking equipment, was observed to have black mold in the accordion folds; the gaskets on the two door Traulsen refrigerator were torn and cracked; the three compartment sink was showing corrosion on the bottom of the sinks at the edges. The floor drain located under the three compartment sink was observed to have excessive garbage/food material as well as black mold growing on the drain pipes, with one of the drain pipes being from the ice machine. On 8/22/23 at approximately 1:45 PM, the nourishment room, near the south courtyard door, containing an ice machine was observed. The drain from the ice machine was draining into a plastic coffee cup on the floor under the counter the ice dispenser was located, and the wall, near the floor, to the left of the machine, was deteriorating due to water damage. Other food service items were stored in this room as well. FDA Food Code 2017 states: 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications 6. On 8/22/23 at approximately 10:55 AM, the nourishment room, near the front entrance and across from the nurses' station, was observed to have a refrigerator containing food for residents, brought in from outside sources. Two pint jars, containing, what appeared to be a tomato based food was observed on the shelf in the refrigerator. The product had a name, but was not labeled with a date it was brought in or when it was to be disposed of. This product was not commercially canned and prepared, rather, was a home canned product. A review of the facility's policy: Personal Food Guidelines dated 3.12.2018 was conducted. This policy stated: Food brought from outside sources by residents, friends or family will be stored in a designated location and labeled as such, separately from facility food. Labeling will include: Product name, Recieved date, use by date (no longer than 3 days), staff member's initials, Resident name. 7. On 8/22/23 and 8/23/23, throughout the observations of the kitchen, KMA was unable to demonstrate knowledge related to the use and testing of the sanitizing compounds used in the three compartment sink and wiping buckets, as well as testing of the high temperature dish machine. KM A failed to monitor staff related to the cooling of potentially hazardous food and ensuring the kitchen equipment was maintained in a clean and sanitary manner. On 8/22/23 at approximately 2:00 PM, an interview was conducted with KM A related to the testing of sanitizing chemicals used in the three compartment sink and buckets for the wiping clothes. When asked how the solutions were tested, KM A stated We use strips. When asked how it was tested, and the product being used, KM A stated, parts per million.' KM A could not identify the chemical being used. KM A then pulled out QT _40 strips, used for testing Quaternary products, then produced chlorine test strips. When asked again which test strips were used and what the chemical being tested was, KM A walked to the three compartment sink, pointed to the container on the floor and stated That. We measure for that. The container was reviewed with KM A and shown the product contained Lactic Acid as the sanitizing chemical. KM A stated I didn't know that. When asked why directions for measuring and testing Quaternary (quat) solutions was posted over the sink, and a dispenser containing quat test strips was adjacent to the sink. KM A did not respond. FDA Food Code 2017 states: 2-102.11 Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by: (A) Complying with this Code by having no violations of PRIORITY ITEMS during the current inspection; (B) Being a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM; or (C) Responding correctly to the inspector's questions as they relate to the specific FOOD operation. The areas of knowledge include: (1) Describing the relationship between the prevention of foodborne disease and the personal hygiene of a FOOD EMPLOYEE; (2) Explaining the responsibility of the PERSON IN CHARGE for preventing the transmission of foodborne disease by a FOOD EMPLOYEE who has a disease or medical condition that may cause foodborne disease; (4) Explaining the significance of the relationship between maintaining the time and temperature of TIME/TEMPERATURE CONTROL FOR SAFETY FOOD and the prevention of foodborne illness; (5) Explaining the HAZARDS involved in the consumption of raw or undercooked MEAT, POULTRY, EGGS, and FISH; (6) Stating the required FOOD temperatures and times for safe cooking of TIME/TEMPERATURE CONTROL FOR SAFETY FOOD including MEAT, POULTRY, EGGS, and FISH; (11) Explaining correct procedures for cleaning and SANITIZING UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B.) Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene was performed during care provided for 3 of 4 residents reviewed for infection control practices. This deficient practice resulted in the potential for the development and spread of infection, and complications associated with infections. Findings include: This citation is related to intake #MI00138172. On 8/22/23 at approximately 10:30 AM, during entrance conference the infection control policies were requested from the Nursing Home Administrator (NHA). On 8/23/23 at 4:18 PM, a second request was made for infection control policies to the NHA. The policies requested were transmission-based precautions, infection surveillance, immunizations (influenza, pneumococcal, and Covid-19 for residents), antibiotic stewardship and over all infection control facility wide. Resident #17 (R17) On 8/24/23 at 8:06 AM, an observation was made of the NHA. The NHA was observed adjusting the catheter tubing of R17 off the floor without gloves on. After the NHA was finished adjusting R17's catheter he failed to immediately sanitize his hands. The NHA then walked down the hallway, entered room [ROOM NUMBER] briefly, and then exited. The NHA next proceeded to walked out down the hallway to the front of the building by the Director of Nursing (DON) office and touched his face/nose area and entered DON's office. On 8/24/23 at 8:15 AM an interview was conducted with the DON. The DON confirmed the NHA should have worn gloves to adjust R17's urinary catheter and should have used hand sanitizer or washed his hands immediately after he was finished. On 8/24/23 at 3:04 PM, a third request was made for current infection control polices to the Director of Clinical Operations. Review of facility policy, Infection Surveillance Guideline, dated 11/28/17, revealed a document that had not been revised or updated in over a year. Review of facility policy, Guideline for Standard and Transmission-based Precautions, dated 11/9/20, revealed a document that had not been revised or updated in over a year. Review of facility policy, Influenza Vaccination Guideline, dated 11/28/17, revealed a document that had not been revised or updated in over a year. Review of facility policy, Guideline for Administering Pneumococcal Vaccination, dated 4/1/22, revealed a document that had not been revised or updated in over a year. Review of facility policy, Infection Prevention and Control Guideline, dated 11/28/17, revealed a document that had not been revised or updated in over a year. Review of the surveillance monitoring for the infection control program, dated January 1, 2023 through July 31, 2023, revealed the most recent outbreak was June 2023 with Covid-19. THIS CITATION WILL HAVE THREE PARTS (A.; B.; C) EACH WITH INDIVIDUAL DEFICIENT PRACTICE STATEMENTS DPS A This citation pertains to intake MI00138612 Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed to ensure proper hand hygiene was performed 1). while assisting 1 resident (R21) to eat, 2). during medication administration/foley catheter care for 1 resident (R26), and resident specific equipment was intact for 1 resident (R21) of 18 residents reviewed for infection control, resulting in the potential of cross-contamination, and harborage of infectious diseases in a vulnerable population of 71 residents. Findings include: Hand Hygiene R21 According to the Minimum Data Set (MDS) 7/13/2023, R21 scored 2/15 (cognitively impaired), on his BIMS (Brief Interview Mental Status), required total dependence on one-person's physical assistance to transfer between surfaces and move about in the facility in a mobility device, with diagnoses that included dementia and a psychotic disorder. During an observation and interview on 8/22/23 at 1:00 PM Certified Nursing Assistant (CNA) N was assisting R21 with eating breakfast. The CNA lifted both resident's heels and felt the bottoms of them with her bare hands then continued to feed the resident without performing hand hygiene. While feeding the resident, CNA N dropped food on the floor and cleaned it up with a napkin from the resident's tray and continued to feed the resident without performing hand hygiene. While feeding R21, the CNA dropped R21's built-up fork on the floor, picked it up and set it on his tray, and continued feeding the resident without performing hand hygiene. CNA N stated, I did not think about cleaning my hands when I did that. I was nervous you were watching me. R26 According to the Minimum Data Set (MDS) 8/7/2023, R26 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status), with diagnoses that included a neurogenic bladder and multiple sclerosis. During an observation and interview on 8/24/2023 at 8:15 AM, Registered Nurse (RN) L was passing morning medications to R26. R26 had a foley catheter hanging off the left side of the bed. R26 stated, I think my catheter bag is full. Look at this. R26 pulled her catheter tubing up from under the bed covers with yellow urine in it. RN L placed the medication cups on the bedside table, leaned over the resident and with both bare hands, took hold of the catheter tubing and pulled up the catheter bag stating, The bag is full and needs to be emptied. I'll have a CNA (certified nursing assistant) do it. Without performing hand hygiene, RN L picked up the medication cup with pills in one hand and in the other hand picked up the resident's personal drinking bottle, handing both to her. After the resident took her medication, RN L moved the bedside table closer to her. Meanwhile, R26's roommate asked for assistance with her breakfast. Without performing hand hygiene, RN L assisted setting up the roommate's breakfast tray. RN stated, I should have washed my hands after I touched the catheter for infection control. During an interview on 8/24/2023 at 12:20 PM the DON stated, Gloves should be worn when touching a foley catheter. Hands should be washed before and after touching a foley catheter. (R26's) foley catheter should not have been touched by the RN's bare hands. Equipment R21 According to the Minimum Data Set (MDS) 7/13/2023, R21 scored 2/15 (severely cognitively impaired), was totally dependent on physical assistance from staff to transfer between surfaces and transport around the facility with the use of a type of wheelchair (Geri-chair). R21 diagnoses included dementia. During an observation and interview on 8/22/2023 at 1:00 PM, R21's high-backed wheelchair had foam exposed to the environment through torn and missing material on the arms of the chair. CNA N stated, (R21) sits in it and goes out in the facility a couple of days a week. C. Based on interview and record review, the facility failed to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria in the facility water system. The failure to develop a comprehensive Water Management Plan has the potential for the proliferation and transmission of Legionella in the circulating water of the building and the spread of Legionella infections in all 71 residents. Findings include: On 8/22/23 at 2:45 PM, a review of the facility's Legionella Plan was conducted. The following components were absent from the facility WMP: A. Designation of a Water Management Team (WMT). B. An assessment of the facility's water system to identify risk locations. C. Identification of control points where effective mitigation measures can used. D. Identification of set critical limits related to the risk areas identified and which can be controlled. E. Identification of defined control measures and locations related to risk and the critical limits which are set. F. Implementation of regular scheduled mitigation program. G. An evaluation process to determine how the WMP is functioning. On 8/23/23 at approximately 9:35 AM an interview was conducted with Maintenance Supervisor (MS) C regarding the facility's Legionella control program and water management plan. MS C stated that there was no documentation regarding any interventions to mitigate risk areas in the building for Legionella. C. Based on interview and record review, the facility failed to develop a policy and implement a procedure for the laundry department to ensure proper disinfection was occurring when transmission based precaution (TBP) sourced laundry was present in the facility. This failure has the potential to result in the transmission of pathogens to all 71 residents through the laundry process if proper disinfection parameters are not met. Findings include: On 8/23/23 at approximately 9:15 AM, observations of the laundry area were conducted with Environmental Services manager (ESM) D. ESM D described the cycles on the washing machines used to control TBP sourced (also referred to as isolation rooms) laundry. ESM D identified Cycle 3 as the cycle which was to be used and thought it contained a higher level of bleach. When asked about testing for the concentration of chlorine (bleach), ESM D stated that no testing or documentation was done to ensure the proper concentration was met during this cycle. ESM D stated that she was not aware of any policy or procedure that required this testing and documentation. As indicated above, during the review of the surveillance monitoring for the infection control program, it was noted the facility had an outbreak of Covid-19 in June of 2023, and required proper handling and disinfection of Transmission Based Precaution sourced laundry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation relates to Intake #MI00137123. Based on interview and record review, the facility failed to provide adequate supervision to prevent a fall with injury for one Resident (#20) of three residents reviewed for falls. This deficient practice resulted in fall with a forehead hematoma and laceration for Resident #20, with the potential for medical and functional decline and additional adverse outcomes. Findings include: Review of Resident #20's Minimum Data Set (MDS) assessment, dated 04/05/23, revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including hip fracture, Parkinson's disease, respiratory failure, rhabdomyolysis (a muscle breakdown), malnutrition, and depression. Resident #20 required two-person assistance with bed mobility, transfers, dressing and toileting. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 99, which showed Resident #20 was unable to participate in the interview. The sensory assessment revealed Resident #20 was able to usually make himself understood, and usually was able to understand others, with severely impaired decision making. The mood assessment revealed a score of 19/27, which showed significant symptoms of depression. The behavioral assessment showed physical and verbal behaviors directed towards others occurred one to three days during the 7-day look back period. The assessment showed Resident #20 had a fall with fracture in the month prior to admission. Review of Resident #20's Accident and Incident Report dated 4/9/23 at 1:20 p.m. revealed, .Fall response [team] was called to resident's [#20's] room. Upon assessment resident [#20] had a [sic] unwitnessed fall and was observed lying on his side with w/c [wheelchair] on top and tipped over resident. Resident [#20] had noted hematoma [blood collection occurring from a blow or sudden pressure] to R [right] forehead and skin tear to L [left] shin. Resident denied pain in neck or back, no increased pain with range of motion. Resident unable to state what happened. Mumbled response. Immediate action taken: Resident [#20] was assisted with a Hoyer [full mechanical] lift into bed, ice pack applied to forehead. VS [vital signs] obtained. On call NP [nurse practitioner] notified, order obtained to send resident to [local hospital] for eval [evaluation] and tx [treatment]. Resident sent to hospital via EMS [Emergency Medical Service]. Level of Pain. 2 [of 10] on a standardized pain assessment for residents with dementia]. Oriented .to Person .Predisposing environmental factors: None .Predisposing Physiological Factors: Recent illness, symptoms of acute illness, Confused, Incontinent .Predisposing situation factors: Wheelchair use .Witnesses: No Witnesses found . Review of Resident #20's Accident and Incident Report, dated 4/9/23, included witness descriptions as follows: 4/9/23: Last time I seen [sic] [Resident #20] was when I got him up [in his wheelchair] around [11:30 a.m.] before his lunch. I passed out lunch trays then I took my lunch. I came back and helped coworkers. Somebody [another staff] asked for my help .I kept checking up on [Resident #20]; everything was fine in chair [wheelchair], tray [table] in front of him; [Resident #20] was calm . By Certified Nurse Aide (CNA) E. 4/9/23: Assisted [CNA E] in getting [Resident #20] out of bed and into chair at 11:30 a.m. I fed him lunch and around 12:30 I heard fall response [called] .and I rushed in there [Resident #20's room] to help. [Resident #20] was laying on his belly on the floor. Not sure if he tried to get up on his own or not. Hi [tray] table was in front of him when he was in the chair [wheelchair]. By CNA F. 4/9/23: I heard a resident's family yell, 'Here was a gentleman on the floor in room [#].' Upon entering the room, resident [#20] was lying face down on the floor with [his] w/c [wheelchair] tipped forward. Initially. resident [#20] would not respond to verbal stimuli then resident [#20] blinked his eyes. His right leg was on the w/c pedal .[Another nurse] and I removed the w/c [off Resident #20] to be able to assess the resident for any injuries . By Registered Nurse (RN) G. Review of Resident #20's hospital ER report, dated 4/9/23, revealed confirmed Resident #20 sustained a hematoma on frontal scalp (forehead) and was sent back to the facility with no additional injuries or concerns found. Resident #20 was described as .[A] chronically ill elderly gentlemen, a bit drowsy . The report showed normal range of motion to the extremities, no concerning neurological symptoms, and confirmed negative CT [CAT Scan] of head, no acute intracranial [brain] hemorrhage [bleed], CT cervical spine was negative, and pneumonia represented on chest x-ray. During a phone interview on 6/21/23 at approximately 6:00 p.m., Resident #20's family member (FM) H, reported they received a call from the facility on 04/09/23, and the nurse explained they found her father on the floor facedown, with the wheelchair on top of him, when he was left alone in his wheelchair in his room, with his lunch tray in front of him. FM H reported the facility discovered a right hematoma on his head and sent Resident #20 to the emergency room for evaluation. FM H reported Resident #20 was observed seated in an upright (not reclining) manual wheelchair during their visits. During a phone interview on 6/22/23 at 10:34 a.m., RN I confirmed they had worked with Resident #20 regularly, and reported they observed him slouching in his wheelchair and leaning to the right side intermittently. RN I stated Resident #20 required maximal assistance for care, and explained he was difficult to arouse before the fall, at baseline, and had little movement. When asked if Resident #20 should have been left alone in his wheelchair, they responded they were not certain, as he did lean to the side (in his wheelchair) and became sleepy often. During an interview on 6/22/23 at 11:08 a.m., CNA J reported they recalled Resident #20 using an upright manual wheelchair, and he would slouch forward and lean to the side in his wheelchair intermittently. They recalled boosting him up in his wheelchair frequently, as he would slide down, and placing a pillow on his side, to keep him more upright. CNA J demonstrated Resident #20's seated position in his wheelchair, and how he was not able to sit upright. CNA J showed surveyor how Resident #20 would slide forward, as Resident #20's hips were not back against the seat and back of the wheelchair (in a sacral seated posture). During an interview on 6/22/23 at 1:01 p.m., CNA K reported they witnessed Resident #20 on 4/9/23 on the floor after he fell and had assisted with his transfer with the Hoyer lift [after the fall]. CNA K explained when Resident #20 was transferred to his wheelchair during their care, he struggled to sit upright, and demonstrated slouching in his wheelchair frequently. CNA K stated, [Resident #20] couldn't be trusted in his room by himself sitting in his wheelchair. Family wanted him up and it was unsafe to get him up. [Resident #20] was not alert enough to get him out of bed [on 4/9/23] . CNA K reported on 4/9/23, they assisted CNA L to transfer Resident #20 into his wheelchair at lunch for a family visit per nursing request and left him in the wheelchair about 45 minutes when the fall occurred. CNA K reported some days Resident #20 could sit up in a wheelchair, and other days he would stay in bed due to sleepiness. CNA K clarified their understanding was regardless of how Resident #20 was doing, they were expected to sit him up in the wheelchair when family visited, per nursing directive. During an interview on 6/22/23 at approximately 1:45 p.m., Physical Therapist (PT) M was asked about Resident #20's sitting and activity tolerance for seated positioning in his manual wheelchair. PT M reviewed Resident #20's therapy notes with Surveyor and acknowledged Resident #20 required moderate assistance for static sitting balance, and upper trunk stabilization, near the time of Resident #20's fall on 4/9/23. PT M recalled Resident #20 had a reclining manual wheelchair and had performance inconsistencies as some days he was lethargic and needed to stay in bed, and on a good day could transfer to his wheelchair and sit upright. PT M stated, I can see why the staff would leave him up as on previous days he was able to tolerate that [sitting upright in his wheelchair]. That would have been a day he was not doing so well. Surveyor asked if the therapy department provided recommendations to staff for Resident #20 regarding communicating a residents wheelchair sitting tolerance, and if there was a process for therapy to nursing communication. PT M reported the evaluating therapist may make those recommendations to nursing staff during the evaluation. PT M confirmed post review of Resident #20's PT evaluation, no communication was documented regarding Resident #20 needing assistance and supervision when he was up in his wheelchair, and they understood the concern. PT M acknowledged Resident #20 needed supervision for safety during his entire stay and should not have been left unsupervised up in wheelchair, given his compromised sit balance and trunk control, and fluctuating alertness. PT M reported therapy would assist Resident #20 back to bed after therapy sessions, due to fatigue and sleepiness. PT M clarified Resident #20 did list to the side sometimes in his wheelchair, however they had not seen him sliding out of his wheelchair. PT M confirmed going forward, a resident with performance inconsistencies or who needed supervision in their wheelchair for safety, balance, or activity tolerance would ideally be placed at or near the nurse's station to have adequate supervision. Review of Resident #20's Care Plan, accessed 6/22/23, revealed no designation for supervision when up in his wheelchair. The Care Plan showed Resident #20 used a walker, and noted he had a history of falls, and intermittent behaviors. After Resident #20's fall on 4/9/23, new interventions were added, including keeping the call light in reach, keeping Resident #20 in bed primarily, and keeping him in line of sight (supervised) when he was up in his wheelchair. During a brief follow-up interview on 6/22/23 at 3:08 p.m., PT M confirmed Resident #20 did not use a walker during his stay and had only stood in the parallel bars with assistance once during therapy for a short period. Review of Resident #20's Grievance form, dated 4/10/23, revealed family members expressed concerns Resident #20 was not provided with 1:1 care (supervision) and was left alone in his wheelchair, resulting in the fall on 04/09/23, and they requested Resident #20 not get out of bed without 1:1 supervision after the fall. The form showed new interventions were added after the fall included a lowered bed and fall mat. Review of Resident #20's physician note, dated 4/03/23, revealed, . [Resident #20] seen resting in bed. [Resident #20] has his entire tray tipped over and all his breakfast in his bed. [Resident #20] is very agitated . Diagnosis and Assessment: .Closed fracture of neck and right femur [thigh bone] .dementia with behavioral disturbance . Review of Resident #20's physician note, dated 4/4/23, revealed, At the time of exam in their room, patient has been unable to participate in therapy due to somnolence [drowsiness], which has been consistent since hospitalization . Lethargy .Resident's [#20's] son states that he typically sleeps a lot throughout the daytime . Review of Resident #20's physician note, dated 4/7/23, revealed, This is [AGE] year-old gentlemen with a history of dementia, recent hip fracture seen today after resident had an aspiration event and chest x-ray and was positive [test results] for pneumonia . Review of Resident #20's physician note, dated 4/10/23, revealed, This is a [AGE] year old gentlemen with a history of dementia, recurrent falls, debility, hip fracture seen after [Resident #20] had a fall .requiring transfer to the emergency department. Resident found to have a hematoma and abrasion to the right side of his forehead, unknown if loss of consciousness. CT of head without contrast negative for acute findings, C-spine [neck bones] CT also negative. [Resident #20] was ultimately sent back to the facility with no new orders. [Resident #20] seen resting in bed. Limited historian secondary to this cognition but does not appear to be in any distress or discomfort .Hematoma secondary to fall . Review of Resident #20's physician note, dated 4/11/23, revealed, . [Resident #20] seen today for management of multiple comorbidities . staff requesting capacity evaluation given noncompliance and difficulty giving care. Recently he did fall . and had emergency room evaluation over the weekend . [Resident #20] is A & O [alert & oriented] x 1, patient is otherwise unable to participate in Mini-Mental evaluation [a cognitive assessment] . Review of Resident #20's therapy fall screen, dated 4/10/23, revealed, Reason for screen .fall .history of falls: Yes .Current Care Plan Fall Interventions [post fall]: Keep out of room when up [out of bed] .Visual observations: Positioning concerns - yes, Bed mobility concerns - yes, transfer concerns - yes, ambulation concerns - yes, ADL [activities of daily living] concerns - yes, balance concerns - yes, safety awareness concerns - yes .Patient questions: Did you hit your head when you fell? Yes .Location of fall and any known details: [Resident #20's] Room with w/c on top of him. Suspected cause: Self transfers. Comments: Patient is currently on therapy . Review of Resident #20's nursing progress note, dated 4/11/23, revealed, Care conference requested by family to discuss care concerns r/t [related to] recent fall [on 4/10/23] .Family very upset that resident [#20] had fallen yesterday .They .request 1:1 care [an assigned staff to care for Resident #20]. [Facility staff] explained that staffing does not allow for resident [#20] to have 1:1 care on a continuous basis. Discussed placing resident in communal areas for frequent visual check [when up in wheelchair]. Family does not like this recommendation and would like resident to be in bed at all times when not receiving therapy services until family can transfer resident out of the facility . Review of Resident #20's nursing progress note, dated 4/9/23 at 2:23 p.m., revealed, Post-fall: Total Fall Risk Score is: 17. Fall risk scored above 5, resident [#20] is a HIGH risk for falls .There is no new pain post fall .Resident has the following injuries noted: Hematoma or bump to the resident's R [right] forehead. Abrasion to residents LLE [left lower extremity]. New interventions for fall .Neuro observation. Resident [#20] is: Confused .Resident [#20] is NOT oriented x 1, oriented to person .Responds to simple commands . Review of Resident #20's Physical Therapy (PT) evaluation, dated 4/1/23, revealed Resident #20 was dependent for transfers, required maximal assistance for bed mobility, and was unable to stand or ambulate. The evaluation showed Resident #20 had decreased dynamic and static balance in sitting, and was unable to sit unsupported 30 seconds, requiring maximal assistance, was unable to stand, and had impaired lower extremity strength. Review of Resident #20's PT progress note, dated 4/6/23, revealed Resident #20 required moderate assistance for sitting balance and tolerance, and tolerated static (steady) sitting for only .[approximately] 10 minutes ., and moderate to maximal assistance with rolling and maximal to dependent assistance to sitting up on edge of bed. Review of Resident #20's PT Discharge summary, dated [DATE], revealed Resident #20 was dependent for transfers, required maximal assistance for bed mobility, and was unable to stand or ambulate. Review of Resident #20's Occupational Therapy (OT) evaluation, dated 4/3/23, revealed Resident #20 was able to sit unsupported three seconds, showing markedly impaired sitting balance and tolerance. During an interview on 06/22/23 at 4:56 p.m., the Director of Nursing (DON) was asked about Resident #20's fall on 4/9/23, and the concerns with his lack of supervision. Surveyor reviewed the following details: Resident #20 was left unsupervised in his room with decreased sitting balance, and postural control issues. Multiple staff reported Resident #20 had stability and balance issues with sitting in wheelchair. Resident #20 also had performance inconsistencies and fluctuations in alertness due to lethargy and sleepiness, particularly noted during therapy sessions. The DON confirmed Resident #20 demonstrated intermittent lethargy during their stay, which was later found in part attributable to behaviors during a subsequent hospital stay on 4/14/23, when he became unresponsive. The DON reported while they had not observed Resident #20 sliding down and leaning in his wheelchair, they understood the concerns. The DON clarified the Root Cause Analysis showed the cause of the fall was Resident #20 was self-transferring, when he required significant two-person assistance. The DON clarified the intervention following the fall was to place Resident #20 at the nurse's station (supervised) when he was up in this wheelchair, per his tolerance. The DON stated facility residents were not made to sit up in their wheelchairs for family visits, staff convenience, or therapy. The DON confirmed there was no 1:1 staff assigned to Resident #20 before or after his fall when he was seated in his wheelchair. The DON stated they had not observed Resident #20 in his wheelchair and was unable to describe Resident #20's posture or type of wheelchair he used Review of the policy, Accidents, dated 6/29 2021, revealed, Purpose: To ensure the environment is free from accident hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable accidents through a systemic approach .Accident refers to any unexpected and unintentional incident, which results or may result in injury or illness to a resident. This does not include other types of harm, such as adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current professional standards of practice (e.g., drug side effects or reaction). Avoidable Accident means that an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual risk of an accident, including the need for supervision and/or assistive devices. Evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident. Monitor the effectiveness of interventions and modify the Care Plan as necessary, in accordance with current professional standards of practice .Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. An effective way to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents .