This citation pertains to Intake: MI00149450. Based on interview and record review, the facility failed to notify the resident's representative of a change in condition for one resident (R901) of one resident reviewed for a change in condition. Findings include: On 1/21/25 at 9:32 AM, Confidential Family Member A was interviewed regarding R901, and explained they were unaware that R901 was showing any signs of a change in condition until another family member went to visit the resident on 1/9/25, and noticed a change in their abilities. Family Member A explained they requested the resident be transferred to the hospital on that day, and was later informed R901's physician had ordered tests to be completed days before the transfer, but wasn't informed of this, as they would have liked to be a part of the decision-making regarding the care of their loved one. A review of R901's medical record revealed they were admitted into the facility on 2/5/24 with diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia, Diabetes, Dementia, and Heart Failure. Further review revealed the resident was severely cognitively impaired, and required limited assistance of one person for transfers and bed mobility per their care interventions initiated on 4/12/24 and 5/7/24. Further review of R901's medical record revealed the following progress notes: 1/6/2025 06:42 (6:42am) Nurses Note Note Text: CNA (certified nursing assistant) reported changes in PT's (patient's) condition. PT no longer assist with bed mobility, noticed not transferring with wheelchair to toilet or bed . 1/6/2025 14:58 (2:58pm) Nurses Note Note Text: Writer informed that resident has a change in condition. Resident has not been transferring or toileting as [R901] normally does. Resident needs 2 people and maximum assist with transfers and toileting. Resident is now needed to be changed instead of toileting and transferring [themselves] . 1/6/2025 15:06 (3:06pm) Nurses Note Note Text: Resident has complained of leg and ankle pain. Denies having any falls. 1/7/2025 19:20 (7:20pm) Nurses Note Note Text: Resident observed in room with mid (mild) distress noted. Resident complains of back and left knee pain. Writer informed that resident has a change in condition. Resident has not been transferring or toileting as [R901] normally does. Resident needs 2 people and maximum assist with transfers and toileting. Resident is now needed to be changed instead of toileting and transferring herself . 1/9/2025 02:41(2:41am) Nurses Note Note Text: Patient has had an acute change in condition, observed within past 2 weeks no longer transferring with w/c (wheelchair), toileting self or getting out of bed . Further review of R901's progress notes revealed R901's guardian had not been contacted when the resident began showing a change in condition. On 1/21/25 at 1:32 PM, an interview was completed with Licensed Practical Nurse (LPN) B regarding R901's change in condition, and explained they were not that familiar with R901 but was initially informed of their change in condition, and asked to complete the documentation. LPN B explained Unit Manager C indicated they would contact the family. On 1/21/25 at 2:17 PM, Unit Manager C was interviewed via phone about R901's change in condition, specifically the family being contacted regarding the change. Unit Manager C explained they contacted the family however, they did not document the attempt. On 1/21/25 at 2:05 PM, the Director of Nursing (DON) was asked about R901's change in condition, and the family not being contacted. The DON explained the family should be notified of a change in condition. A review of the facility's Acute Change in Condition policy did not address the resident's representative being notified of a change in condition.

This citation pertains to Intake M100147854. Based on interview and record review, the facility failed to complete a comprehensive nutritional assessment in a timely manner for one (R801) of three residents reviewed who were admitted with nutrional at-risk indicators. Findings include: Review of the facility record for R801 revealed an admission date of 10/15/24 with diagnoses including Dysphagia (difficulty swallowing), Diabetes Mellitus, and Dementia. A transfer order from the hospital indicated the resident required a pureed diet. The resident's weights were documented on 10/15/24 (140 pounds) and 11/02/24 (131.7 pounds). R801's Care Plan indicated they required Extensive Assistance for eating. The Nurse Practitioner (NP) progress note dated 10/21/24 stated decreased oral intake, monitor for now. The Change of Condition note dated 11/08/24 indicated decreased appetite. Further review revealed no comprehensive nutritional assessment was completed by the Registered Dietician (RD). On 11/08/24 at 12:06 PM, RD A was interviewed by phone. RD A reviewed R801's record and confirmed they had not completed a nutritional assessment and stated It looks like it got missed. RD A reported their resident assessment would normally be completed within the first week of the resident's stay. On 11/08/24 at 12:57 PM, the facility Director of Nursing (DON) indicated the RD had located additional information so RD A was interviewed further via phone. RD A reported they had completed the Minimum Data Set (MDS) nutrition (Section K) assessment on 10/18/24 but confirmed the MDS section was not a comprehensive dietary evaluation and the full assessment did get missed. Considering the multiple dietary-related indicators (dysphagia/pureed diet, requiring eating assistance, decreased oral intake, decreased appetite and weight loss) RD A was asked if it was likely completion of a full RD assessment would have led to additional care interventions and they were not able to provide a definitive answer. On 11/08/24 at 1:02 PM, the DON was asked what their expectation was for completion of the Registered Dietician's full initial assessment and they stated they would have to review the policy before providing that information. By completion of the survey a response regarding the expectation was not provided. A facility policy addressing the indications for and the timeliness of a dietary evaluation was requested however the provided policy addressed only the MDS assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor a resident's request to be sent out for a higher level of care for one resident (R33) of one reviewed for self-determination. Findings include: On 9/18/24 at 8:47 AM, R33 was observed lying in bed, and asked to speak to the surveyor. R33 explained that their pain management has not been managed well, specifically with them not receiving their prescribed as needed medications timely. R33 further explained that they have a history of kidney stones, and felt as though they had one last week Wednesday, which was causing excruciating pain. R33 explained that as a result, they asked to speak to the Director of Nursing and their physician as they wanted to be transferred to the hospital. R33 further explained that they never spoke to the DON or the physician, but was told that the nurse spoke to the physician who did not order a transfer to the hospital, and that if they chose to transfer on their own they would have to sign themselves out Against Medical Advice (AMA), and be responsible for the transportation bill. R33 further explained that they didn't want a bill, and remained in excruciating pain for the duration of the day and night. A review of R33's medical record revealed that she was admitted into the facility on [DATE] with diagnoses that included Chronic Kidney Disease, Acute Pyelonephritis (Kidney Infection), and Anemia. Further review revealed that the resident was moderately cognitively impaired, and required one-person for assistance for bed mobility, toileting and dressing. Further review of R33's medical record revealed the following progress notes: 9/11/2024 15:41 (3:41pm) Nurses Note Text: Resident states at 10:30am [they want] to speak with [physician] and DON regarding pain/kidney stones. Both notified. Pain meds given as ordered. Resident states ineffective. 9/12/2024 16:30 (4:30pm) Physician Progress Notes Late Entry: Note Text: Called to bedside secondary to medical evaluation and maintenance of care Increased pains in b/l (bilateral) mid-back. Hx (history) of kidney stones and stated similar pains to that. Pain improved today, but quite bad yesterday. Pt (patient) stated [they] requested to go to hospital, but staff stated physician denied. No conversation did occur to indicate [they] needed transfer the night prior when discussing with nursing. Apologized for not completing [their] needs - indicate will work better in future to do so. Pt appears to be ok with today's results. Indicated will start IV (intravenous) to flush any remaining stone that may be present and reminded of muscle relaxers ordered . On 9/19/24 at 10:07 AM, a phone call was made to Licensed Practical Nurse (LPN G), the nurse assigned to R33 during midnight shift on 9/11/24. LPN G explained that they had received report from the previous nurse informing them that R33 was in pain, and that the doctor had been contacted. LPN G explained that they provided R33 their pain medications per the active orders, and attempted to contact the physician again to no avail. On 9/19/24 at 11:35 AM, an interview was completed with LPN C, assigned nurse during the day shift for R33. LPN C was asked about R33's complaints of pain, and request to go to the hospital. LPN C explained that R33 did request to go to the hospital, but when they spoke to the physician regarding the resident's concerns, they did not provide any new orders for the resident. LPN C reports that she continued to provide R33 their pain medications per their current orders. LPN C was asked if they were aware of anyone telling the resident that they would have to sign themselves out AMA, and they stated that they are not sure. On 9/19/24 11:47 AM, an interview was completed with the DON regarding R33 and their request to go to the hospital. The DON explained that the resident has a right to go out to the hospital when they chose, and would follow-up with the resident regarding their concerns. On 9/19/24 at 1:29 PM, the Nursing Home Administrator (NHA), was asked about a resident being told that they couldn't be transferred to the hospital if initiated by the resident themselves, and it being considered an AMA. The NHA explained that it is the resident's right to be transferred and it would not be considered an AMA. A review of the facility's Resident Rights policy revealed the following, .Resident rights. The resident has the right to a dignified existence, self -determination, and communication with and access to persons and services inside and outside the facility 6. Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to .b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration when an extended-release medication was crushed for one Resident (R62) of six residents reviewed for medication administration. Findings include: On 9/18/24 at approximately 9:30 a.m., R62 was observed in their bed with fisted hands, wearing a hospital gown, with Licensed Practical Nurse (LPN) L present. When LPN L was leaving the room, R62 was heard to say they wanted their medications crushed. On 9/18/24 at approximately 9:32 a.m., LPN L started to crush R62's medications. LPN L was asked if R62 should have had their medications crushed, as this was not observed in the physician's orders. LPN L reported R62 sometimes liked their medications crushed and continued to crush R62's medications as follows: -Colace Oral Capsule, 100 mg (milligram). Give 1 capsule two times a day for constipation. -Loratadine Oral Tablet. 10 mg. Give 1 tablet by mouth one time a day for allergies. -Duloxetine Hcl Capsule. Delayed-release particles 60 mg. Give 1 capsule by mouth once a day for depression. -Fenofibrate tablet. 145 mg. Give 1 tablet once a day for coronary artery disease. -Hydroxyzine Hcl Oral tablet. 25 mg. Give 25 mg by mouth two times a day for Anxiety. -Hydromorphone Hcl Oral tablet. 4 mg. Give 1 tablet by mouth every four hours as needed for pain. Review of R62's six medications orders, accessed 9/18/24, revealed none of R62's six medications administered had orders to be crushed. Review of R62's Minimum Data Set (MDS) assessment, dated 8/23/24, revealed R62 was admitted to the facility on [DATE] with diagnoses including paraplegia (paralysis of lower body), schizophrenia (chronic mental disorder), and seizure disorder. R62 was dependent for self-care, bed mobility, and transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 11/15, which showed R62 had moderate cognitive impairment. Review of the Electronic Medical Record (EMR) showed R62 had a guardian. The record also revealed R62 was on a regular texture diet, with thin liquid consistency for fluids. On 9/19/24 at 9:08 a.m., the Director of Nursing (DON) was asked about R62's medications being crushed on 9/18/24. The DON reported LPN L had notified them of this occurrence on 9/18/24 after the medications were passed. The DON stated they had contacted the physician afterwards, who ordered R62's medications to be crushed as needed. The DON was asked if R62 had any adverse outcome and reported they had not been made aware of any. Surveyor reviewed concerns related to the potential for adverse effects when medications not ordered as crushed were dispensed in crushed form. Upon review, the DON called the facility pharmacist, Pharmacist M, with Surveyor present, to inquire if any of the six medications administered were DO NOT CRUSH medications. On 9/19/24 at approximately 9:30 a.m., the DON reviewed R62's six medications which were crushed by LPN L during morning medication pass on 9/18/24 with Pharmacist M on the phone. Pharmacist M reported they reviewed a DO NOT CRUSH medication list and found R62's six medications which were crushed on 9/18/24 were not on the DO NOT CRUSH list and were able to be crushed. Pharmacist M referenced the reference they used as an ISMP (Institute for Safe Medication Practices) - DO NOT CRUSH LIST. Review of the ISMP weblink, Oral Dosage Forms That Should Not Be Crushed 2016 (ismp.org), and a web search including recent literature and resources showed no current ISMP list of DO NOT CRUSH medications since 2016. Review of a response email from ISMP, dated 9/24/24 at 11:12 a.m., revealed, .On November 17, 2022, ISMP removed the table of Do Not Crush Medications from our website. This is because ISMP did not own, update, or review new or existing content on the List of Oral Dosage Forms That Should Not Be Crushed. On May 1, 2023, the updating, printing, and sales of wall charts with the list, by [NAME] Land Publishers, was discontinued .ISMP encourages that organizations maintain, update, and periodically review a list of oral dosage forms that may require alteration through evaluation of package inserts, drug manufacturer inquiries, tertiary drug information resources, and primary literature . Review of the drug manufacturer's literature for R62's six medications administered as crushed revealed one of the six crushed medications, Duloxetine, also known as Celexa, should not have been crushed, as it was a delayed-release medication (designed to release the active ingredient after taking the medication). Review of R62's medication order, dated 8/20/24, revealed, Duloxetine HCl Capsule Delayed-Release Particles. 60 mg. Give 1 capsule by mouth one time a day for depression. There was no directive to crush this medication. Review of R62's medication order, dated 9/19/24, accessed 9/19/24 with the DON, showed a new order, dated 9/18/24 at 19:00 [7:00 p.m.], May crush allowable meds, every shift. The DON confirmed this order was entered after R62 received six medications crushed on 9/18/24 during the morning medication pass. Review of the package insert, revised 2023, Cymbalta - duloxetine hydrochloride capsule, delayed- release, [NAME] Lily and Company, revealed, on Page 1, Indications and Usage: CYMBALTA is a serotonin and norepinephrine reuptake inhibitor (SNRI = medication class) indicated for the treatment of the following conditions: Major depressive disorder (MDD) in adults .Dosage and administration: Take CYMBALTA once daily, with or without food. Swallow whole; do not crush, chew, or open capsule . Review of the article, Meds that Should Not Be Crushed, https://pharmacist.therapeuticresearch.com/Content/Segments/PRL/2014/Aug/Meds-That-Should-Not-Be-Crushed-7309, accessed 9/26/24, revealed, Crushing pills can improve ease of administration, but some shouldn't be crushed. Crushing extended-release meds can result in administration of a large dose all at once. Crushing delayed-release meds can alter the mechanism designed to protect the drug from gastric [stomach digestion] accidents or prevent gastric mucosal [lining] irritation . The list included Duloxetine as a medication which should not be crushed due to being a modified release medication. Review of the facility policy, PCU018 - Medication Administration and General Guidelines, received 9/19/24, revealed, .2. Medications are adminstered in accordance with written orders of the attending physician On 9/19/24 at approximately 3:30 p.m., concerns were reviewed with the DON related to R62's medications being crushed without a physician order. The DON reported medications could be crushed when necessary, and it was a resident's right to have their medications crushed per their preference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an assistive communication device for one resident (R35) of five reviewed for communication, resulting in limited communication between R35 and staff. Findings include: On 9/17/24 at 10:30 AM, R35 was met in their room for observation and interview. R35 was unable to answer any questions asked. R35 gave a thumbs up, when asked if they were okay. On 9/18/24 at 9:03 AM, R35's Certified Nursing Assistant (CNA) B was interviewed and asked about how they communicated with R35. CNA B stated, [R35] gestures and gives a thumbs up. CNA B was asked if R35 had a communication board to assist with communication with staff. CNA B stated, No, not that I'm aware of. CNA B indicated it would be helpful for R35 to have a communication board. A review of R35's electronic medical record (EMR) revealed that R35 was most recently admitted to the facility on [DATE] with diagnoses that included Ceberal infraction (stroke) and Type 2 diabetes. R35's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R35 had a severely impaired cognition, was dependent upon staff for all activities of daily living (ADL's) other than eating. Per R35's MDS, they were rarely/never understood. A review of R35's care plan revealed that R35's communication goal on their care plan did not include an intervention regarding a communication board. On 9/18/24 at 4:11 PM, Rehabilitation Director (RD), D was interviewed regarding communication involving R35. Based on a review of R35's rehabilitation/therapy record, with RD D it was revealed that R35's most recent Speech Evaluation and Plan of Treatment was dated with an end date of 4/14/21 and addressed R35's swallowing. On 9/18/24 at 4:39 PM, RD D later stated, [R35] has a communication board by their bed. They use it sometimes. On 9/19/24 at 9:24 AM, a follow up visit was conducted with R35 in their room. R35 was observed sleeping and no communication board was observed to be in R35's room. On 9/19/24 at 9:27 AM, Nurse/LPN (Licence Practical Nurse) C was interviewed and asked about R35 having a communication board. Nurse C stated, I've never seen [R35] use one. [R35] gives a thumbs up, and thumbs down, that's about it. On 9/19/24 at 10:00 AM, the Administrator (NHA) was asked about their expectations for providing assistive communication devices, such as a communication board, to non-verbal residents. The NHA stated, If a resident can't communicate, they should get a communication board. The NHA further indicated if a resident was unable to use a communication board, staff should figure out ways to communicate with them. A review of a policy titled, Communication: Sensory and [NAME] Impairments with no date, revealed the following, Policy: It is the policy of this to ensure that qualified persons with disabilities, including those with impaired .speaking .have meaningful access to adequate and effective care . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure broken glasses were addressed for one resident (R109) out of one resident reviewed for vision. Findings include: On 9/18/24 at 10:24 AM, R109 was observed in their room wearing glasses which were observed to be missing a section of the frame and the entire lens on the right side. The lens on the left side was observed to be dirty with many specks of unknown particles covering it and smeared with a greasy appearing substance. R109 was asked how long their glasses had been broken. R109 explained they had been broken for quite a while. R109 was asked if they were able to see. R109 stated, I can see but not very well. R109 was asked if the facility was helping them get new glasses. R109 stated no. they said I had to get them myself. A review of R109's medical record revealed they were admitted to the facility on [DATE] with the following diagnosis: Other sequelae of cerebral Infarction; Ataxia following Cerebral Infarction. A review of R109's Brief Interview for Mental Status revealed a score of 14 indicating mild cognitive impairment. A review of R109's care plan revealed the following: I have impaired visual function r/t (related to) impaired vision. I will use appropriate visual devices to promote participation in ADLS (activities of daily living) and other activities. I wear glasses Please help me with them as needed. A review of R109's progress notes revealed an optometry visit note dated 8/8/24 stating the following: Chief complaint: DM (diabetes mellitus) eye exam .Corrective lenses 1. Yes. Pts (patients) own. A description or mention of R109's broken glasses or an explanation of why they were not fixed or replaced was not included in the note. On 9/19/24 at 9:37 AM, during an interview, Unit Manager (UM E) was asked if they were aware R109's glasses were broken. UM E explained they were not aware and they would let social work know. UM E then stated, social work will place (them) on the list to be seen by the eye doctor. On 9/19/24 at 10:36 AM, R109 was observed sitting on their bed, squinting their eyes, while writing on a piece of paper. R109 was observed to be wearing their broken glasses. R109 confirmed they were seen by an eye doctor in August. R109 was asked if the eye doctor was aware their glasses were broken. R109 stated yes. R109 was asked what the eye doctor said about the broken glasses. R109 stated (they) said I had to get my own. On 9/19/24 at 10:46 AM, Certified Nurse Assistant (CNA F) was asked if how long R109's glasses had been broken. CNA F stated, I think ever since (they've) been here. On 9/19/24 at 10:52 AM, during an interview, Social Worker (SW I) was asked if they were aware that R109s glasses were broken. SW I explained UM E had called them about it and they sent an email to the eye doctor and are awaiting a response. SW I explained when a resident has broken glasses and are seen by optometry they usually repair or replace them right away if possible or they will order new ones and says it should have been addressed during the visit. On 9/19/24 at 11:48 AM, during an interview, the conversation with R109 and a description of R109's glasses was described to the Director of Nursing (DON). The DON was asked to describe what happens when a resident has an issue with their glasses, or their glasses are broken. The DON stated, they are put on a list to be seen. If it's an emergent situation like this one, we would contact optometry right away and have them seen. The DON was asked what the staff should have done when they noticed that R109's glasses were broken. The DON stated, They should have reported it, and optometry should have fixed or replaced them last month when they saw (them). A review of the facility's policy titled Appointments revealed the following: When a resident requires an appointment with a consulting physician or service, the Social Service staff or designee will assist the resident to secure an appointment. If routine service is needed and the service is conducted within the facility (i.e. podiatrist, eye doctor, etc.), the resident will be placed on the schedule for the next scheduled visit. If emergency service is needed, the Social Service staff or designee will contact the physician or service for an appointment .Documentation related to appointments should be placed in the resident record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a splinting program for one (R68) of five residents reviewed. Findings include: On 09/17/24 at 09:56 AM, R68 was asked about a hand splint that was observed laying on the heat register in their room. R68 reported the splint was for their left hand and stated They never put it on anymore. Review of the facility record for R68 revealed an admission date of 12/17/20 with diagnoses including Cerebral Infarction with Left Hemiplegia and Muscle Wasting and Atrophy. The record also indicated R68 required total assistance for dressing tasks. On 09/17/24 at 03:27 PM, R68 was observed laying in bed. The hand splint was observed laying on the heat register. Additional review of R68's record revealed the most recent Occupational Therapy (OT) evaluation dated 06/06/24 and Discharge summary dated [DATE] made no reference to a left hand splint or related interventions. An OT evaluation dated 06/01/21 did reference the left hand splint and stated Short-term goal: Patient will safely wear a resting hand splint on the left hand for up to one hour with minimal signs/symptoms of redness, swelling, discomfort, or pain. The evaluation further indicated the recommendation for resting hand splint for prevention of further contracture and pain in the left hand. On 09/18/24 at 09:28 AM, R68's hand splint was observed laying on the heat register. R68 was asked if the splint was put on the previous evening or during the night and they stated No. R68 was asked if they knew why the hand splint was not being used and they reported they didn't know. When asked if they had any pain in the left hand they stated Sometimes I do. R68 was asked if they wanted the splint to be used and stated It probably should, my hand hurts sometimes and I can't use it anyway. On 09/18/24 1:35 PM, R68 was observed in their room. The hand splint was laying on the heat register. On 09/19/24 at 9:05 AM, R68 was observed laying in bed. The hand splint was laying on the heat register. R68's left arm was laying unsupported and turned inward and the left hand was under the left leg. R68 was asked about the position of their hand and stated I can't always feel where it is unless I grab it with my other hand. On 09/19/24 at 10:13 AM, Certified Nurse Assistant (CNA) B reported they've never used the left hand splint with R68 and have never been made aware of any instruction to do so. On 09/19/24 at 10:14 AM, CNA K reported they had an extended history of caring for R68 and they couldn't recall ever using the left hand splint. On 09/19/24 at 10:23 AM, the facility Director of Rehab (DOR) reported R68's current left hand splint was not being used because an orthotics service evaluated the resident for a new splint and they were waiting for the splint to arrive. The DOR indicated the splint was delayed in arriving due to the resident's payor source and authorization process. The DOR was informed no documentation could be located indicating the current splint was contraindicated, ineffective or otherwise deemed inappropriate. They were asked if they were aware of any reason the splint had been discontinued and no reason was specified. The DOR was asked to provide any documentation supporting discontinuation of the current splint at any point. The DOR subsequently provided an orthotics order for a left wrist/hand orthosis dated 07/23/24 with an attached restorative nursing order that included the statement New left resting hand splint waiting to be delivered by orthotist. Effective: 7/26/24 this order was electronically signed by the OT on 09/19/24. No additional documentation addressing any discontinuation of the original hand splint was provided. On 09/19/24 at 01:15 PM, the DOR was asked their expectation regarding documentation when a resident's splint is discontinued and they reported the discontinued splint should be removed from the resident's room and when a replacement is available the direct care staff would be instructed in an updated restorative program. The documentation expectation was not specified. On 09/19/24 at 01:27 PM, the facility Administrator (NHA) was asked their expectation regarding documentation of the discontinuation of a resident's splint. The NHA stated If a new splint was ordered I would assume there was a reason the old one was no longer appropriate whether it be a skin problem or some other reason. The NHA did not specify a documentation expectation. A facility policy addressing splints and orthotics was requested via email and in person and was not provided by the conclusion of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain a physician order for oxygen for one resident (R76) out of two residents reviewed for oxygen. Findings include: On 9/17/24 at 10:15 AM, 9/17/24 at 11:43 AM, 9/17/24 at 1:34 PM, 9/17/24 at 3:36 PM, 09/17/24 04:04, 9/18/24 at 8:46 AM, 9/18/24 at 11:56 AM, and 9/18/24 at 1:42 PM, R76 was observed lying in bed wearing oxygen at four liters per minute via nasal cannula. A review of R76's medical record revealed they were admitted to the facility on [DATE] with the following diagnosis: Cerebral Infarction due to Embolism of Right Cerebellar Artery; Chronic Obstructive Pulmonary Disease; Acute Respiratory Failure with Hypoxia. A review of R76's Brief Interview for Mental status revealed a score of 15 indicating intact cognition. A review of R76's care plan revealed the following: I have altered respiratory status/difficulty breathing in my respiratory status r/t (related to) COPD (chronic obstructive pulmonary disease) Acute respiratory failure, cardiac arrest. Oxygen settings: O2 (oxygen) via nasal cannula @ 2-3 L (liters). A review of R76's physician orders revealed no orders for oxygen. On 9/18/24 at 1:46 PM, during an interview, with Licensed Practical Nurse (LPN J) was asked if R76 was on oxygen. LPN J stated, I believe its prn (as needed). LPN J was observed reviewing R76's electronic medical record. LPN J confirmed there was no physician order for oxygen and explained that they would clarify with the doctor. LPN J was asked if there should be a physician order if a resident is wearing oxygen. LPN J stated yes. Unit Manager (UM E) was also present at the time of the interview and explained there should be a physician order if a resident is on oxygen. On 9/19/24 at 11:48 AM, during an interview, the Director of Nursing (DON) was asked to explain their expectation regarding physician orders for oxygen. The DON explained if a resident is on oxygen there should be a physician order stating the type and amount of oxygen that they are on. On 9/19/24 at 10:00AM, during an interview, the Nursing Home Administrator (NHA) was asked to explain their expectation for physician orders for oxygen. The NHA explained if a resident is on oxygen there should be a physician order for it. A review of the facility's policy titled Oxygen Administration revealed the following: A resident will receive oxygen per physician orders and facility protocol. The resident's disease, physical condition, and age will help determine the most appropriate methos of administration. This is performed by a licensed nurse or respiratory therapist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R22 On 9/17/24 at 12:51 PM, R22 was observed awake lying in bed with family at bedside. An albuterol inhaler was observed on top of the dresser. R22 was asked if they use the inhaler. R22 stated sometimes. On at 9/18/24 at 8:41 AM, R22 was observed awake in bed. The albuterol inhaler was observed still on the dresser. On 9/18/24 at 8:45 AM, Licensed Practical Nurse (LPN) J was shown the inhaler in the room and was asked if the inhaler should be at R22's bedside. LPN J stated, no I don't think so. LPN J was asked if residents can keep medications at the bedside. LPN J explained sometimes residents keep medications at the bedside but there should be a physician order if they do. A review of R22's medical record revealed they were admitted to the facility on [DATE] with the following diagnosis: Nontraumatic Subdural Hemorrhage, Unspecified. Chronic Obstructive Pulmonary Disease Unspecified. A review of R22's Brief Interview for Mental Status revealed a score of 14 indicating mild cognitive impairment. A review f R22's physician orders revealed the following: Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 base) MCG/ACT (albuterol Sulfate) 1 puff inhale orally every 4 hours as needed for SOB (shortness of breath). R44 On 9/17/24 at 9:56 AM, R44 was observed asleep in bed. Fluticasone nasal spray and saline nasal spray were observed on top of the dresser in the room. On 9/18/24 at 8:51 AM, R44 was observed awake in bed. The two nasal sprays were observed to still be on the dresser in the room. R44 was asked if they use the nasal spray. R44 explained that they hadn't used them in a while but could if they needed to. A review of R44's medical record revealed they were admitted to the facility on [DATE] with the following diagnosis: Chronic Obstructive Pulmonary Disease Unspecified; Obstructive Sleep Apnea. A review of R44's Brief Interview for Mental Status revealed a score of 15 indicating intact cognition. A review of R44's physician orders revealed the following active order: Saline Nasal Spray Solution (saline) 1 spray in each nostril every 2 hours as needed for congestion Further review revealed the following discontinued order: Fluticasone Propionate Suspension 50 MCG/ACT 1 spray in each nostril one time a day for dryness. Discontinued 7/9/24. On 9/18/24 at 9:09 AM, LPN L was shown the two nasal sprays in R44's room and was asked if they should be in the room. LPN L stated No, they should not. (R44) does not have an order to have them at the bedside. LPN L was asked if there should be a physician order for a resident to have meds at the bedside. LPN L stated Yes. There should be an order in pcc (the electronic medical record) that says they can self-administer and keep medications at bedside. On 9/19/24 at 10:00 AM, during an interview, the Nursing Home Administrator (NHA) was asked to describe their expectation regarding medications at a resident's bed side. The NHA explained that medications should not be left at a resident's bedside unless there is a physician order and the nurse should watch the residents take their medications before leaving the room. On 9/19/24 at 11:48 AM, the Director of Nursing (DON) was informed of the observations of medications at the bedside of R22 and R44 and was asked to explain their expectation regarding medications at a resident's bedside. The DON explained medications should not be left at a resident's bedside unless the resident has had an assessment done and documented that they are able to self-administer medications and have a physician's order to self-administer the medication. A review of the facility's policy titled Self-Administration of medications by residents revealed the following: Each resident who desires to self-administer medication is permitted to do so if the facility's interdisciplinary team/or facility policy allows or has determined that the practice would be safe for the resident and other residents of the facility. Procedure. 1. Each resident is offered the opportunity to self-administer his or her medications during the routine assessment by the facilities interdisciplinary team. 3. the interdisciplinary team determines the resident's ability to self-administer medications by means of skill assessment .4. the results of the interdisciplinary team assessment are recorded on the medication self-administration form, which is placed in the resident's medical record .7. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and then give unauthorized medications to the charge nurse for return to the family or responsible party. Based on observation, interview, and record review, the facility failed to ensure resident medications were not left at the bedside for four residents (R22, R44, R63 and R71) of four residents reviewed for medication storage. Findings include: R71 On 9/16/24 at 8:40 AM, R71 was observed lying in bed. An inhaler was observed lying on their bedside table. A review of R71's medical record revealed the resident was admitted into the facility on [DATE] with diagnoses included Chronic Obstructive Pulmonary Disease, Alcohol Abuse, and Adjustment Disorder. Further review revealed the resident was moderately cognitively impaired, and required limited assistance with Activities of Daily Living. On 9/17/24 at 12:55 PM, R71 was observed lying in bed awake, inhaler located on their bedside table. On 9/19/24 at 9:19 AM, R71 was observed lying in bed, inhaler lying on their bedside table. R71 was asked about the inhaler, and explained it's their Albuterol recuse inhaler. R71 was asked when was the last time they used it and stated, Today. Just now. A review of R71's physician orders revealed an order for ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally four times a day for sob (Shortness of Breath). Further review of the medical record did not reveal an assessment for the self-administration of medications. On 9/19/24 at 9:24 AM, Unit Manager H was asked about the inhaler at R71's bedside and whether there was an assessment completed for the resident to self-administer their own medications. Unit Manager H explained they were unable to locate one for the resident. R63 9/17/24 at 11:06 AM, R63 was observed in bed, and easily aroused. Observed on the resident's bedside table were a stack of medication cups, and located next to the stack was a medication cup with pills inside. R63 was asked about them, and immediately ingested the medications and explained they were from last night. A review of R63's medical record revealed they were admitted into the facility on 4/6/23 with diagnoses included Heart Failure, Diabetes, and Chronic Kidney Disease. Further review revealed the resident was cognitively intact and required limited to supervision for Activities of Daily Living. On 9/18/24 at 8:46 AM, R63 was observed in bed asleep, a medication cup with two pills were observed sitting on the resident's bedside table. Licensed Practical Nurse (LPN) I was approached outside of R63's room, and asked if they had passed R63's medications yet. LPN I explained they had not, as they were just coming on for their shift. LPN I was asked to view the medications at R63's bedside, and explained they did not provide the resident with those medications. LPN I removed the medication cup from the room, and made observations of the medications statin, It looks like a Gabapentin and a Buspar (Pain medication and an anti-anxiety medication).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to serve food in a palatable manner and at the preferred temperature for one resident (R47) and ten confidential group residents of thirteen reviewed for food palatability, resulting in dissatisfaction during meals. Findings include: On 9/17/24 at 9:25 AM, R47 was met in their room for observation and interview. R47's breakfast was observed to consist of two biscuits, two pancakes, cereal, a small carton of milk, syrup and butter. The only protean observed with R47's breakfast was the carton of milk. R47 was interviewed about the food served to them at the facility and stated, The food is [swear word]. On 9/18/24 at 8:38 AM, a followup visit was conducted with R47 and they were asked how their breakfast was. R47 stated, It tasted like garbage, I had two hard boiled eggs, toast, and cereal. A review of R47's electronic medical record (EMR) revealed that R47 was most recently admitted to the facility on [DATE] with diagnoses that included Congestive heart failure and Type 2 diabetes. R47's most recent quarterly minimum data set assessment (MDS) revealed that R47 had a moderately impaired cognition. A review of Food Council Meeting notes dated 8/12/24 revealed the following, The food is horrible, the green beans are nasty and not seasoned at all. The chicken tenders are horrible and the breading is soggy. The food is terrible, I can't eat the food, it has no taste and it's cold. Need more soups, can't mess that up. I wish the food could be better at times. The meat doesn't taste like meat. The pork chop can't even be cut with a knife and the meatloaf is nasty. On 9/18/24 at 10:05 AM, a confidential group meeting was conducted with a group of of ten residents and they were asked about the taste and temperature of the food served to them at the facility. The whole group indicated that the food was cold and didn't taste good. One group member indicated that the dinner portions were small and they frequently were still hungry after finishing their dinner. On 9/18/24 at 12:30 PM, a food cart on one of the units was observed with two food trays on top of the cart, no plate warmers underneath the plates, and the doors to the food cart open while staff was serving meals to the residents. On 9/18/24 at 12:33 PM, Dietary Manager (DM) A temperature tested a random tray and the results were the following, Crusted Parmesan Chicken: 113 degrees Fahrenheit. There was no sauce observed on the chicken. Garlic Buttered Fettuccini: 115.6 degrees Fahrenheit. The noodles appeared to be plain with no butter on them. There was no cooked carrots or apple crumble observed on the plate, these items were indicated to be part of the meal per the menu. DM A was asked about no carrots being served with the meal and stated, Do you want some. DM A was asked about the preferred temperature for the food and stated 100 degrees Fahrenheit or above and per resident preference. On 9/17/24 at 12:45 PM, a test tray was done. The internal temperature of the pork chop was measured to be 107 degrees Fahrenheit. The pork chop was tasted and was lukewarm. The pork chop was extremely fatty, with very little actual meat available to eat. A review of a policy titled, Food Palatability-Hot Food Temperatures Date: 3.13.2018 revealed the following, Policy: The healthcare community prepares and serves food .that [is] palatable, attractive and .[at] appetizing temperature[s].

This citation pertains to Intake: MI00146189 Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by eliminating harborage conditions in the kitchen. This deficient practice has the potential to affect all residents in the facility. Findings include: 09/17/24 at 9:15 AM, there was standing, stagnant, slimy water observed on the floor, in the corner underneath the garbage grinder at the 3 compartment sink. In addition, there were cobwebs and numerous gnats observed in the same area. When queried, Dietary Manager (DM) A stated that the pipe for the garbage grinder was small and sometimes over-flows. DM A did not provide an explanation for why the standing water in the kitchen was not cleaned up, in order to prevent a breeding ground for gnats. On 9/17/24 at 9:20 AM, there was standing water on the floor between the coffee maker and the juice dispenser. There were gnats observed flying about in the same area. When queried, DM A was unsure where the water was coming from. Review of the pest control service reports for 9/12/24 and 9/5/24 noted that the target pests were gnats, and the service report for 8/22/24 noted lots of gnats. According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00140309. Based on observation, interview, and record review the facility failed to ensure timely incontinence care was provided to a dependent resident (R902) of three reviewed for activities of daily living (ADLs), resulting in and the potential for the resident in a soiled brief for an extended period of time and or skin irritation. Findings include: On 01/17/24 at 7:39 AM, R902 was observed out in the hallway near the common area on the [NAME] unit. R902 was dressed and seated in a wheelchair. On 01/17/24 at 8:45 AM., 9:45 AM, 11:25 AM, 1:30 PM and at 3:20 PM, R902 was observed sitting up in wheelchair appropriately dressed at a table in the dining room. There was a grey and white toy cat placed on the table in front of R902 that occupied their attention. R902 was not interviewable due to their cognitive ability. At 1:30 PM, R902 was observed in the same spot and had recently finished eating as evident by the food crumbs on their clothing. On 01/17/24 at 8:45 AM., 9:45 AM., 11:25 AM, 1:30 PM and 3:15 PM, two unused incontinence briefs (one green and one beige) stacked on top of each other were observed at the foot of R902's bed. The briefs were clearly observable upon entering the room and had not been moved. On 01/17/24 at 3:20 PM, Nurse F was asked about the toileting and Activities of Daily Living (ADL) care for R902. Nurse F stated, R902 gets up in the morning and is put back to bed on the afternoon shift. When asked how often residents are toileted, Nurse F replied, every 2-4 hours if needed. On 01/17/24 at 3:25 PM, two certified nursing assistants (CNAs) were observed assisting R902 to their room to provide care. CNA A moved the two briefs off the foot of bed in order to lay R902 down to provide care. An observation of the brief before incontinence was done revealed a dark blue line indicating wetness was visible on the beige brief and it was sagging/saturated with urine. On 01/17/24 at 4:00 PM, upon interview the Director of Nursing (DON) stated, my expectations for toileting residents in memory care should be every 2-4 hours and as needed. R902 was admitted to the facility on [DATE] with medical diagnoses of severe dementia with mood disturbance, peripheral vascular disease, and cognitive communication deficit. A review of R902's care plan in the electronic medical record (EMR) noted, Focus: I am incontinent of bowel/bladder related to my weakness. Initiated 8/9/23. Goal: I will be free of odor while maintaining dignity, will not become impaired related to incontinence . Interventions included, check me at least every two hours during the day and change my brief if needed initiated 08/09/23 keep me as clean and dry as possible . The care plan Focus: I need assistance with my ADLs related to weakness . was initiated on 8/9/23. Goal: I will maintain my current level of functioning through next review date. Interventions with toileting included 1-2 person assistance needed. The care indicated the resident to be incontinent. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition with a 8/15 Brief Interview for Mental Status (BIMS) score and the need for substantial to maximal assistance for toileting hygiene, upper body dressing and lower body dressing. A review of facility toileting policy titled, Toileting not dated, revealed, Purpose: To help the resident maintain normal and adequate bowel and bladder habits as indicated by his or her condition. Procedure: 1. When a resident indicates either verbally or non-verbally a need to use the bathroom, staff should promptly assist the resident . The policy no significant information regarding the timeliness of toileting cognitively impaired residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to update a care plan following a change in code status for one resident (R64) of two residents reviewed for advanced directives, resulting the incorrect code status as an intervention. Findings include: A review of R64's medical record noted, progress note, [DATE] 13:07 Social service Quarterly Review: Social worker met with resident in a common area for [R64's] quarterly review. Resident was sitting in [R64's] wheelchair alert . Resident has a guardian who is responsible for [R64's] care decisions and requested for resident to remain a full code and long-term care . Care plan: Focus: CODE STATUS: My Guardian has reviewed my advanced directives with the social worker/physician and wishes for me to receive CPR (full code). My Guardian has consented for all other physician recommended medical or surgical treatments. Goal: My guardians wishes will be honored through the next review date. Interventions: Communicate any change of condition with me and my guardian. Explain any medical or surgical treatments being recommended by the physician and how they pertain to my quality of life. Report any change of condition to the nurse or social worker. Review medical or surgical treatments quarterly or when a change in condition occurs. A review of the current Physician orders noted do-not-resuscitate order (DNR). A review of R64's miscellaneous tab in the electronic medical record (EMR) noted, DNR authority form granting a DNR, dated [DATE]. On [DATE] at 1:01 PM, the Director of Nursing (DON) was asked R64's code status and was observed to review the EMR, miscellaneous tab for R64 and stated, DNR. The DON was asked about R64's care plan that noted full code and explained that she would have the Social Worker explain. On [DATE] at 1:31 PM, the Regional Social Worker was asked via phone about R64's care plan and explained that the care plan should reflect DNR and that it was not updated with the change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00132448, MI00137217, and MI00137909. Based on observation, interview and record review, the facility failed to provide timely incontinence care and/or bathing assistance for three resident (R46, R86, R101) of 24 residents reviewed for Activites of Daily Living (ADL) care resulting in resident feelings of poor hygiene, dissatisfaction with care and potential for compromised skin integrity. Findings include: R86 Review of the facility record for R86 revealed an admission date of 04/27/23 with diagnoses that included Acute Lower Extremity Deep Vein Thrombosis, Thrombocytopenia and Hematuria. The Minimum Data Set (MDS) assessment dated [DATE] indicated R86 required maximum assistance for bathing. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. On 07/31/23 at 8:44 AM, R86 reported I haven't had a shower in a week or two. I get a bed bath sometimes but not twice a week. Review of the R86's electronic medical record TASK completion checklist for bathing July 2nd to 28th, 2023 revealed documentation of the resident being bathed on 07/04/23, 07/11/23, and 07/28/23 (3 times in 27 days). On 08/02/23 at 8:43 AM, Certified Nurse Assistant (CNA C) reported that resident showers/baths are documented in the Task section of the electronic medical record as well as on paper shower sheets. CNA C reported that once shower sheets are completed they are taken to the Director of Nursing's (DON) office. Review of the shower sheets for R86 for the month of July 2023 revealed sheets dated twice weekly for each week of July 2023. The sheets were signed and dated and included notes regarding skin condition but no indication of resident acceptance/refusal, bathing completion or bathing method (shower vs bed bath). On 08/02/23 at 1:24 PM, the facility DON reported that their expectation is that residents receive a shower or bed bath at least twice weekly and additionally as requested or needed. The DON reported that the expectation for bathing documentation is that it be entered into the electronic medical record Task and on a paper shower sheet, and if both are not completed then bathing is considered not completed. R101 On 7/31/23 at 9:13 AM, during an initial tour of the [NAME] unit, a strong smell of bowel movement permeated outside the room of R101. Upon entering the resident's room, the smell of bowel movement increased even though the window was observed as cracked open. R101 was observed on lying in bed on their side asleep with their brief exposed, which was observed as saturated with urine and bowel movement. On 7/31/23 at 10:33 AM, R101 was observed asleep in the same position as observed an hour and 20 minutes prior. Their brief was still saturated with urine, as the bowel movement began to seep out of their brief. On 7/31/23 at 10:45 AM, a certified nursing assistant was observed to enter R101's room with supplies to clean R101. A review of R101's medical record revealed that they were admitted into the facility on 8/17/22 with diagnoses that include Alzheimer's Disease, Dysphagia, and Muscle Weakness. Further review of their medical record revealed that they were severely cognitively impaired and required extensive assistance for toileting. On 8/2/23 at 4:02 PM, the Director of Nursing (DON) was asked about their expectations for ensuring timely incontinence care, and explained that resident's should receive check and changes every two hours, and that the expectation is that a resident should not be lying in a wet and soiled brief for a long period of time. R46 On 07/31/23 at 9:58 AM, R46 was observed to be in bed on their back dressed in a hospital gown with hung off the right shoulder. R46's hair appeared oily and R46 was asked if their hair was washed during their shower. R46 reported that they did not get showers but did have bed baths. R46 further reported on query they their hair was not often washed during the bed bath. R46 was asked if they would take a shower rather than a bed bath and said yes. On 08/01/23 at 1:10 PM, R46 was observed to be more flat than upright in bed with the lunch tray on the table over the bed. The table was above the level of the chest and the shoulders were down toward the break to raise the head of the bed. R46's hair appeared oily and was dressed in a hospital style gown. R46 was asked if they had received a shower the day before and reported they had not. On 08/02/23 at 7:55 AM, Certified Nurse Assistant (CNA) E reported R46 won't let you take them to the shower and that staff can use a dry shampoo or shampoo and water for hair. CNA E acknowledged R46 had oily hair and reported a hospice aide also come in to provide baths but was unsure how often. A review of the clinical record for R46 revealed R46 was admitted into the facility on [DATE]. Diagnoses included Heart Disease, High Blood Pressure and Dementia. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition with a 6/15 Brief Interview for Mental Status score and the need for extensive or total assistance of one or two persons for all Activities of Daily Living. A review of the bath task in the electronic medical record revealed a shower had been documented as completed for R46 on 07/31/23. A visit by the dentist was not found documented in the electronic medical record. Review of the undated facility policies Tub Bath or Shower and Bed Bath revealed, Tub baths and or showers are used to cleanse the body . but revealed no directive or expectation of bathing frequency.

This citation pertains to Intake MI00132448. Based on interview and record review, the facility failed to ensure services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, resulting in the potential for inadequate coordination of care and negative clinical outcomes, affecting all residents currently residing in the facility. Findings include: On 8/2/23 at 2:55 PM, the Nursing Home Administrator (NHA) was asked about Registered Nurse (RN) coverage and stated, We have two, but had three until a couple of weeks ago. A review of staffing for Monday July 31st and Wednesday August 2nd, revealed, the facility did not have an RN that worked other than the Director of Nursing (DON). On 8/02/23 at 3:06 PM, the NHA was asked if the facility had any other RN's that was not the DON in the building that was a RN during the dates of 7/31/23 and 8/2/23. The NHA reported, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to consistently provide meals of a palatable taste and temperature for two (R86 and R33) of six residents reviewed for food satisfaction and nine of nine anonymous group members, resulting in resident dissatisfaction with the meal experience. Findings include: On 07/31/23 at 8:44 AM, R86 reported The food is lousy, it just isn't good and it's not hot enough. Review of the facility record for R86 revealed an admission date of 04/27/23 with diagnoses that included Acute Lower Extremity Deep Vein Thrombosis, Thrombocytopenia and Hematuria. The Minimum Data Set (MDS) assessment dated [DATE] indicated R86 required set up assistance for meals. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. On 08/01/23 at 9:11 AM, R86 reported their breakfast was lousy, I think it was something like biscuits and gravy, I'm not sure, but it was cold whatever it was. On 08/01/23 at 9:36 AM, review of Resident Council meeting minutes for February through June 2023 revealed food concerns had been expressed on a monthly basis including food quality, taste, temperature and preferences. On 08/01/23 at 12:40 PM, a random lunch tray was pulled from the tray cart prior to being served and tested for taste and temperature with the following findings: The ground meat with gravy was 100.7 Fahrenheit (F) and tasted minimally warm and bland. The white rice with gravy was 112.2 F and tasted minimally warm and bland. The sliced vegetable was 115.3 F and tasted minimally warm and bland. The pineapple chunks were 42.4 F and tasted satisfying and appropriately cold. On 08/01/23 at 1:11 PM, R86 reported their lunch was too cold and stated that they did not know what the meat was. R86 demonstrated that their meal ticket does not identify the items served and they stated that they did not have a monthly menu for August yet. On 08/01/23 at 2:30 PM, nine of nine anonymous attendees of the resident council meeting reported that their food quality and temperature had been consistently poor. On 08/02/23 at 8:33 AM, R86 reported the eggs and sausage on their breakfast were cold and the oatmeal was fine. On 08/02/23 at 12:29 PM, the lunch tray intended for R86 was pulled directly from the tray cart prior to being served and was tested immediately following removal of the cover, with the following findings: The ground meat temperature was 109.5 F and tasted minimally warm. The mashed potato with gravy temperature was 110.1 F and tasted minimally warm. The mixed vegetable temperature was 106.1 F and tasted minimally warm. On 08/02/23 at 1:34 PM, the facility Dietary Manager (DM) reported that the food temperature is taken at the steam table but temperature audits are not being completed otherwise. The DM reported they have not been getting complaints about the food temperature. When asked about steam table temperatures, the DM and facility Dietician (RD) reported that the minimal goal temperature is 135-140 F and up to 150-170 F. When asked what their expectation is for serving temperatures of hot food the DM reported that they did not have an expected temperature range because it varies according to resident preference and no numerical goal temperature was provided. Review of the facility policy titled Meal Frequency and Preferences dated 09/01/21 includes the following entries: Guidelines: .d. Ensure that everyone, including dependent diners, receive foods at the correct temperatures .Food Palatability - Hot Food Temperatures The healthcare community prepares and serves food and beverages that are palatable, attractive and at safe and appetizing temperatures. On 8/01/23 at 12:55 PM, during a dining observation. R33 was observed to have a piece of chicken that was untouched. The chicken appeared dry, and with a dark reddish color around the outer part. R33 was asked about the chicken and why R33 had not eaten the chicken. R33 explained that they were unable to eat it because it was dry and hard. R33 was observed to pick it up and tried to break it with their hands and was unable to. An unknown resident that was sitting across R33, plate was observed to have the outer parts of the chicken laying on the side of the tray. On 8/01/23 at 1:01 PM, the Dietary Manager (DM) was asked about the chicken and the observation of R33 not being able to cut the chicken and explained, the chicken does look a little dry, but R33 may not be strong enough to cut the chicken. On 8/01/23 at 1:05 PM, the DM was observed to cut into the chicken. The DM was observed to turn the knife sideways and then to rock the knife side to side to cut the chicken. During the observation, the table the plate was on was observed to shake. The DM was observed to apply pressure to cut the chicken and stated, The outside of the chicken is dry, but the middle is tender. During the dining observation the DM asked the residents if they wanted a sandwich instead of the chicken. Five of the residents in the dining room requested a sandwich. One resident that requested a grilled cheese sandwich stated, That the chicken was cold and nasty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00132448. Based on observation, interview, and record review the facility failed to ensure hand hygiene was completed, a glucometer (device used to check blood sugar levels), oxygen tubing, and tube feeding pole were cleaned after patient care was completed resulting on the potential for the spread of infection. Findings include: On 8/01/23 at 12:55 PM, staff were observed to assist two residents with feeding. At one point during the meal assistance the two staff members switched residents and were not observed to complete hand hygine. On 08/02/23 at 9:10 AM, Licensed Practical Nurse D was observed to prepare medication for room [ROOM NUMBER]. LPN D administered the medication to the resident and exited the room. LPN D then removed the glucometer from the medication cart and entered the room next door. A blood sugar check was completed and LPN D returned to the medication cart and placed the glucometer in the drawer. LPN D then began to prepare the next resident's medication. Hand hygiene had not been done and the glucometer machine was returned to cart without having been disinfected. The observation was reviewed with LPN D to which they acknowledged the observation and continued on. R59 Review of R59's medical record noted, R59 was admitted to the facility on [DATE] with diagnoses of Cerebral infarction due to embolism and quadriplegia. A review of R59's Minimum Data Set (MDS) assessment noted R59 with a severely impaired cognition and total dependent from staff for activities of daily living. On 7/31/23 at 11:23 AM, during the initial tour of the facility R59's tube feeding pole and floor surface area was observed to have dried tube feeding formula on it. On 8/01/23 at 3:12 PM, R59's tube feeding pole area was in the same condition as on 7/31/23. On 8/02/23 at 8:44 AM, oxygen tubing that attached to R59's trach mask was observed on the floor not attached to trach. On 8/02/23 at 8:53 AM, the Director of Nursing (DON) was shown the observation of the tubing and asked to measure R59's oxygen. The DON, called the assigned Nurse F for R59. Nurse F was observed to pick the tubing off the floor and reattach it to R59's trach mask. The tubing was not observed to be cleaned prior to attaching back to the trach mask. The DON was asked during the observation if the tubing should be cleaned and was observed to ask Nurse F, Do you have any alcohol wipes in here. Nurse F reported, No. I will use the saline. At 4:10 PM, the Director of Nursing (DON) reported the standard of practice was to complete hand hygiene after care and to clean glucometer after use with the wipes on the cart. Review of the undated Infection Prevention and Control Standard Operating Procedure (SOP) titled Hand Hygiene revealed .Hand Hygiene shall be regarded by this organization as the single most important means of preventing the spread of infections . Review of the undated Nursing SOP titled Blood Glucose Machine Test revealed, .1. Clean the monitor between resident's .

Based on observation, interview and record review the facility failed to ensure biologicals were dated when opened in four medication carts resulting in the potential for used of expired medication and decreased efficacy of medications. Findings include: On 08/01/23 at 8:55 AM, a check of the [NAME] one medication cart revealed a Trelegy Ellipta inhaler had not been dated when opened. The patient care information from the manufacturer's web site revealed, Safely throw away Trelegy Ellipta in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler . On 08/01/23 at 9:25 AM, a check of the [NAME] two medication cart revealed one insulin without a date when opened. On 08/01/23 at 2:25 PM, a chcek of the Lavender High medication cart revealed a Combivent inhaler that was undated when opened the manufacuter's insert indicated it was good for three months post after opening. On 08/02/23 at 8:07 AM, a check of the Lavender medication room revealed the tuberculin vial was not dated on vial when opened. On 08/01/23 at 8:32 AM, a check of the [NAME] south medication cart revealed a Combivent inhaler not dated when opened. On 08/02/23 at 4:10 PM, the Director of Nursing (DON) reported the expectation was to date the items when opened. A review of the undated Expired Medications and Medications with Shortened Expiration Dates policy revealed, .4. In the event that a medication has a shortened expiration date once opened, the medication will be labled with the date opened .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R331 On 07/31/23 at 9:05 AM, R331 reported I never saw a nurse last night, I haven't had any medicine since yesterday afternoon. When asked if they usually receive medicine during the night shift they stated yes. Review of the facility record for R331 revealed an admission date of 07/21/23 with diagnoses including Vertebral Compression fracture of T9-T10, Diabetes Mellitus with Diabetic Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease. The Minimum Data Set (MDS) assessment dated [DATE] included the Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. Review of the Medication Administration Record (MAR) for R331 on the evening of 07/30/23 to the morning of 07/31/23 revealed the missed administration of 10 ordered/scheduled medications/treatments. R39 On 07/31/23 at 9:24 AM, R39 reported they don't have enough help. The aide told me last night there was no nurse here when I asked for a pain pill and I never did see a nurse until this mornings shift. Review of the facility record for R39 revealed an admission date of 07/26/23 (original admission date: 03/08/23) with diagnoses that included Cerebral Infarction with Left Hemiplegia, Congestive Heart Failure and Hypertension. The MDS assessment dated [DATE] included the BIMS score of 15/15 indicating intact cognition. Review of the Medication Administration Record (MAR) for R39 on the evening of 07/30/23 to the morning of 07/31/23 revealed the missed administration of 11 ordered/scheduled medications/treatments. R112 On 07/31/23 at 11:07 AM, R112 reported there was no nurse on the hall last night. R122 stated I walked around and I couldn't find anyone anywhere. I turned the light on and the aide came about 10 minutes later but they turned the light off and left. I was looking because my roommate needed to be cleaned, his colostomy (devise that holds bowel movement) was all over. Review of the facility record for R112 revealed an admission date of 02/01/23 with diagnoses that included Myocardial Infarction, Pneumonia, Diabetes Mellitus and Acute Congestive Heart Failure. The MDS assessment dated [DATE] includes the BIMS score of 15/15 indicating intact cognition. Review of the Medication Administration Record (MAR) for R112 on the evening of 07/30/23 to the morning of 07/31/23 revealed the missed administration of five ordered/scheduled medications/treatments. R86 On 08/01/23 at 12:22 PM, When asked about the evening of 07/31/23 R86 stated I never saw a nurse, I didn't ask for help that night but my roommate did and nobody ever came. Review of the facility record for R86 revealed an admission date of 04/27/23 with diagnoses that included Acute Lower Extremity Deep Vein Thrombosis, Thrombocytopenia and Hematuria. The Minimum Data Set (MDS) assessment dated [DATE] included the BIMS score of 15/15 indicating intact cognition. Review of the Medication Administration Record (MAR) for R86 on the evening of 07/30/23 to the morning of 07/31/23 revealed the missed administration of five ordered/scheduled medications/treatments. On 08/01/23 at 2:40 PM, during resident council meeting one anonymous resident reported that this past Friday evening (07/28/23) there was no nurse available and they did not receive their medication. Of the eight remaining anonymous attendees, seven reported that on either this past Friday or Sunday evening they could not get a nurse's assistance and/or did not receive their medication. On 8/02/23 at 11:24 AM, the Director of Nursing (DON) was asked about the staffing for Sunday, July 30, 2023, midnight shift and reported that unit Lavender (low numbers) and [NAME] South (rooms 62-80s) were without a nurse. The DON was asked how many nurses were in the building and stated, Four. The DON was asked how the facility became aware that the units were without a nurse and explained, that they started getting complaints from residents about medications not given. The DON was asked the process for call ins and stated, They should report the call ins to the Nurse Supervisor or the DON. On 8/02/23 at 4:53 PM, the DON was asked about Saturday July 15 - 17, 2023, midnight shift and explained, [NAME] unit had one nurse call in (notify facility not coming to work), Lavender unit had three nurses call in, and [NAME] had one nurse call in. The DON also explained that the [NAME] unit had two nurses until 12am (Shift 7:00 PM- 7:00 AM). Sunday July 16th, [NAME] unit had two nurses that called in, [NAME] unit had two nurses that called in, and on July 17th, [NAME] unit had one nurse call in, Lavender unit had one nurse call in. A request was made for each unit census on the above dates, the facility provided the following: 7/15 - 17 census 124, and 7/30 census 121. This citation pertains to Intake MI00133113. Based on observation, interview and record review the facility failed to ensure appropriate and/or sufficient staff were available to meet the needs of the residents for 19 residents (R4, R24, R28, R46, R57, R60, R66, R78, R81, R87, R93, R103, R106, R11, R331, R39, R112, R86) of 32 reviewed resulting in unmet care needs. Findings include: R4 A review of the clinical record for R4 revealed R4 was admitted into the facility on [DATE]. Diagnoses included High Blood Pressure, Depression, Anxiety and Insomnia. The Minimum Data Set (MDS) assessment dated [DATE] documented moderately impaired cognition and the need for supervison for most Activities of Daily Living. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Trazodone (for sleep) and Norco (for pain control) were not documented as given. The assessments for pain, anti-depressant side effects, and the vital signs were also not documented as done. The Levothyroxine was not documented as given for 6 AM dose on 07/31/23. R24 A review of the clinical record for R24 revealed R24 was admitted into the facility on [DATE]. Diagnoses included Heart Valve Insufficiency and Chronic Kidney Disease. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition with a 8/15 Brief Interview for Mental Status score and the need for extensive assist for most Activities of Daily Living. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Trazodone (for sleep) were not documented as given. The assessment for pain, anti-coagulant side effects, anti-depressant side effects, anti-psychotic side effects and the vital signs were also not documented as done. R28 On 07/31/23 at 9:42 AM, R28 reported they did not receive their midnight dose of pain medication and it was to be provided every six hours. R28 also reported staff may not answer the call light at night. A review of the clinical record for R28 revealed R28 was admitted into the facility on [DATE]. Diagnoses included Diabetes, Depression, Bipolar Disorder, Paralysis on one side and Difficulty Swallowing. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 12/15 Brief Interview for Mental Status score and the need for extensive assistance of one person for most Activities of Daily Living. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Atorvastatin (for high cholesterol), Detemir Insulin (controls high blood sugar), Mirtazepime (controls anxiety), Hydralazine (controls high blood pressure), Fluticasone (for breathing), Metamucil (for constipation), Metoprolol (for blood pressure), Baclofen (muscle relaxant), Gabapentin (for neuropathic pain) and Novolog Insulin (controls blood sugar) were not documented as given; The vital signs, blood sugar level and pain assessment were also not documented as done. The Norco (pain reliever) dose was not documented as given at 12 AM nor 0600 AM on 7/31/23. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Atorvastatin (for high cholesterol), Basaglar Insulin (for diabetes control), trazadone (for insomnia), gabapentin (for pain), Atrificial Tears (for dry eyes), hydralazine (for high blood pressure), Fluticasone (nasal spray/allergy), Famotadine (antacid), Metoprolol (for high blood pressure), Magnesium Oxide (diet supplement) and Spironolactone (water pill/diuretic) were not documented as given. The vital signs, pain assessement, anti-depressant, anti-anxiety and anti-coagulant side effects checks were not documented as completed. R46 A review of the clinical record for R46 revealed R46 was admitted into the facility on [DATE]. Diagnoses included Heart Disease, High Blood Pressure and Dementia. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition with a 6/15 Brief Interview for Mental Status score and the need for extensive or total assistance of one or two persons for all Activities of Daily Living. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Keppra (controls seizures), Liquid Protein (for skin health), Docusate/Senna (for constipation), Lorazepam (for anxiety) and Norco (for pain) were not documented as given; The vital signs, pain assessment were also not documented. The Lorazepam dose was not documented as given at 0600 on 7/31/23. The assessment of the PEG (feeding tube) site was not documented as assessed on 07/22/23, 7/23/23, 7/29/23, and 7/30/23. R57 A review of the clinical record for R57 revealed R57 was admitted into the facility on [DATE]. Diagnoses included High Blood Pressure, Ajustment Disorder and Dementia. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition and the need for extensive assist for most Activities of Daily Living. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Aricept (for Dementia), Gabapentin (for pain), Lipitor (for high cholesterol), Supplement (for weight loss), Glipizide (controls blood sugar level), Magnesioum Oxide (diet supplement), Metformin (controls blood sugar level) and Novolog (insulin to control blood sugar). The vital signs nor the blood glucose (sugar) were documented as checked. R60 On 07/31/23 at 4:43 PM, R60 reported they they did not receive their medication last night because there was no nurse available. A review of the clinical record for R60 revealed R60 was admitted into the facility on [DATE]. Diagnoses included Heart Failure, High Blood Pressure, Diabetes and Adjustment Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status score and the need for extensive assistance of one or two persons for mostl Activities of Daily Living. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Ezetimibe (controls cholesterol), Lorazepam (for anxiety), pravastatin (for high chloesterol), and Metformin (controls blood sugar) were not documented as given. The assessment for blood sugar level, pain and the vital signs were also not documented as done. R66 A review of the clinical record for R66 revealed R66 was admitted into the facility on [DATE]. Diagnoses included High Blood Pressure, Diabetes and Difficulty Walking. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status score and the need for supervison for eating and extensive assist for most other Activities of Daily Living. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Aricept (for Dementia), Flomax (for prostate) and Keppra for seizure prevention) were not documented as given. The assessment for pain and the vital signs were also not documented as done. R78 A review of the clinical record for R78 revealed R78 was admitted into the facility on [DATE]. Diagnoses included High Blood Pressure, Diabetes and Difficulty Walking. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status score and the need for supervison for most Activities of Daily Living. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Keppra (for seizure prevention) and Metformin (controls blood sugar) were not documented as given. The assessment for pain and the vital signs were also not documented as done. R81 A review of the clinical record for R81 revealed R81 was admitted into the facility on [DATE]. Diagnoses included Heart Failure, High Blood Pressure and Insomnia. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition with a 6/15 Brief Interview for Mental Status score and the need for extensive assistance of one or two persons for all Activities of Daily Living. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Atorvastatin (controls cholesterol), flomax (for prostate), gabapentin (for neuropathy and pain) and the Peridex solution (for gingivitis/gum disease) were not documented as given. The assessment for anti-coagulant side effects, pain and the vital signs were also not documented as done. R87 On 07/31/23 at 10:25 AM, R87 reported there was no night nurse on Sunday 07/30 into 07/31/23 and did not get any medications at all and that this was not the first time. R87 further noted everybody disappeared and there was nobody at the nurse's and the aides didn't come when called. R87 was observed to be in bed. A review of the clinical record for R87 revealed R87 was admitted into the facility on [DATE]. Diagnoses included Major Depressive Disorder, Adjustment Disorder, Adjustment Insomnia and Diabetes. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status score. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Atorvastatin (controls cholesterol), Glargine insulin (controls/lowers blood sugar), Melatonin (help to sleep), Remeron (antidepressant), Carvedilol (controls high blood pressure), Hydralazine (controls blood pressure) and Entresto (controls high blood pressure) were not documented as given; The vital signs were also not documented. The Gabapentin (for pain) dose was not documented as given at 1800 on 07/27/23 and the 0600 dose on 7/31/23. R93 On 07/31/23 at 8:36 AM, R93 reported they had not received their nighttime medications on Sunday 7/30/23. A review of the clinical record for R93 revealed R93 was admitted into the facility on [DATE]. Diagnoses included Depression, High Blood Pressure and Diabetes. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 14/15 Brief Interview for Mental Status score. A review of the July 2023 Medication Administration Record (MAR) revealed the evening/night doses of Atorvastation (controls cholesterol) and Carvedilol (controls high blood pressure) were not documented as done for 07/30/23. The Levothyroxine due 07/31/23 at 0600 was not documented as done. Also on the evening/night of 07/30/23, vitals were not documented, the diabetic snack was not documented as offered, the blood glucose was not documented, and assessment of diuretic (water pill) side effects were not documented. The bilateral lower extremity dressing were not documented as done on 07/23/23 and 07/29/23. R103 A review of the clinical record for R103 revealed R103 was admitted into the facility on [DATE]. Diagnoses included High Blood Pressure, Heart Disease, Anxiety and Depression. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition and the need for extensive assist for most Activities of Daily Living. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Mirtazepine (for anxiety and appetite), Baclofen (for muscle spasms), Lidocaine cream (for pain), Hydrocodone (two doses scheduled for Pain), Duoneb (two treaments missed to help shortness of breath), The vital signs, assessment for pain, assessment for anti-depressant side effects nor the oxygen assessment were documented as completed. R106 A review of the clinical record for R106 revealed R106 was admitted into the facility on [DATE]. Diagnoses includedHeart Disease, High Blood Pressure and Difficulty Walking. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 12/15 Brief Interview for Mental Status score. A review of the July 2023 Medication Administration Record (MAR) revealed the evening/night doses of Xarelto (blood anti-coagulant), Docusate Sodium (stool softener), and Tizanidine (muscle relaxant) were not documented as done for 07/30/23. The assessment of vital signs and pain were not documented as done. R110 A review of the clinical record for R110 revealed R110 was admitted into the facility on [DATE]. Diagnoses included High Blood Pressure, Anxiety, Paraplegia and Pulmonary Disease. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status score and the need for extensive assist for most Activities of Daily Living. A review of the July 2023 Medication Administration Record (MAR) revealed on 07/30/23 the evening/night doses of Montelukast (to help breathing), Trazodone (for help sleeping), Methocarbamol (muscle relaxant), Norco (for pin control), Atrovent (for breathing), Duoneb (for breathing) and Diltiazem (for heart and blood pressure) were not documented as given. The assessment for pain and the head of the bed up to help breathing were also not documented as done.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: There was a dusty box fan blowing in the direction of the steam table during breakfast service. When queried about the dusty fan, Culinary Director A stated I just bought those. According to the 2017 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. There were 2 clean pitchers on drying rack, sitting upright with the lids on, observed with moisture inside with water pooling at the bottom of the pitchers. When queried, Culinary Director A confirmed the pitchers should be air dried in an inverted position. According to the 2017 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; . There were 2 rubber spatulas observed on the clean side drainboard of the 3 compartment sink, with deep grooves on the surface of the rubber spatula and chunks missing along the edges of the spatula, rendering the utensils no longer smooth and easily cleanable. According to the 2017 FDA Food Code section 4-202.11 Food-Contact Surfaces, (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices;. There were 2 rolling carts next to the food preparation counter, observed with crumbs and sticky spills on the shelves. There was food debris and cloudy water in the wells of the steam table. When queried, Culinary Director A stated they would get the steam table cleaned up later that day. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. There were cobwebs observed in the window well above the 2 compartment sink next to the stove. In the dish room, there were cobwebs in the window well located behind the clean dishware rack. There was a buildup of food debris on the floor underneath the food prep area/table. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.

This citation pertains to Intake MI00132086. Based on observation, interview and record review, the facility failed to provide and/or document showers for one sampled resident (R902) of one resident reviewed for showers resulting in unmet care needs. Findings include: A review of Intake MI00132086 revealed the following, Complainant states residents are not receiving the care they need. On 5/20/23 at 9:00am, R902 was observed in bed awake, and indicated that they were in pain, and awaiting for the nurse to bring them their pain medication. At this time, the resident had bouts of confusion, and the interview was not completed. A review of R902's medical record revealed that they were admitted into the facility on 9/19/22 with diagnoses that included Fracture of unspecified part of right clavicle, Metabolic Encephalopathy, Syncope and Collapse, and Adjustment Disorder. Further review revealed a Quarterly Minimum Data Set assessment dated for 3/8/23 revealing a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and that the resident required extensive assistance of two persons for bed mobility, transfers, and dressing. Further review of R902's medical record revealed that for May 2023, R902 received a total of four showers on the following dates: 5/3/23, 5/10/23, 5/13/23, and 5/24/23. Further review revealed that the resident was scheduled for showers on Wednesdays and Saturdays on the afternoon shift. Further review of the medical record did not reveal refusals by the resident, or discharges from the facility. On 5/30/23 at 3:52 PM, the Director of Nursing (DON) was asked about the missing shower documentation for R902, and explained that her expectation is for staff to provide and document showers.

This citation pertains to Intake: MI00132086 Based on observation, interview, and record review, the facility failed to document wound care treatments and ensure wound care interventions were in place for one sampled resident (R902), of one resident reviewed for wound care, resulting in missing wound care treatments, and the potential for the worsening of pressure ulcers. Findings include: A review of intake: MI00132086 revealed the following,Patients asks complainant to complete their wound care at the end of [their] shift because they know it will not be done until the complainant comes back to work . On 5/20/23 at 9:00 AM, R902 was observed in bed awake and indicated that they were in pain, and awaiting for the nurse to bring them their pain medication. At this time, the resident had bouts of confusion, and the interview was not completed at that time. A review of R902's medical record revealed that they were admitted into the facility on 9/19/22 with diagnoses that included Fracture of unspecified part of right clavicle, Metabolic Encephalopathy, Syncope and Collapse, and Adjustment Disorder. Further review revealed a Quarterly Minimum Data Set assessment dated for 3/8/23 revealing a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and that the resident required extensive assistance of two persons for bed mobility, transfers, and dressing. Further review of R902's medical record revealed that R902 was admitted into the facility with pressure ulcers to their sacrum, left ankle, right thigh, and right hip, and had the following physician orders in place: Cleanse right lateral thigh with wound cleanser, apply xeroform and cover with dry dressing, secure with tape, initial. one time a day every 2 day(s) for wound care. This order was put into place on 9/20/22 and discontinued on 10/20/22. A review of R902's September and October Treatment Administration Records (TAR) revealed that the treatment was not completed on 9/22, 9/24, 9/28, 9/30, 10/2, 10/8, 10/10, 10/14, and 10/18.There were no documented refusals noted on the TARs. Santyl Ointment 250 UNIT/GM (Collagenase) Apply to right hip topically one time a day for wound care cleanse right hip with wound cleanser apply santyl then cover with dry dressing. This order was put into placed on 9/21/22, and discontinued on 10/20/22. A review of R902's September and October TARs revealed that the treatment was not completed on the following dates: 9/21, 9/22, 9/23, 9/24, 9/25, 9/28, 9/29, 9/30, 10/1, 10/2, 10/4, 10/5, 10/7, 10/8, 10/10, 10/11, 10/12, 10/13, 10/14 and 10/19. There were no documented refusals noted on the TARs. Cleanse sacrum with soap and water, apply Calazime paste. every shift for wound care. This order was put into place on 9/20/22, and discontinued on 10/20/22. A review of R902's September and October TARs revealed that the treatment was not completed on the following day shift: 9/21, 9/22, 10/3, 10/4, 10/5, 10/9, 10/12, 10/15, 10/16, 10/17, 10/18. Treatments were also not completed on the following dates of the night shift: 9/20, 9/21, 9/22, 9/23, 9/24, 9/25, 9/28, 10/1, 10/2, 10/5, 10/8, 10/10, 10/11, 10/14, and 10/19.There were no documented refusals noted on the TARs. Heel suspension boots while in bed every shift for relief of pressure points. This order was put into place on 9/20/22 and discontinued on 11/28/22. A review of R902's September, October, and November TARS revealed that the treatment was not completed on the following dates on the day shift: 9/21, 9/22, 10/3, 10/4, 10/5, 10/9, 10/12, 10/15, 10/16, 10/17, 10/18, 10/20, 10/21, 10/24, 11/12, 11/13, 11/22, 11/25, 11/26, and 11/27. Night shift: 10/1, 10/2, 10/5, 10/8, 10/10, 10/11, 10/14, 10/19, 10/21, 11/12, 11/26, 11/27, and 11/28. There were no documented refusals noted on the TARs. On 5/30/23 at 3:52 PM, the Director of Nursing (DON) was interviewed regarding R902's wounds and treatments not being completed, and she explained that her expectation is for wound care treatments to be completed per order. A review of the facility's Skin Management Facility Guidelines revealed the following, 3. residents admitted with skin impairments will have: Appropriate interventions implemented to promote healing. A physician's order for treatment, Treatment record initiated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 38 (R38) On 5/18/2022 at 11:52 AM, R38 was observed wandering into rooms [ROOM NUMBERS]. R38 had a phone charger and a plastic bag in their hand. R38 was heard saying that they were looking for their son and then going home. A review of the medical record revealed R38 admitted into the facility on 1/3/2022 with the following medical diagnoses, Dementia, Anxiety Disorder, Alzheimer's Disease, and Delusional Disorder. A review of the Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10/15 indicating a moderately impaired cognition. R38 also required one person supervision with bed mobility and transfers. On 5/19/2022 at 8:04 AM, an interview was held with Social Work Assistant (SWA) A and Social Worker (SW) B regarding R38 not having a care plan to address their wandering and exit seeking. SWA A stated, We typically only put people on the list that are actively exit seeking, not just wandering around. SW B stated, [R38] usually knows where [they] are going and as far as I know [R38] doesn't actively exit-seek. SW B was asked how they were notified of exit-seeking behaviors and they stated, From the nurses, observations, or progress notes. A review of a progress note dated 4/1/2022 at 6:49 PM revealed the following, Resident is exit seeking. currently on the phone with [R38] ex-husband and he was observed telling resident how to exit from the front door. not easily redirected. resident is currently in [their] room laying on bed with purse. Further review of R38 assessments revealed an Elopement assessment dated [DATE] with a score of 12 indicating that R38 was at high risk to wander. No care plan was noted in R38's chart related to wandering and/or exit seeking. A review of an undated policy titled, Elopement Book revealed the following, It is the policy of this facility to coordinate and help identify residents with cognitive loss that have been assessed and identified as being at risk for unobserved exit from the facility. Resident 47 (R47) On 5/17/2022 at 11:55, R47 was observed in their room with palm guards on while laying in bed. On 5/18/2022 at 1:14 PM, R47 was observed up in their chair with their palm guards on. CNA E was asked if they put the palm guards on R47. CNA E stated, They were on when I got [R47] dressed. A review of the medical record revealed that R47 admitted into the facility on 1/13/2022 with the following diagnoses, Severe Protein-Calorie Malnutrition, Muscle Weakness, and Vascular Dementia. A review of the MDS dated [DATE] revealed a BIMS score of 0/15 indicating severely impaired cognition. R47 also required one-to-two-person total dependence in bed mobility and transfers. A review of R47's care plans, was negative for a care plan related to R47's palm guard. On 5/19/2022 at 1:10 PM, an interview was conducted with the Nursing Home Administrator (NHA) regarding a care plan for R47's palm protectors. The NHA stated, Yes, there should be a care plan. Based on interview and record review the facility failed to develop comprehensive resident centered care plans for three sampled Residents (R38, R47, and R115) of six reviewed for care plans, resulting in the potential for elopement, lack of goals/interventions for psychiatric treatment, range of motion (ROM), and fall safety issues. Findings include: Resident #115 (R115) On 5/19/22 at 10:10 AM, R115's electronic medical record (EMR) was reviewed and revealed that R115 had diagnoses of Depression/anxiety and Delirium due to their psychiatric condition. The orders section of R115's EMR indicated that R115 was prescribed Trazodone (antidepressant medication) 50 mg (milligrams) 1x daily, with the order dated 5/2/22. R115 was also prescribed Risperdone (antipsychotic medication) 1 mg at hs (bedtime) for psychosis. On 5/19/22 at 10:20 AM, a review of R115's care plan revealed no goal and/or interventions listed on the care plan which addressed R115's psychiatric treatment. On 5/19/22 at 11:33 AM, and 1:10 PM, the Administrator (NHA) was interviewed regarding their expectations for resident care plans and indicated that goals and interventions implemented for residents should be on their care plans. The NHA acknowledged that R115 did not have any psychiatric goal/interventions on their care plan and was receiving psychiatric services. On 5/19/22 at 11:55 AM, a facility policy titled Comprehensive Plan of Care undated was reviewed and stated the following, Policy, Each resident will have a comprehensive care plan developed .Fundamental Information, The comprehensive care plan must be person centered .and describe that each resident is provided the necessary care and services .The comprehensive plan of care must address the resident's individual needs .Include goals with measurable objectives .Reflect interventions to meet both short and long term resident goals .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain a diagnosis and/or remove an unnecessary catheter for one resident (Resident #332) of two residents reviewed for catheters, resulting in the likelihood of infection, trauma, and unnecessary pain. Findings include: On 05/17/2022 at 01:33 PM, Resident #332 was observed sitting up in their wheelchair dressed and groomed. The Resident was wearing shorts and had a catheter with urine draining in the tubing. There was a large red abrasion on Resident #332's right inner thigh where the old catheter anchor had been. Resident #332 was interviewed in regard to their catheter use. The Resident had clear speech and answered questions appropriately. Resident #332 explained that they had gotten the catheter while in the hospital because they were Peeing a lot. On 05/18/2022 at 10:41 AM, Resident #332 was visiting with their Significant Other. The Resident still had the catheter inserted and had commented that while in the hospital, they had asked for a catheter because they were urinating so much (because of the water pills) and that they were recently being treated for Congestive Heart Failure (CHF). Neither the Significant Other or Resident #332 knew how long they were to keep the catheter in for. A review of the progress notes revealed no diagnosis for the catheter. A review of the hospital notes revealed no indication for the need of a catheter. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #332 had a Brief Interview for Mental Status (BIMS) score of 13, indicating an intact cognition. A review of the face sheet for Resident #332 revealed that the Resident was admitted to the facility on [DATE] with the diagnosis of CHF. A review of the care plan for Resident #332 revealed the following: Focus-I have a chronic foley catheter . Goal-I will remain free from catheter related trauma through review date. Intervention- CATHETER: I have a catheter, please position my catheter bag and tubing below the level of my bladder and away from entrance room door. Provide me with a leg starp (sic) and use a dignity bag to cover my catheter bag. Observe me for any s/sx (signs and symptoms) of UTI (Urinary Tract Infection) such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, and report. Observe me for pain/discomfort due to my catheter. Please check to make sure my tubing has no kinks in it. On 05/19/2022 at 11:20 AM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were interviewed in regard to Resident #332 having a catheter with no appropriate diagnosis. The DON stated, We try to have them (the catheters) pulled if we can. We contact the physician, if we can, we get an order for a bladder scan to check how the bladder is. (Resident #332's) Family wants it pulled before (Resident #332) goes home. We don't like to see Foleys. The DON further explained that the facility usually reviews new residents upon admission and determines the need for the Foley catheter at that time. On 05/19/2022 at 12:23 PM, the DON was interviewed again in regard to the Foley catheter for Resident #332, the DON stated, We still don't have a diagnosis, we are waiting on the doctor for that because we just can't pull it (pull the catheter out without a physician order). A review of the facility policy titled Indwelling Catheter Care undated, did not address the need for a diagnosis and or discontinuation of a catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to label and/or change oxygen (O2) tubing timely for three of three residents (Resident #121, #332 and #334) reviewed for respiratory care, resulting in the potential for respiratory infections. Findings include: Resident #121 (R121) On 05/17/2022 at 11:41 AM, Resident #121 was sitting up in their wheelchair dressed and groomed. The Resident had clear speech and answered questions appropriately. The Resident had oxygen tubing leading from their nose to an oxygen concentrator. There was no date noted on the oxygen tubing. Resident #121 was asked if they knew when their oxygen tube was last changed and stated, They haven't changed it since I got here; I've been here about three weeks. Resident #121 was mildly short of breath with exertion. On 05/18/2022 at 12:33 PM, Resident #121 was up in their wheelchair, dressed and groomed. Resident #121's oxygen tubing was not dated. A review of the Physician Orders for Resident #121 revealed the following: Change and date O2 tubing every week. Ordered on 05/16/2022. O2 via NC (nasal cannula) ATC (around the clock). A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #121 was admitted to the facility on [DATE] with the diagnoses of Chronic Respiratory Failure, Congestive Heart Failure and Lung Cancer. Resident #121 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition, and needed extensive assistance with activities of daily living (ADL). Resident #332 (R332) On 05/17/2022 at 01:33 PM, Resident #332 was observed sitting up in their wheelchair dressed and groomed. Resident #332 had oxygen tubing extending from their nose to an oxygen concentrator. There was no date on the oxygen tubing indicating whether or not the tubing had been changed. Resident #332 had clear speech and answered questions appropriately. Resident #332 was interviewed in regard to their stay at the facility and explained that they were recently hospitalized for Congestive Heart Failure (CHF) and was at the facility for rehabilitation. On 05/18/22 at 12:22 PM, Resident #332 was observed up in their wheelchair. The oxygen tubing was still not dated. A review of the MDS assessment dated [DATE] revealed that Resident #332 had a Brief Interview for Mental Status (BIMS) score of 13, indicating an intact cognition. The Resident was admitted to the facility on [DATE] with the diagnoses of CHF and Chronic Obstructive Pulmonary Disease (COPD). Resident #334 (R334) On 05/17/2022 at 09:28 AM, Resident #334 was observed dressed and groomed ambulating in their room. The Resident had clear speech and answered questions appropriately. Resident #334 had oxygen tubing extending from their nose to an oxygen concentrator. The tubing was not dated. Resident #334 was asked if they knew when the tubing was last changed and stated that the facility had not changed it yet. A review of the face sheet for Resident #334 revealed that the Resident was admitted to the facility on [DATE] with the diagnoses of COPD and Acute and Chronic Respiratory Failure with Hypoxia. A review of the Physician Orders for Resident #334 revealed an order written on 05/16/2022 to change and date the oxygen tubing every week. A review of the facility policy titled Oxygen Administration (undated) revealed the following: .A resident will receive oxygen per physician's orders and facility protocol . The policy did not address the dating/changing frequency of the tubing.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days per week, affecting all residents residing in the facility, resulting in the likelihood for inadequate supervision, inadequate coordination of emergent or routine care, and inaccurate assessments that could cause negative resident outcomes. Findings include: On 05/19/2022 at 10:15 AM, staff postings were reviewed with facility Staff Member D who is responsible for staffing the building. While reviewing the postings, the following dates revealed to not have eight hours of RN coverage: 01/27/2022, 01/29/2022, 02/14/2022, 02/21/2022, 02/24/2022, 03/09/2022 and 03/11/2022. Staff Member D was interviewed in regard to the missing RN hours and stated, It is hard to find RN coverage these days, we have to use the DON (Director of Nursing) on those days. On 05/19/2022 at 11:10 AM, the DON and Nursing Home Administrator (NHA) were interviewed in regard to the lack of RN coverage on some work days. The DON explained that they were having trouble finding RN's that wanted to work in the field and that she was picking up the slack and working the medication carts when she had to. On 05/19/2022 at 12:10 PM, a policy on staffing was requested but not received by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call light accessibility for 13 Residents (R48, R43, R90, R39, R4, R13, R82, R67, R9, R56, R55, R34, R102) on the [NAME] Unit and Resident #19, out of 26 reviewed for accommodation of needs, resulting in frustration, dissatisfaction with care, and loss of autonomy. Findings include: On 5/17/2022 at 11:32 AM, a tour of the facility was completed. Upon the tour multiple unsampled residents were observed with their call lights out of reach, R48 in room [ROOM NUMBER]B was observed with their call light behind the bed and out of reach. R43 in room [ROOM NUMBER]A was observed with their call light on the floor and out of reach. R90 in room [ROOM NUMBER]B was observed with their call light on the floor and out of reach. R39 in room [ROOM NUMBER]A and R4 in room [ROOM NUMBER]B were observed with their call light on the floor and out of reach. R13 in room [ROOM NUMBER]A was observed with their call light wrapped in their assist bar and on the floor. R82 in room [ROOM NUMBER]B was observed with their call light clipped inside a curtain out of reach. They were asked how they ask for help if needed. They replied, I can't find that light half the time, someone clipped it up on that curtain, but I can to it. R67 in room [ROOM NUMBER]A was observed with their call light on the floor. R9 in room [ROOM NUMBER]B was observed up in their wheelchair with their call light on the floor and out of reach. They were asked how they asked for help if needed. They replied, Well, I don't know. There is a thing I press, but I don't know. R56 in room [ROOM NUMBER] was observed with their call light on the floor. R55 in room [ROOM NUMBER]A was observed with their call light clipped to the curtain and out of reach. R34 in room [ROOM NUMBER]B was observed with their call light behind their bed and out of reach. R101 in room16A was observed with their call light behind their bed and out of reach. On 5/19/2022 at an interview was conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) regarding call lights being accessible. The DON stated, I expect for call lights to be always within reach. They should be clipped where the resident can always reach them. A review of a policy titled, Call Light Policy and reviewed and/or Revised on 2/17/20 revealed the following, It is the policy of this facility to answer call lights as promptly as possible. Resident #19 On 05/17/2022 at 08:37 AM, Resident #19 was observed lying in bed awake listening to the radio. Resident #19 was dressed in bed. While interviewed, the Resident explained that the staff did not change their soiled brief when they needed it changed and that they would often wait for several hours before someone would come in to help change them. Resident #19 was asked what staff says when they come in to answer the call light. Resident #19 stated, I don't know, they just come in and say they are busy and will be back later and then don't come back until hours later. At this time, the Resident's call light was observed to be lying on the ground, out of reach. The Resident was asked how they ask for assistance if needed. The Resident stated, I can't see, so if I don't have my call light, my room mate will call for me. At that time, the Room mate stated, I will press my call light. Resident #19 was asked when the last time they were changed and explained that they were not sure how long it had been but had been laying in a soiled brief for hours. A review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 revealed the following: Resident #19 was most recently admitted to the facility on [DATE] with the diagnosis of Depression and Anxiety. Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition, and needed extensive assist with toileting needs and personal hygiene. A record review of the care plan for Resident #19 revealed the following: Focus-I have an ADL (activity of daily living) deficit and require assistance r/t (related to) poor vision, dx (diagnosis) bi polar disorder, major depressive disorder, OA (osteoarthritis), and muscle weakness. Goal-I will be well groomed and dressed daily with assisting as much as able .Intervention- Encourage me to use my call light for assistance. Keep it within my reach .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 30 (R30) On 5/18/2022 at 11:34 AM, R30 was observed to have a fall out their chair in front of the nurse's station. A review of the medical record revealed that R30 was admitted into the facility on 7/7/2021 with the following diagnoses, Alzheimer's Disease, Major Depressive Disorder, Anxiety Disorder, and Muscle Weakness. A review of their Minimum Date Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1/15 indicating severely impaired cognition. R30 also required one-person limited assistance with bed mobility and transfers. A review of progress notes revealed R30 had falls on the following dates, 7/12/21, 7/14/21, 9/16/21, 3/13/22, 3/14/22, and 5/18/22. A review of R30's care plan related to falls, noted the last intervention added was on 7/14/2021. Resident 51 (R51) On 5/17/2022 at 11:30 AM, R51 was observed ambulating with a walker. R51 was observed with a hard shoe on and bruises to their face in various stages of healing. R51 was walking with family member E who stated, [R51] had a fall and broke their toe. That's why they have the special shoe and the bruising on their face. But it looks much better than when it first happened. A review of the medical record revealed R51 admitted into the facility on 7/22/2021 with the following diagnoses, Dementia, Adjustment Disorder with Depressed Mood, and Presence of Cardiac Pacemaker. A review of the MDS dated [DATE] revealed a BIMS score of 4/15 indicating a severely impaired cognition. R51 also required one person supervision for bed mobility and transfers. A review of progress notes revealed that R51 had falls on the following dates, 8/6/2021, 11/28/2021, 4/21/2022, and 5/4/2022. A review of R51's fall care plan revealed that the last intervention added was on 8/6/2021. On 5/19/2022 at 11:06 AM, an interview was conducted with the Director of Nursing and the Nursing Home Administrator regarding fall interventions being updated after a fall. The Director of Nursing stated, We update the care plan and usually have therapy screen the resident after a fall. I would have to look into why the interventions weren't put in place for those two residents. Based on observation, interview, and record review, the facility failed to follow/develop care plan interventions following falls and for pressure ulcer treatment for five sampled Residents (R30, R44, R51, R61, and R335) of six residents reviewed for care plans, resulting in the potential for continued falls and ineffective pressure ulcer treatment. Findings include: Resident #44 (R44) On 5/17/22 at 1:17 PM, R44 was interviewed about their care at the facility and indicated that they had a fall approximately one week ago. On 5/19/22 at 9:00 AM, R44's fall incident and accident (I/As) reports were reviewed and revealed that R44 had unwitnessed falls on: 5/2/22, 3/15/22, 2/22 (exact day of month not indicated), and 1/9/22. No apparent injuries were indicated for any of R44's falls. On 5/19/22 at 9:25 AM, R44's fall care plan was reviewed and revealed that there were no fall interventions listed on R44's care plan following their falls on 5/2/22 and 2/22. On 5/19/22 at 11:33 AM, and 1:10 PM, the Administrator (NHA) was interviewed regarding their expectations for resident care plans and indicated that goals and interventions implemented for residents should be on their care plans and interventions updated as needed. On 5/19/22 at 11:45 AM, R44's electronic medical record (EMR) was reviewed and indicated that R44 was originally admitted to the facility on [DATE] with diagnoses that included, Type 2 diabetes and Muscle wasting. R44's most recent minimum data set assessment (MDS) dated [DATE] indicated that R44 had an intact cognition and required extensive to limited 1 person assistance for all activities of daily living care (ADLs) other than eating. On 5/19/22 at 11:55 AM, the facility's undated policy titled Comprehensive Plan of Care was reviewed and stated the following, Policy, Each resident will have a comprehensive care plan developed .Fundamental Information, The comprehensive care plan must be person centered .and describe that each resident is provided the necessary care and services .The comprehensive plan of care must address the resident's individual needs .Include goals with measurable objectives .Reflect interventions to meet both short and long term resident goals .Be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur . Resident #335 (R335) On 05/17/2022 at 11:21 AM, Resident #335 was observed lying in bed, resting with their eyes closed. The bed was in the lowest position, almost to the floor. There was a beveled mat on each side of the Resident's bed. On 05/18/2022 at 11:52 AM, Resident #335 was observed awake, sitting up at the edge of the bed. The Resident has their sheets wrapped around their body and was attempting to unravel them. When a interview was attempted, the Resident was unable to answer questions appropriately. Beveled mats on each side of the bed, were still present. On 05/19/2022 at 09:14 AM, Resident #335 was observed awake in bed. The Resident was attempting to sit up in bed while picking at their sheets and blankets. A review of the face sheet for Resident #335 revealed the Resident was admitted to the facility on [DATE] with the diagnoses of Dementia and Weakness, A review of the incident report dated 05/15/2022 for Resident #335 revealed the following: .Resident observed on floor outside of bedroom in a supine position, on the hallway floor, Resident denies pain. Quarter sized area to back, below right shoulder blade. Resident able to complete full ROM (range of motion). CNA (Certified Nurse Assistant) verbalizes resident having a bowel movement and some had gotten on the floor .was cleaning it up and resident ran out the room and before he could stop (them) (Resident #335) tripped and fell . A review of the care plan for Resident #335 revealed the following: Focus-I am at risk for falls . Goal-(no specific goal listed) Interventions-Be sure my call light within reach .ensure that I am wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair) .I need a safe environment with floors free from spills and/or clutter; adequate, glare free light; a working and reachable call light, the bed in lowest position and personal items within reach .PT/OT to evaluate/treat as needed. There were no other interventions listed; the care plan was created on 05/15/2022. On 05/19/2022 at 11:10 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed, in regard to the process for when a resident falls. The DON explained that the facility usually has therapy screen the residents to make sure they are okay and they review the falls as a team. A review of the facility policy titled Fall Management Guidelines (undated) revealed the following: .11. The IDT (interdisciplinary team) will review all resident falls at the next morning meeting to evaluate/investigate the circumstances and root cause for the fall. 12. The IDT will review/modify the plan of care to minimize the risk of repeated falls .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 281 (R281) A review of intake MI100127096 noted the following, Complainant states on 2/15/22 her husband visited the resident and found their hair matted in 2 different spots. Complainant states her husband brought this to the social worker attention and [Social Worker] states it would be taken care of immediately. Complainant states on 2/21/22 the resident was hospitalized , and [R281] hair was in the same condition. A review of the medical record revealed that R281 was admitted into the facility on 9/20/2019 with the following diagnoses, Dementia, Muscle Weakness, and Dysphagia. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 99 indicating that R281 was unable to complete the assessment. R281 also required one-to-two-person total dependence with bed mobility and transfers. A request for documentation showing if R281 had a shower or bed bath during their stay was requested, but not provided prior to survey exit. This citation pertains to intake numbers: MI00127096, MI00127498 and MI00127828 Based on observation, interview, and record review, the facility failed to ensure that timely incontinent care, grooming, and showers were provided for six sampled Residents (R6, R19, R65, R68, R97, and R281) of eight residents reviewed for activities of daily living care (ADLs), resulting in feelings of resident frustration, humiliation, and dissatisfaction with care. Findings include: Resident #68 (R68) On 5/17/22 at 2:06 PM, R68 was interviewed about their care at the facility and indicated that they typically wait an hour or more to be changed. R68 indicated that they needed a brief change currently and had been waiting for approximately an hour. R68 stated, Can you change me. On 5/19/22 at 10:45 AM, R68's electronic medical record (EMR) was reviewed and revealed the following, R68 was originally admitted to the facility on [DATE] with diagnoses that included, Lobar pneumonia and moderate protein-calorie malnutrition. R68's most recent minimum data set (MDS) assessment dated [DATE] revealed that R68 had an intact cognition and required extensive assistance of 1 person with all activities of daily living care (ADLs) other than eating. Resident #65 (R65) On 5/17/22 at 2:26 PM, R65 was interviewed about their care at the facility and indicated that they frequently had to wait a long time for their brief to be changed. R65 stated, They turn off my call light and don't come back. R65 indicated that they felt Upset and undignified, lying in feces and urine. On 5/19/22 at 10:50 AM, R65's EMR was reviewed and revealed that R65 was originally admitted to the facility on [DATE] with diagnoses that included, Congestive heart failure and Type 2 diabetes. R65's most recent MDS assessment dated [DATE] revealed that R65 had a moderately impaired cognition and required extensive assistance of 1 person for all ADLs other than eating. Resident #6 (R6) On 5/17/22 at 2:36 PM, R6 was interviewed about their care at the facility and indicated that they frequently wait an hour or more to get their brief changed, especially on afternoon and midnight shifts. R6 stated, I'm not happy about it. On 5/19/22 at 11:00 AM, a review of R6's EMR revealed that R6 was originally admitted to the facility on [DATE] with diagnoses that included, Cerebral infraction (stroke) and Hypertension (high blood pressure). R6's most recent MDS dated [DATE], revealed that R6 had an intact cognition and required extensive assistance of 1-2 people for all ADLs other than eating. Resident #97 (R97) On 5/17/22 at 4:20 PM, R97 was interviewed about their care at the facility and indicated that they did not receive enough help with their ADL care. R97's hair was observed to be un-groomed, disheveled, and sticking up all over their scalp. On 5/19/22 at 11:05 AM a review of R97's EMR revealed that R97 was originally admitted to the facility on [DATE] with diagnoses that included, Dementia with behavioral disturbance and Major Depression. R97's most recent MDS dated [DATE] revealed that R97 had an intact cognition and required 1 person limited assistance for all ADLs other than eating. On 5/19/22 at 11:27 AM, the Director of Nursing (DON) was interviewed about their expectations regarding staff responding to ADL care needs of residents. The DON indicated that staff should be responding to residents call lights within, 5-10 minutes. The DON further indicated that the resident's call light should remain on until the care need was met. On 5/19/22 at 1:14 PM, Certified nursing assistant (CNA) A was interviewed about their ability to be able to respond to resident care need requests and to provide resident care in a timely manner. CNA A stated, It's overwhelming we need more staff. On 5/19/22 at 1:30 PM, facility policies titled, Tub Bath or Shower no date, and Hair Care no date. were reviewed and stated the following, Purpose, Tub baths and/or showers are used to cleanse the body, stimulate circulation, and condition & assist debriding skin .Hair Care, Purpose, Hair care is given to maintain or improve personal appearance . Resident #19 (R19) On 05/17/2022 at 08:37 AM, Resident #19 was observed lying in bed awake listening to the radio. Resident #19 was dressed in bed. While interviewed, the Resident explained that the staff did not change their soiled brief when they needed it changed and that they would often wait for several hours before someone would come in to help change them. Resident #19 was asked what would staff say when they came in to answer the call light. Resident #19 stated, I don't know, they just come in and say they are busy and will be back later and then don't come back until hours later. At this time, the Resident's call light was observed to be lying on the ground, and out of reach. The Resident was asked how they ask for assistance when needed. The Resident stated, I can't see, so if I don't have my call light, my room mate will call for me. At that time, the Room mate stated, I will press my call light. Resident #19 was asked, when was the last time they were changed and explained that they were not sure how long it had been, but had been laying in a soiled brief for hours. The Resident's light was on at this time to alert staff that help was needed. Resident #19 lifted their sheet up to reveal a stain covering the whole buttocks/peri area region, soaking through their brief and their pants onto the pad under the resident. The pad had a brown liquid stain outlining where the Resident was laying. There was one staff member observed passing out breakfast trays in the hallway. A review of the physician orders for Resident #19 revealed the Resident was on Macrobid (an antibiotic) for 30 days for chronic urinary tract infections. On 05/18/2022 at 08:40 AM, Resident #19 was observed awake in bed. Their breakfast tray was on a table at the side of the bed. Resident #19 stated, I won't be eating much, my stomach is upset after the night I had. The Resident was asked to elaborate and explained that they were impacted (constipated) last night and had been sitting in their soiled brief for over an hour now. The Resident lifted their sheet to reveal a large brown stain that smelled of stool that soaked through their brief, their clothes and onto their pad on the bed. There was also a yellow ring stain around the stool stain observed on the pad. The Resident stated, They (the staff) came in here, but they said that I would have to wait until after breakfast to change me. There was no staff observed in the hallway at that time. On 05/18/2022 at 10:01 AM, Resident #19 was observed lying in bed awake and was asked if they were still in their soiled brief and stated, No, they changed me a few minutes ago. A review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 revealed the following: Resident #19 was most recently admitted to the facility on [DATE] with the diagnosis of Depression and Anxiety. Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition, and needed extensive assist with toileting needs and personal hygiene. On 05/19/2022 at 11:10 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed in regard to changing Resident #19 when soiled and stated, (Resident #19) often refuses care and has had a change in their condition (terminally ill). I know that (care refusals) has been care planned. (Resident #19) uses there light frequently. I have been in there several times with them and the family. Mostly they just want their Norco (pain medication) and have no other complaints. We do round frequently. A review of the facility policy titled, Call Light Policy revised 2/17/20 revealed the following: It is the policy of this facility to answer call lights as promptly as possible.

This citation pertains to intake MI00127096 Based on observation, interview, and record review the facility failed to complete weekly skin assessments for five sampled residents (9, 47, 61, 126, and 281) and implement wound care interventions for one sampled resident (R47) out of five reviewed for skin, resulting in the potential for missed skin alterations, delay in treatment, delay in healing, and pain. Findings include: Resident 281 (R281) A review of intake MI00127096 revealed the following, Complainant states during the hospitalization the resident was observed with an ulcer on their heel, a sore on their shin, and toenail falling off (rt (Right) big toe). A review of R281's weekly skin assessment was completed on 2/9/2022. Prior to that one the last one completed was on 12/22/2021. Resident 9 (R9) On 5/18/2022 at 12:29 PM, an observation of R9's skin was completed after R9 complained of soreness to their bilateral buttocks. Upon observation, R9's bilateral buttocks appeared red with no open areas. CNA E said that they were going to put some house barrier cream on R9's bilateral buttocks and inform the nurse. A review of R9's skin assessments showed that their last weekly skin assessment was completed on 4/13/2022. Resident 47 (R47) On 5/18/2022 at 11:52 AM, R47 was observed laying in bed. R47 was observed to have their heels resting on the mattress. No heel boots were observed in the room. On 5/19/2022 at 9:39 AM, R47 was observed laying in bed. R47 was observed to have their heels resting on the mattress. No heel boots were observed in the room. A review of the Minimum Data Set Assessment Set dated 2/16/2022 revealed that R47 has a pressure ulcer/injury, scar over a bony prominence, or a non-removable dressing/device. A review of R47's physician orders revealed a wound consult order dated 3/2/2022 for under left foot. Further review of R47's physician orders revealed the following, Order: Heel Protective Boots to bilateral heels when in bed .Start Date: 1/23/2022. On 5/18/2022, a review of R47's skin assessments showed that their last weekly skin assessment was completed on 3/1/2022. Resident 61 (61) On 5/17/2022 at 11:30 AM, R61 was observed in bed with their left foot wrapped. R61's heels were laying on the mattress. On 5/18/2022, A review of R61's weekly skin assessments were completed and showed that their last skin assessment was completed on 5/9/2022. The most recent skin assessment completed prior to 5/9/2022 was completed on 4/11/2022. Resident 126 (R126) On 5/18/2022, a review of R126's weekly skin assessments revealed that the last assessment was completed on 4/13/2022. On 5/19/2022 at 11:06 AM, an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) regarding skin assessments not being completed weekly. The DON stated, We have been having issues with things not prompting and saving in Point Click Care. We are working with them to get it fixed, but they should be completed weekly. A review of an undated policy titled, Skin Management Facility Guidelines revealed the following, Place each resident on a weekly head-to-toe skin assessment on PPC and indicate day and shift on which the check will be conducted.

Based on observation, interview and record review, the facility failed to label and store medications per standards of care for the Dementia Unit and the Rehabilitation Unit, resulting in the potential for medication administration errors. Findings include: On 05/18/2022 at 12:06 PM, the [NAME] North medication cart was observed for medication storage with Unit Manager F. Upon opening the top drawer, there were three small plastic cups filled with pills (taken out of their original labeled package/container) in them stacked on top of each other. Unit Manager F was asked what the medications were for and explained that the medications were for three residents that were currently receiving dialysis outside of the building. Unit Manager F stated, See, they have their name on it (the cups had light, illegible handwriting on them). As soon as they get back from dialysis I am going to give them their medications. On 05/19/2022 at 11:10 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed in regard to the medications removed from their packaging being stacked in cups in the medication cart. The DON stated that the nurses are not supposed to pass medications that way. On 05/19/2022 at 02:28 PM, the DON approached this Surveyor and stated, Just so you know, I educated the Unit Manager (F) on medication pass (not pre-pouring medications) and she signed it and everything. A review of the facility policy titled Medication Administration and General Guidelines dated 2022 revealed the following: .5. Medications are administered at the time they are prepared. Medications are not pre-poured .

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen and dish machine room, and failed to ensure potentially hazardous food items were dated, resulting in the increased potential for cross contamination and foodborne illness. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 5/17/22 between 8:40 AM-9:30 AM, during an initial tour of the kitchen, the following items were observed: There was a cell phone stored on the food preparation table. Dietary Staff I picked up the phone, placed it in her pocket, and went back to work in the kitchen, without performing any hand hygiene. On 5/17/22 at 3:45 PM, when queried about cell phone usage by dietary staff, Certified Food Manager (CFM) H confirmed that staff are not to use cell phones while in the kitchen, and should wash their hands after handling their phones, before returning to work in the kitchen. There was a dusty fan blowing onto the food preparation area. According to the 2013 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306 The flooring throughout the kitchen was sticky and stained, with a buildup of grime. There was heavy buildup in the corners, along the baseboards, underneath the 3 compartment sink, and at the threshold leading into the kitchen. According to the 2013 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. In the True reach-in cooler, there was an opened, undated package of deli turkey, 2 undated individual salad bowls, 2 undated dressing cups, 3 undated deli sandwiches, an opened, undated 1 gallon container of Italian dressing, an opened, undated 1 gallon container of tartar sauce, and an opened, undated 1 gallon container of mayonnaise. On 5/17/22 at 3:45 PM, CFM H confirmed that all food items need to be dated when opened. According to the 2013 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. There was a dusty ceiling vent cover located above the bread rack. According to the 2013 FDA Food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. The food preparation table located in front of the oven was observed with a buildup of crumbs and food debris on the bottom shelf. There were 2 bins of clean bowls stored on the soiled shelf. The clean bowls were stored uncovered, with the opening facing up. According to the 2013 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, (A) Except as specified in (D) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. There was a stainless steel cart with a tray of cereal bowls and lids stored on the cart. The shelves of the cart were soiled with dried on food debris, with an accumulation of crumbs in the corners of the shelves. According to the 2013 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The top interior surface of the microwave was peeling, leaving a porous, rusty surface underneath. According to the 2013 FDA Food Code section 4-101.19 Nonfood-Contact Surfaces, NonFOOD-CONTACT SURFACES of EQUIPMENT that are exposed to splash, spillage, or other FOOD soiling or that require frequent cleaning shall be constructed of a CORROSION-RESISTANT, nonabsorbent, and SMOOTH material. The clean drainboard of the 3 compartment sink was soiled with a dried on pinkish/red, sticky substance. In the walk-in cooler, there was a large, rolling rack with 4 trays of individual fruit cups. The fruit cups were not covered, and the rack was sitting directly underneath the dusty exhaust fans. In addition, the flooring in the walk-in cooler was soiled with dried on spills and debris accumulated underneath the racks. On 5/17/22 at 3:50 PM, CFM H confirmed that the rack of fruit cups in the walk-in cooler should have been covered. According to the 2013 FDA Food Code section 3-305.11 Food Storage, 1. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination;. The steam table electrical cord, plugged into a ceiling outlet directly above the steam table, was coated with a layer of dust. The shelf underneath the steam table was observed to be soiled with crumbs and dried on food stains. The water inside the wells of the steam table were cloudy and there was a buildup of food debris at the bottom of the wells. According to the 2013 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In the dry storage room, there was an accumulation of trash, a package of graham crackers, cookies and an oatmeal cream pie on the floor underneath the racks. In the dish machine room, there was an open window with no screen in the window. 6-202.15 Outer Openings, Protected, (D) Except as specified in (B) and (E) of this section, if the windows or doors of a food establishment, or of a larger structure within which a food establishment is located, are kept open for ventilation or other purposes or a temporary food establishment is not provided with windows and doors as specified under (A) of this section, the openings shall be protected against the entry of insects and rodents by: (1) 16 mesh to 25.4 mm (16 mesh to 1 inch) screens; (2) Properly designed and installed air curtains to control flying insects; or (3) Other effective means. The flooring in the dish machine room was heavily soiled with buildup and grime. There was muddy sand and silt on the tile surrounding the floor drain in the center of the room. On 5/17/22 at 3:55 PM, when queried about the flooring in the dish machine room, CFM H stated that the floor drain had backed up due to all the rain, and after the water receded, the muddy silt was left behind on the flooring. 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 5/17/2022 at 10:44 AM, room [ROOM NUMBER] was observed with an isolation cart in front of the door with contact/droplet isolation signage. An unidentified agency nurse was observed in the room taking a blood pressure with only a surgical mask on. On 5/17/2022 at 10:46 AM, two unidentified Certified Nursing Assistants (CNA) were seen in the room with only surgical masks on. On 5/17/2022 at 11:25 AM, an unidentified CNA was observed in the room emptying a urinal with only gloves and a surgical mask on. On 5/17/2022 at 1:29 PM, an unidentified agency nurse was observed speaking to bed one with nothing on but a surgical mask. On 5/18/2022 at 11:49 AM, a visitor was observed in room [ROOM NUMBER] with bed one. No mask was observed on the visitor. On 5/18/2022 at 2:53 PM, an interview was conducted with the Infection Control Nurse regarding the observations. The Infection Control Nurse stated, The personal protective equipment (PPE) that should be used in isolation rooms include gowns, gloves, mask, and face shield if they are under observation. If there is an isolation cart and signs on the door, then they should follow what they see. The Infection Control Nurse was queried regarding what visitors should wear when visiting patients. The Infection Control Nurse stated, They must wear a mask. If they are visiting someone under isolation, then they should have on the full PPE. If they don't comply, then they are explained the risk and the conversation would be documented. This citation pertains to intake #MI00127498. Based on observation, interview and record review, the facility failed to place a Resident in isolation timely, and failed to use personal protective equipment (PPE) consistently for one resident (Resident #334) of one reviewed for transmission based precautions, resulting in the potential to transmit infection from staff to resident. Findings include: On 05/17/2022 at 09:27 AM, during an initial tour of the short term rehabilitation unit, Resident #334 was in their room with their door partially closed. There was no isolation cart outside the room. On 05/17/2022 at 11:19 AM, an isolation cart was observed to now be outside of Resident #334's room. There were two isolation signs up indicating the resident was in contact isolation and upon entering the room, staff should wear a mask, gown and gloves. Resident #334 had clear speech and was able to answer questions appropriately. The Resident was ambulatory and was on oxygen daily. Resident #334 was asked if anybody had been putting on PPE when entering their room and stated, No, no one has done that, you are the first one. Resident #334 further explained that they had not been vaccinated from the Covid-19 virus. On 05/17/2022 at 11:22 AM, an unknown housekeeper was observed in Resident #334's room cleaning. The housekeeper had on only a mask and gloves. On 05/18/2022 at 11:39 AM, Resident #334 was in the hallway talking to an unknown staff member, the staff member and a housekeeper were observed to walk in the room and into the bathroom with only a mask on. The Resident did not have a mask on. On 05/19/2022 at 11:21 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed in regard to the process of new residents who are not vaccinated against Covid-19. The DON stated, If we have a new one that is not fully vaccinated, we do a seven day isolation. We put them in contact isolation. I would have to look at (Resident #334). On 05/19/2022 at 09:27 AM, an unknown staff member walked in Resident #334's room with only a mask on. A review of the face sheet for Resident #334 revealed that the Resident was admitted to the facility on [DATE] with the diagnoses of Chronic Obstructive Pulmonary Disease and Acute and Chronic Respiratory Failure with Hypoxia. A policy for isolation was requested, a How to determine Quarantine Status was given with no date that revealed for newly admitted residents that were not vaccinated were to be quarantined (did not have specific length of time).