**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility did not ensure residents with limited range of motion (ROM) received services to maintain or prevent further reduction in ROM for 1 out of 2 residents (R) (R30). R30's restorative care plan from therapy on 1/24/2025 was not implemented. R30's restorative care plan from therapy on 7/1/2024 was not being followed. Findings include: R30 admitted to the facility on [DATE] with diagnoses to include post polio syndrome, osteoarthritis, and pain in right shoulder. R30's quarterly Minimum Data Set (MDS) assessment dated , 2/7/2025, indicated R30 had no impairment in ROM in both upper extremities and impairment on both lower extremities. R30 needed maximum assist in multiple areas of mobility. R30 had therapy services that were discontinued on 1/21/2025, and a restorative program was ordered on 01/24/2025. Physical therapy orders stated, Patient will benefit from daily seated lower extremity and core home exercise program. Patient needs minimum assist for bilateral lower extremities range of motion especially left lower extremity. Please see handout set up in his room (closet door) per patient's consent. R30's care plan, dated 7/1/2024, did not include the 1/24/2025 restorative order. Related section of the care plan was last updated 7/1/2024. Care plan stated the restorative order from 7/1/24. The order stated, Patient will benefit from bilateral LE AAROM (active assisted range of motion) program on both lower extremities incorporated for AM cares as tolerated (daily) to prevent joint contractures and includes a sheet of exercises. R30's restorative order was not listed in the Treatment Administration Record (TAR) report dated January 2025 and February 2025. No documentation was provided that exercises were being completed. On 2/24/2025, at 9:58 AM, R30 stated that he did not have therapy or a restorative program. R30 stated that facility staff did not do exercises with R30. R30 indicated that R30 did not need them. R30 denied a decline in ADLs. R30 reported he had polio when he was 5 and that he was not going to get any stronger. On 2/25/2025, at 1:01 PM, Surveyor observed the [NAME] (CNA plan of care) hanging inside the closet door for R30. The order for LE exercises from 7/1/2024 was under the Resident Care section of the [NAME]. On 2/25/2025, at 2:51 PM, Surveyor observed Director of Nursing (DON) B attempt to find documentation of exercises being performed with R30. DON B stated she was unable to find documentation and she would have to get some help to find things. DON B stated that the process is that, when a new order comes in, she transcribes it to the care plan and actions go on the [NAME] so CNAs know what to do. DON B stated two copies are printed. One copy is put in the CNA binder and one copy is put on the door of resident's closet. On 2/25/2025, at 3:41 PM, DON B stated she was unable to find documentation. DON B stated it was not being done and she took full responsibility. On 2/26/25, at 11:50 AM, Surveyor interviewed CNA D who stated that CNAs know what to do with each resident because it is on the [NAME]. CNA D stated that the [NAME] is posted inside the door of each patient room and in the binder at the CNA desk. CNA D stated CNAs do the restorative program. CNA D stated that R30 does not sleep in bed and that it is difficult to do the exercises when R30 is not in bed. When asked if DON B talked to them about doing R30 exercises or if she knew he had them. CNA D said no.

Based on observation, interview, and record review, the facility did not provide assistive devices with meals to prevent accidents for 1 of 6 residents (R)(R2) reviewed for accidents. R2 was assessed and care planned as requiring lids on cups during meals in order to prevent spills. This was not provided for 2 of 2 observed meals. Findings include: R2 admitted to the facility in February of 2024 with diagnoses to include multiple sclerosis, hypertension, paraplegia, and weakness. R2's Minimum Data Set (MDS) assessment, dated 01/10/25, indicated that R2 had limited range of motion on one side of his upper extremities, and required set up assistance for meals. R2's Care Plan, dated 02/24/24, stated Handled cups with lids at meals. R2's Nutrition/dietary note, dated 01/05/25, stated in part, Handled cups with lids and divided plate are provided at meals to support independent eating. Nursing is providing meal set up. On 02/25/25 at 9:00 AM, Surveyor observed R2 having breakfast. R2 had a divided plate and 3 coffee cups with liquids. Surveyor observed that none of the cups had lids on them. Surveyor observed R2's shaking movements while eating independently. On 02/25/25 at 9:29 AM, Surveyor observed R2 eating when he spilled liquids on himself. R2 spilled liquids on R2's right arm and right pant leg. Staff were observed to wipe up the spill and asked R2 if R2 would like to have pants changed. R2 refused and stated that he was okay. Surveyor observed no change in coloration where R2 spilled the coffee on R2's arm. At 9:33 AM, staff refilled R2's coffee cup with coffee per R2's request. The cup did not have a lid. On 02/25/25 at 9:50 AM, Surveyor interviewed R2 and asked about using cups with lids. R2 responded that sometimes R2 used cups with lids. When asked if R2 was okay after spilling coffee, R2 indicated R2 was okay. On 02/25/25 at 12:43 PM, Surveyor observed R2 receive two coffee cups with fluids in at lunch, neither of the cups had lids on them. On 02/25/25 at 12:53 PM, Surveyor interviewed Life Enrichment (LE) G who confirmed that there were no lids on R2's cups. On 02/25/25 at 4:00 PM, Surveyor interviewed Director of Nursing (DON) B who confirmed R2's care plan indicated R2 should utilize handled cups with lids. Surveyor told DON B about the observations above. DON B responded that should not have happened. R2 needed the lid in place to keep from spilling coffee or other fluids on self.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide pharmaceutical services, including procedures that ensured the accurate acquiring, dispensing, and administering of drugs and biologicals, for 1 of 6 residents (R)(R11) reviewed for medication administration. The staff did not correctly administer an Advair inhaler for R11. Findings include: Surveyor reviewed instructions from the Michigan Medicine Care Guide titled, How to use your Advair HFA (fluticasone/salmeterol) inhaler last revised 10/2017 which stated, in part: .How to use your Advair HFA: .8. If your doctor has prescribed more than one dose (puff), wait 30 seconds and repeat above . R11 admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R11 was cognitively intact. R11 had diagnoses of gangliosidosis (a genetic disorder that progressively destroys nerve cells in the brain and spinal cord) and quadriplegia (paralysis that affects all four limbs). On 02/25/25 at 7:42 AM, Surveyor observed Licensed Practical Nurse (LPN) D administer Advair inhaler to R11. LPN D gave R11 one puff of the inhaler and within 10 seconds gave a second puff of the inhaler. Surveyor asked LPN D, Should there be a longer wait time in between puffs? LPN D replied, Yes, but this resident breathes fast. On 02/25/25 at 9:30 AM, Surveyor informed Director of Nursing (DON) B of the observation of LPN D with the Advair inhaler. DON B replied, She (LPN D) should have waited at least 30 seconds before giving the second puff. On 02/26/25 at 7:48 AM, DON B informed Surveyor that it is a 30 second wait time between puffs of the Advair inhaler and provided surveyor with the instructions from Michigan Medicine.

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice has potential to affect all 46 residents residing in the facility. The facility's Dietary Manager (DM) has been in the position for over 2 years, had enrolled in a course in 8/2022, but did not complete the steps to become certified. The facility does not have a full-time Registered Dietician (RD) at the facility. Findings include: On 2/25/25, at 7:57 AM, Surveyor interviewed Dietary Manager (DM) E. DM E reported that she became the Dietary Manager 2 years ago. When DM E was asked about her qualifications, she stated she was not a certified dietary manager, certified food service manager, nor did she have a related associates degree. DM E stated she was done with the class and took the test last October but had failed. DM E indicated her 90-day wait was about up and she would be rescheduling the exam. DM E stated Registered Dietician (RD) services are contracted and she did not know if the RD was at the facility at least 35 hours per week. DM E did not know if the facility had a waiver for Dietary Management. On 2/25/25, at 3:20 PM Surveyor interviewed Nursing Home Administrator (NHA) A about DM E. NHA A stated that DM E started her position as Dietary Manager a couple years ago. NHA A stated DM E is not certified. NHA A stated that DM E started the course almost right away upon starting as Dietary Manager. NHA A stated she was not sure why the lapse, but DM E had taken the exam in October (2024) and failed. NHA A stated that DM E will be rescheduling the test because DM E's 90-day retake waiting period was up last week or coming up soon. NHA A stated that RD services are contracted. NHA A does not know if RD services are 35 hours per week just for the facility as the RD covers a number of buildings. When asked, NHA A stated the facility did not have a waiver for dietary management. On 2/26/25, at 7:15 AM, NHA A stated the facility did not have 35 hours per week of RD services. NHA A confirmed that DM E started her job as Dietary Manager on 8/15/2022 and has been in her role for almost 2 ½ years.

Based on interview, record review, and observation, the facility failed to implement correct monitoring of the dish washer for sanitization purposes. This has the potential to affect all 46 residents residing in the facility. The facility did not ensure facility protocol was followed to ensure safe sanitization of dishware via their dishwasher. Findings include: The facility protocol on log sheet: Report if wash Temperature is Less than 110 Report if rinse temp is 120 Report if test strip does not reach between 50-100ppm (parts per million) The Association of Nutrition and Foodservice Professional titled, Know Your Sanitizer states, .If PPM sanitizer solution is too high, it can be considered unsafe and ineffective, potentially leaving harmful chemical residues on surfaces and posing a health risk due to excessive chemical exposures. On 02/26/25, at 10:43 AM, Surveyor interviewed, Culinary Aide (CA) F asking how dishes were cleaned and how temperatures were taken. CA F stated that staff check wash and rinse temps as well as the test strip. CA F demonstrated where test strips are kept, demonstrated how to use test strips, and showed Surveyor the log where staff record results. 0n 02/26/25, at 10:52 AM, Surveyor reviewed the logs for sanitizer ppm and sanitizations levels of the dishwasher in dining area kitchen. The log showed 7 out of 31 days in January and 9 out of our 26 days in February tested out of range with ratings of 150ppm. The range for safe sanitization levels is between 50-100ppm. On 02/26/25, at 10:54 AM, Surveyor interviewed Dietary Manager (DM) E, who stated temperatures and test strips are done every 2 hours while the machine is in use. DM E demonstrated proper use of the test strip during a wash cycle. It tested 150 ppm. DM E was not aware it was testing out of range. Surveyor asked what steps have been taken related to these out-of-range results. DM E stated that she did not know and that she would call the company today and get the situation figured out. Surveyor asked if there were any other steps needed. On 02/26/25, at 11:03 AM, DM E sought out surveyor. DM E stated that she called the company about the dishwasher, and they identified facility staff were not using the right test strips to check sanitizer levels. Surveyor and DM E went back to kitchen where DM E demonstrated proper use of test strips during a wash cycle. The new test result was 50ppm. Chlorine test strips had been switched out to Iodine test strips. Surveyor clarified with DM E that staff were completing the sanitizer level test strips per protocol, but they were using the incorrect strips. The out-of-range levels of sanitizer should have been reported and acted upon.