Aberdeen Rehabilitation And Skilled Nursing Center

Based on observation, interview, and record review, the facility failed to ensure consistent proper working order of the walk-in freezer and that the drain line from the commercial ice machine was protected against contamination from sewage or other sources of contamination. These deficient practices had the potential to affect all residents that eat from the kitchen. Findings include:During the initial tour of the kitchen on 9/9/25 at 8:30 AM with Dietary Manager (DM) G the following was observed:- The internal temperature of the walk-in freezer was 11 F (Fahrenheit). The temperature documented on the freezer temperature log, obtained earlier in the day, was 5 F. A four-ounce cup of ice-cream stored in the freezer was observed soft, not frozen solid. DM G said the temperature in the freezer should be zero or below. DM G added that there was a leak in the freon line, and they have been refilling it.- The drain line from the commercial ice machine was observed to not have an airgap (an unobstructed vertical space between the end of the ice machine drain line and the flood rim of the floor drain). DM G said if water backed up from the floor drain, the water could contaminate the ice machine. On 9/11/25 at 11:42 AM, the Regional Director of Operations said kitchen staff should have notified maintenance if the freezer was not operating correctly, and acknowledge a deficiency with the air gap. A review of the 2013 FDA Food Code revealed the following:- Section 3-501.11. Stored frozen foods shall be maintained frozen.- Section 5-402.11. Backflow prevention. Except as specified in paragraph (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to transmit Minimum Data Set (MDS) assessments for three (R15, R17, and R29) of six residents reviewed for resident assessments in a timely manner. Findings include: On 9/10/25 at 3:05 P.M. Registered Nurse (RN)/ MDS Coordinator M, was queried regarding the MDS submissions to CMS. RN M said that she completes the MDS assessments and then puts them in a 'batch' to be sent to MDS. RN M said that she has to obtain a code from the Corporate Director of Operations, RN D. RN M said the following resident's MDS assessments are completed but in batched status and had not been sent or accepted by CMS at this time. We usually send them all at the same time to CMS. Usually twice a month. 1. R15's quarterly MDS assessment dated [DATE] was in 'batch status', due for submission on 8/21/25 but had not been submitted. 2. R17's quarterly MDS was dated 8/9/25 was in 'batch status', due for submission on 8/23/25 but had not been submitted. 3. R29's quarterly MDS was dated 8/7/25 was in 'batch status', due for submission on 8/21/25 but had not been submitted. On 9/11/25 at approximately 12:00 PM, RN D said that RN M could obtain their own code to submit MDS assessments to CMS and was unsure why that had not been done. RN D said it was the facility's expectation that MDS assessments be submitted timely and in accordance with CMS regulations.

Based on observation, interview, and record review the facility failed to follow the standard of practice for transcribing physician's orders for one (R47) of seven residents reviewed for medication administration resulting in R47 missing nine doses of a multivitamin. Findings include:During observation of medication administration for R47 on 9/10/25 at 8:37 AM with Registered Nurse (RN) C, R47 did not receive a Multi-Vitamin (MVI) with minerals. According to R47's Electronic Health Record (EHR) the physician ordered MVI with minerals once a day on 8/18/25. A review of the R47's Medication Administration Record (MAR) for 9/2025 revealed the order for 'MVI with minerals once a day', did not get transcribed on the September 2025 MAR. On 9/10/25 at 9:56 AM, the Director of Nursing (DON) reviewed R47's EHR and confirmed that R47 and was supposed to get MVI w minerals once a day as of 8/18/25. The DON said the resident had not received the MVI with minerals since 8/31/25 because that order (MVI with minerals once a day) did not get transcribed onto 9/2025 MAR. The DON said the physician's prescription order was accidentally placed under the wrong category in 9/2025 and did not get transcribed on R47's MAR. The DON confirmed that R47 had missed 9 days of the MVI with minerals: 9/1/2025 - 9/09/2025. According to the facility's undated Medication Administration policy: Procedure:3. Medications must be administered in accordance with the orders, including any required time frame.

Based on observation, interview, and record review the facility failed to have a medication error rate below 5%.During the medication administration task three errors were observed from 28 opportunities and subsequently a 10.4% medication error rate. #1. On 9/10/25 at 9:19 AM, Registered Nurse (RN) C was observed to administer R28 medications at the bedside. RN C proceeded to sign out all the medications that were administered. R28 did not receive Ozempic 2 milligram (mg)/3 milliliter (ml)give 0.5 ml subcutaneous injection. Upon inquiry RN C confirmed all the resident's medications were given. R28's Medication Administration Record (MAR) was reviewed with RN C, and they were asked about the Ozempic prescription. RN C said, Oh, was that supposed to be given today? Yes, I should have given that. Its every Wednesday. Today is Wednesday. According to R28's Electronic Health Record (EHR) on 3/5/25 the physician prescribed Ozempic (2mg/3 ml) administer 0.5 ml subcutaneous once a day on Wednesdays. R28's MAR accurately documented the physician's order for the Ozempic every Wednesday.#2. On 9/10/25 at 8:10 AM Registered Nurse (RN) B was observed to administer R47 medications at the bedside. RN B proceeded to sign out all the medications that were administered. R47 did not receive Eliquis 5 milligrams (mg). Upon inquiry RN B confirmed all the resident's medications were given. R47's Medication Administration Record (MAR) was reviewed with RN B, and they were asked about the Eliquis prescription. RN B said, Yes, that should have been given. It wasn't in the medication cart at the time I was passing meds. According to R47's Electronic Health Record (EHR) on 8/24/25 the physician prescribed Eliquis 5 mg twice a day 9:00 AM and 9:00 PM. R47's MAR accurately documented the physician's order for the Eliquis 5 mg twice a day. #3. During reconciliation of R47's Medication Administration it was determined the resident had not received a multi-vitamin with minerals since 8/31/25. According to R47's Electronic Health Record (EHR) the physician ordered MVI with minerals once a day on 8/18/25. A review of the R47's Medication Administration Record (MAR) for 9/2025 revealed the order for 'MVI with minerals once a day', did not get transcribed on the September 2025 MAR. R47 had not received the multi-vitamin since 8/31/25 and missed 9 doses. On 9/10/25 at 9:56 AM the Director of Nursing (DON) reviewed R47's EHR and confirmed that R47 and was supposed to get MVI w minerals once a day as of 8/18/25. The DON said the resident had not received the MVI with minerals since 8/31/25 because that order (MVI with minerals once a day) did not get transcribed onto 9/2025 MAR. The DON said the physician's prescription order was accidentally placed under the wrong category in 9/2025 and did not get transcribed on R47's MAR. The DON confirmed that R47 had missed 9 doses of the MVI with minerals: 9/1/2025 - 9/9/2025. Procedure:3. Medications must be administered in accordance with the orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to: 1. Properly date-label food in the walk-in cooler and walk-in freezer; 2. Adequately clean surfaces in the kitchen; 3. Consistently ensure the dish machine was operating properly; and 4. Maintain cleanable wall surfaces near the dish machine. These deficient practices had the potential to affect all the residents who consumed from the kitchen resulting in the potential for food-borne illness. Findings include: During tours of the kitchen beginning on 9/9/25 at 8:30 AM with Dietary Manager (DM) G the following was observed: Inside the walk-in cooler a plastic container of feta cheese was dated 8/9/25. DM G stated the opened cheese should be thrown out in seven days. There was an open and undated bag of cinnamon raisin bread. Inside of the walk-in freezer the following items were opened and undated: a bag containing four individual size cheese pizzas and a bag of sausage patties. The stove drip tray was soiled with dried and burnt food debris. DM G said the drip tray was supposed to be cleaned on Sunday. DM G added, I doubt that it was cleaned (yesterday). DM G indicated the dish machine used sodium hypochlorite (a bleach used as a disinfectant) to sanitize dishware and other kitchenware processed through the dishwashing unit. DM G said they use a chlorine test strip to test the dish machine for proper sanitization of the dishware once a week. When the dish machine sanitizing log was requested, none was available. Sections of the walls surrounding the dish machine were observed to be missing tiles. The exposed surfaces were not smooth. Approximately ten square wall tiles, measuring approximately 4 x 4 each, were missing. On 9/10/25 at 3:36 PM, Certified Dietary Manager (CDM) I, who worked at another building but oversees the kitchen operation of the facility being surveyed, incorrectly stated that the facility's dish machine used quaternary ammonium to sanitize dishware. CDM I confirmed and agreed with DM G that the dish machine was tested for proper sanitization once weekly. CDM I stated that if the dish machine was not tested prior to each use that we don't have a guarantee that it was properly sanitizing the dishware. CDM I acknowledged that the walls with missing tiles were not easily cleanable. On 9/11/25 at 11:42 AM, the Regional Director of Operations said opened food items should be dated. According to the 2013 FDA Food Code:Section 3-101.11, Safe, Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under S 3-601.12, honestly presented. Section 4-204.117 Warewashing Machines, Automatic Dispensing of Detergents and Sanitizers. (B) Incorporate a visual means to verify that detergents and sanitizers are delivered.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. 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. Section 6-201.11 Floors, Walls, and Ceilings. Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable.

Based on interview and record review, the facility failed to ensure proper use of the legally protected professional designation of Registered Dietitian. Findings include:On 9/9/25 at 3:00 PM, the facility provided survey prep book was examined and revealed that dietitian H was listed as the Registered Dietitian (RD) that worked at the facility. However, the RD credentials available in the survey prep book were for RD J. On 9/9/25 beginning at 3:49 PM the Regional Director of Operations (RDO) D was interviewed about dietitian H. RDO D acknowledged that dietitian H was not a Registered Dietitian, but RD J, who worked at another building, was a Registered Dietitian and supervised dietitian H. RDO D added that RD J does not have to be physically in the building and It has never been a problem before. On 9/9/25 at 4:05 PM during an interview, Human Resources (HR) K said that dietitian H completed a Coordinated Undergraduate Program at a local university September 2018 but had not obtained Registered Dietitian status. HR K stated, 100% I would know if she obtained a RD status. On 9/10/25 at 4:08 PM during an interview, RD J said Registered Dietitians are certified through the Commission on Dietetic Registration (CDR). RD J said she oversees the work that dietitian H performs at the facility. RD J said dietitian H completed a dietetic program, but she had not been certified as a registered dietitian. RD J said she was aware that dietitian H was using RD credentials but did not have the authority to use them. RD J acknowledged that she cannot impart her credentials on anyone and that the CDR was the organization that grants permission for an individual to use RD credentials. On 9/11/25 at 8:33 AM, dietitian H said she was eligible to become a RD and has been using RD credentials for six years but never put thought into if this was a concern. On 9/11/25 at 11:37 AM, RDO D said dietitian H was put into the electronic health record (EHR) computer system as a RD, but that designation was in the process of being corrected. The following dietary progress notes, designated with an electronic signature of RD H (signifying a legally recognized confirmation of accountability), for the following residents were reviewed on 9/9/25 at 3:30 PM:- R8. Dietary note written on 9/2/25.- R17. Dietary note written on 2/13/25- R22. Dietary note written on 9/2/25.- R43. Dietary note written on 8/1/25. On 9/11/25 at 1:10 PM, the electronic signature for the dietary notes referenced above had been changed to RD-EC for dietitian H. On 9/11/25 at 1:26 PM, dietitian H reported that RD-EC refers to Registered Dietitian-Exam Candidate. On 9/11/25 at 1:30 PM, Representative L from the CDR reported that Registered Dietitian-EC was not a standard, recognized credential by the CDR. The RD credential stands alone for those who earned it and cannot be modified or used for those who have not earned it. Representative L provided the following link related to misuse of RD credentials: https://www.cdrnet.org/use-misuse. The CDR affirmed that only individuals who have met the academic and professional requirements, completed supervised practice, and passed the national registration examination administered by the Commission on Dietetic Registration (CDR) can use the Registered Dietitian (RD/RDN) credentials. These credentials are legally protected designations, meaning they cannot be used by anyone without meeting the specific standards set by the CDR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI001221903.Based on observation, interview, and record review, the facility failed to ensure that a call button was within reach for one resident (R110) out of four residents reviewed for call light access.Findings include: It was reported to the State Agency that residents' call lights were placed out of reach.On 7/16/25 at 3:05 PM, R101 was observed sitting in her wheelchair in her room. R101 was heard calling for help. R101 stated, I'm hurting, and I need to get in bed.On 7/16/25 at 3:06 PM, Activity Aide (AA) H entered R101's room and stated, (R101) likes to lay down. R101's call button was positioned approximately three feet from where R101 was sitting in her wheelchair. AA H said that R101 was not able to reach her call light.On 7/16/25 at 3:40 PM, the Director of Nursing (DON) joined the Surveyor in R101's room. R101 was observed sitting in her wheelchair but no longer stated she was in pain and needed to get in bed. The call light remained approximately three feet from where R101 was sitting in her wheelchair. The DON stated, The call light was not within her reach.A review of the clinical record for R101 documented an admission date of 12/7/24 and readmission date of 6/16/25. R101's diagnoses included chronic obstructive pulmonary disease, hemiplegia and hemiparesis, muscle weakness, and difficulty in walking. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and the use of a wheelchair for mobility. Record review of R101's risk for fall care plan, dated 6/16/25 documented, Keep call light in reach at all times while I am in my room.A review of the facility policy titled, Answering the Call Light, dated 3/10/2010, documented When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.On 7/17/25 at 12:45 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

This citation pertains to MI1221903.Based on observation, interview, and record review, the facility failed to ensure the Unit 300 shower room was maintained in a clean and sanitary manner, resulting in the residents' environment not being homelike and the potential for spread harmful pathogens. Findings include:It was reported to the State Agency that the facility was not maintained clean and sanitary.On 7/16/25 at 2:54 PM, observations of two shower stalls located in a Unit 300 shower room were made with Certified Nurse Aide (CNA) G. A wet, used face cloth and gloves were on the floor of the shower stall typically used with a shower chair. On the floor of the shower stall typically used with a shower gurney was a used patient gown and two wet used face cloths. CNA G said she was at the end of her shift and neglected to clean the shower. CNA G said the shower rooms should not have been left that way.On 7/17/25 at 11:53 AM, the Director of Nursing (DON) said approximately 18 residents use the shower room on Unit 300. The DON said staff were supposed to clean the shower room after every shower for infection control purposes. Used linen should be placed in a bag and put in the soiled utility room.A review of the facility policy titled, Showers, dated 9/2018, documented in part the following:- Pick up all towels, bath cloths, soiled clothing, etc. Discard in the soiled laundry container inside the bath area. (Note: Laundry/linen soiled with visible blood should be discarded in a biohazard container [e.g., red bags].) - Clean equipment used. Use a disinfectant solution.On 7/17/25 at 12:45 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R3:
According to R3's Electronic Health Record (EHR) the resident admitted to the facility with multiple diagnoses that included Intellectual Disabilities and altered Mental Status. The Pharmacist's Drug Reviews dated 5/6/24 and 7/2/24 indicated there were pharmacy recommendations and documented; Please take the following action described below. There was no further documentation to describe the recommendation of action from the Pharmacist.
On 8/28/24 at approximately 1:00 PM the Director of Nursing (DON) was asked where the Pharmacist's recommendations for R3 were. The DON reported that they were located in an office and were not part of the clinical record. The DON could not produce or determine what the pharmacist's recommendations on 5/6/24 or 7/2/24 for R3 were at this time.
On 8/28/24 at 3:30 PM the Regional Director of Operations (RDO) said the facility could not locate the actual Pharmacist's recommendations and the pharmacy was requested to fax them over to the facility. The RDO said, The Pharmacist reports and recommendations should be part of the resident's medical record and the physician should be notified of them.
On 8/29/24 at 9:00 AM the DON provided R3's pharmacy recommendations for 5/6/24 and 7/2/24. The pharmacy recommendation for 5/6/24 did not have any notation or signature by the physician or a physician extender to indicate they had been notified of the recommendations.
Review of the facility's policy titled, Pharmacy Medication Review revision date 8/2021 documented in part the following:
Guidelines:
1. The MRR should be conducted by a pharmacist with specialized training and clinical expertise to perform medication reviews.
2. The Medical Records Designee is responsible to the Director of Nursing for maintaining the Medical Records program.
3. The intent of a MRR is to address any clinically significant medication issues in a timely manner.
Procedure:
1. The MRR will be completed by a pharmacist on a monthly basis and as needed or required.
2. The pharmacist will submit a recommendation for each resident reviewed.
3. The recommendation will be submitted via email to the Director of Nursing (DON) and the Medical Records Designee within 48-72 hours of the review.
4. The Medical Records Designee will place all pharmacy recommendations on the attending physician's clipboard for review.
5. The physician/physician extender may agree or disagree with the pharmacy recommendation and must sign off on all recommendations. Once the pharmacy recommendation has been signed, a medication order must be created and added to the resident's Medication Administration Record (MAR), once the order is added the document should be returned to the attending physician ' s clipboard to be uploaded into the resident's EHR, by the Medical Records Designee. The Physician is required to provide a rationale for not agreeing with any pharmacy recommendations, and the rationale must be documented in a progress note or on the pharmacy recommendation
7. The Medical Records Designee is responsible for reporting any discrepancies/concerns to the DON and/or Medical Director in a timely manner, all emergency matters should be reported immediately.
8. The DON is responsible for overseeing the Pharmacy Recommendation process and reporting any discrepancies/concerns to the Medical Director and Administrator.
Based on interview and record review the facility failed to obtain and address Medication Regimen Review (MRR) recommendations timely for two residents (R3 and R12) of five residents reviewed for medication regimen review, resulting in the potential for the continuance of unnecessary medications and lack of communication of recommended medication changes between pharmacist and physician.
Findings include:
R12:
On 8/24/24 at 11:14 a.m. review of the clinical record documented R12 was admitted into the facility on 8/17/22 with diagnoses that included diabetes mellitus, type 2, acute respiratory failure with hypoxia, congestive heart failure, dementia, and asthma. According to the quarterly Minimum Data Set (MDS) dated [DATE], R12 had moderate cognitive impairment and dependent for most activities of daily living.
Review of R12's physician orders documented the resident's current medications as follows:
- Basaglar Kwik Pen U-100 Insulin (insulin glargine) 100 unit/mL (3 mL) inject 33 units subcutaneous daily. Start date 8/13/24.
- Insulin Aspart U (Novolog)-100 unit/ml inject 8 units subcutaneous twice a day. Start date 7/12/24.
- Metformin 1000 mg oral twice a day. Start date 6/6/24.
Review of monthly pharmacy recommendations in the electronic medical record documented the following:
-3/19/24- Pharmacist Drug Regimen Review . Please take the following action described below . See report:
Note to Attending Physician/Prescriber: This resident is currently on a sliding scale coverage with Novolog insulin. Recent AGS Beers Criteria suggest avoiding the use of a sliding scale insulin due to the risk of hypoglycemia without improvement in hyperglycemia management. Please evaluate if this patient may benefit from the addition of a long-acting insulin or an increase in their current medications. If the sliding scale insulin is continued, please provide documentation to support therapy.
Response: 1. Change sliding scale Insulin to . 2. Continue sliding scale insulin. The benefits outweigh the risks.
The Physician/Prescriber Response was blank. There was no documented response from the facility.
-4/2/24- Pharmacist Drug Regimen Review. There was no Recommendation made by facility.
-5/6/24- Pharmacist Drug Regimen Review. There was no Recommendation made by facility.
On 8/28/24 at 2:05 p.m. the Director of Nursing (DON) submitted an email from the pharmacist dated 8/28/24 at 1:33 p.m. the pharmacy recommendation for 3/19/24 was attempted to be updated in the electronic medical record. The DON said the recommendation had not been addressed because it was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for two (R3 and R12) of 15 residents reviewed for medical records, resulting in resident's pharmacy recommendations being unclear and not maintained in the resident's Electronic Health Record (EHR) with the potential for miscommunication of pharmacy recommendations, physician's orders, and an unclear picture of the resident's health care status.
Findings include:
R3:
According to R3's Electronic Health Record (EHR) the resident admitted to the facility with multiple diagnoses that included Intellectual Disabilities and altered Mental Status. The Pharmacist's Drug Reviews dated 5/6/24 and 7/2/24 indicated there were pharmacy recommendations and documented; Please take the following action described below. There was no further documentation to describe the recommendation of action from the Pharmacist.
On 8/28/24 at approximately 1:00 PM the Director of Nursing (DON) was asked where the Pharmacist's recommendations for R3 were. The DON reported that they were located in an office and were not part of the clinical record. The DON could not produce or determine what the pharmacist's recommendations for R3 were at this time.
On 8/28/24 at 3:30 PM the Regional Director of Operations (RDO) said the facility could not locate the actual Pharmacist's recommendations and the pharmacy was requested to fax them over to the facility. The RDO said, The Pharmacist's reports and recommendations should be part of the resident's medical record.
According to the facility's Pharmacy Medication Review policy last revised 8/2021 in part reads;
Purpose:
The purpose of a Pharmacy Medication Regimen Review (MRR) is to identify Medication-related problems and to provide a safe and effective medication treatment plan for all residents. Pharmacy recommendations will provide guidance to the interdisciplinary team and a thorough evaluation of the medication regimen for each resident, with the goal of promoting positive outcomes and minimizing adverse consequences related to medications. The review should include preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities as well as collaboration with other members of the interdisciplinary team.
Procedure:
5. The physician/physician extender may agree or disagree with the pharmacy recommendation and must sign off on all recommendations. Once the pharmacy recommendation has been signed, a medication order must be created and added to the resident ' s Medication Administration Record (MAR), once the order is added the document should be returned to the attending physician ' s clipboard to be uploaded into the resident ' s EHR, by the Medical Records Designee. The Physician is required to provide a rationale for not agreeing with any pharmacy recommendations, and the rationale must be documented in a progress note or on the pharmacy recommendation.
R12:
On 8/24/24 at 11:14 a.m. review of the clinical record documented R12 was admitted into the facility on 8/17/22 with diagnoses that included diabetes mellitus, type 2, acute respiratory failure with hypoxia, congestive heart failure, dementia, and asthma. According to the quarterly Minimum Data Set (MDS) dated [DATE], R12 had moderate cognitive impairment and dependent for most activities of daily living.
Review of monthly pharmacy recommendations in the electronic medical record documented the following:
3/19/24- Pharmacist Drug Regimen Review . Please take the following action described below . See report.
6/4/24- Pharmacist Drug Regimen Review . Please take the following action described below . See report.
The pharmacy recommendation reports were not readily available in the electronic medical record and the facility had to search for them.
On 8/28/24 at 2:05 p.m. the Director of Nursing (DON) submitted an email from the pharmacist dated 8/28/24 at 1:33 p.m. for the pharmacy recommendation dated 3/19/24 that read an attempt was made to update in the electronic medical record.

Based on observation, interview, and record review the facility failed to practice proper infection control techniques for one (R4) of one resident reviewed with enhanced barrier precautions, resulting in the potential for widespread infection.
Findings include:
08/28/24 at 2:15 PM, R4 was observed to be returned to bed for brief changed and wound care. Registered Nurse, (RN) O and Certified Nursing Assistant, (CNA) S were observed to perform care on R4 without wearing a gown.
Review of R4 Electronic Medical Record, (EMR) noted an admission date to the facility on 2/16/24 with a pertinent diagnosis of Stage II to buttocks. R4's Brief Interview of Mental Status, (BIMS) score was 14/15 (intact cognition).
08/28/24 at 2:25 PM, RN O was interviewed and acknowledged staff should have been wearing a gown. Unit Manager, UM R was interviewed and added there was a sign on the door and the staff should have been wearing a gown when performing change of brief as well as wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00138801.
Based on interview and record review, the facility failed to seek timely medical evaluation of an injury of unknown origin for one resident (R102), out of three residents reviewed for falls, resulting in the potential for delay in the provision of resident care needs.
Findings include:
The State Agency received a complaint that the resident fell, and the facility failed to seek timely medical evaluation and treatment.
A review of Resident #102's (R102) clinical record documented an admission date of 1/18/2020. R102's diagnoses included Alzheimer's Disease, Atrial Fibrillation, and Diabetes Mellitus-Type 2. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A review of R102's care plans documented resident was at risk for falls due to muscle weakness and diagnosis of dementia with a start date of 7/20/2023.
A review of nursing notes documented the following:
- Date/time: 8/3/2023 at 4:48 AM: Resident was pleasant and cooperative with staff. All medications administered as ordered. Resident observed walking in the hall at 4:00 AM, was naked from the waist down. CNA (Certified Nurse Aide) went and retrieved a brief, bottoms, and socks for him. Upon putting the garments on resident, CNA called me to come look at resident's skin. Resident has purple bruising that encompasses his left buttocks and down the back of his left leg to behind his knee. Resident does not remember falling or how the bruising occurred. Continue with current POC (plan of care) and monitor skin.
- Date/time: 8/3/2023 at 3:49 PM: Resident has c/o (complaint of) waist and left hip pain 5/10 while wife in room. Wife is aware of the bruise on this resident. Purple bruising in his left buttocks and down the back of his left leg to behind his knee reported to (R102's Physician), ordered to transfer resident to (local hospital emergency room) for further evaluation and treatment as resident is on (apixaban: a blood thinner that reduces blood clotting). Resident does not remember falling or how the bruising occurred. (Medical transportation) called, awaiting pick up. Endorsed to assigned nurse to follow-up at this time.
A review of a facility document titled, Staff Statement of Event, dated 8/3/2023, CNA M acknowledged the following: On Wednesday, 8/2/2023 during 3p - 11p shift, I gave shower to (R102). I saw a big bruise around his butt and thigh (bottom). Asked him if he fell. He answered No. What happened? He did not know. I reported to the nurse (Nurse N) about it.
An interview and record review were conducted with Registered Nurse (RN) C on 9/11/2023 at 3:47 PM. RN C was designated as the Charge Nurse in the absence of the Director of Nursing (DON). A review of R102's clinical record and witness statements documented that on the afternoon shift of 8/2/2023, CNA M observed a bruise on R102's body and reported it to the nurse. RN C said that when the nurse knew about R102's bruises that she should have called and notified the doctor, DON, and family, obtained an order for a stat x-ray, and told R102 to stay in bed to potentially prevent further injury. RN C stated, It's not good that they waited that long, because if he had broken his hip, he could have fallen again. There is no reason (R102) should have had to wait until the next day to get an x-ray. Record review revealed the DON created a stat x-ray order on 8/3/2023 at 3:19 PM of R102's right and left hip and lumber spine related to pain.
During an interview on 9/11/2023 at 4:28 PM, the Nursing Home Administrator (NHA) acknowledged there was a delay in the initiation of an assessment of R102's bruising. The nurse should have reported it to the physician to see how to proceed.
On 9/11/2023 at 5:45 PM, during the exit conference, the NHA was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and no substantially new information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains To Intake #MI000135054
Based on observation, interview and record review, the facility failed to ensure the protection of residents and thoroughly investigate allegations of abuse for one (Resident #9) of 5 reviewed for abuse, resulting in the potential for further abuse to occur and allegations of abuse not being thoroughly investigated.
Resident #9
According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 9 (R9) was a [AGE] year old male admitted [DATE] with diagnosis that included Parkinson's disease and depression. Further review of the MDS reflected R9 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status.
On 08/09/23 at 09:00 AM, R9 was interviewed in his room, R9 was observed sitting in his recliner. R9 was engaging and articulate when queried about former facility employee Licensed Practical Nurse (LPN) D, R9 winced and made a grimaced facial expression. R9 further reported LPN D was not very nice, he had a very evil attitude and was rough. R9 further reported he had made several complaints to multiple staff members (unable to recall names) about LPN D being mean.
On 08/08/23 at 07:32 AM, during an interview with Director of Nursing (DON) B she confirmed that several residents had complained that LPN D Was not nice. DON B further elaborated that LPN D was terminated due complaints of being too rough with residents. When queried if the allegation was investigated and reported to the State Agency, DON B stated that was a question for the Nursing Home Administrator (NHA) A.
On 08/08/23 at 07:50 AM, during an interview with NHA A she reported LPN D no longer works at the facility and she would have find the investigation as she could not recall any details. It was requested to review the facility's investigation on abuse that pertained to R9 and LPN D at that time.
On 08/08/23 at 09:20 AM, during an interview with NHA A and Regional Director of Operations (RDO) H a second request was made to provide the investigation of alleged abuse that involved R9. RDO H provided one written statement, authored by Dietary Aide G which reflected and stated the facility abuse coordinator was Social Worker/Activity Director C. At this time, writer approached Social Worker/Activity Director C whom reported she had no further information or documents that pertained to R9's allegation of abuse.
On 08/08/23 at 01:32 PM , additional type written undated document that listed six resident names was provided and stated States no concerns at this time. A separate statement dated 2/22/23 was provided. The signature was not legible nor did it have a title along with a typed statement dated 2/22/23 that reflected on 2/21/23 that R9 alleged LPN D was mean and rough with him, shoved medications in his mouth, was rough and forced him back to bed. The following page of the document was signed by Social Worker/Activity Director/facility abuse coordinator C, and revealed a statement that she recommended (list of 3 names of unsampled residents) past concerns be re-reviewed along with the statement from a former employee whom mentioned LPN D and a fourth unidentified resident in her resignation letter. There was no additional interviews with other midnight staff and no signed or written statement from LPN D. NHA A and RDO H were probed about the undated documents and the 6 hour time lapse to produce them along with no additional statements/interviews from the midnight shift where the allegation initiated. RDO H stated she was not really convinced that rough or being mean constituted an actual abuse allegation, thus additional interviews may not have been required. RDO H further reiterated that the State Agency rules were going to ease up on the abuse topic according to a recent training she had attended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #26 (R26)
Review of the medical record revealed R26 admitted to the facility on [DATE] with diagnoses that included muscle weakness, cellulitis, protein-calorie malnutrition, convulsions, anxiety, pressure ulcer, hypotension, diabetes, and seizures.
Review of the progress note dated 7/4/23 revealed R26 was transferred to the hospital for a blood transfusion. There was no documentation of a written transfer notice.
In an interview on 08/08/23 at 11:20 AM, Director of Nursing (DON) B reported R26 did not receive a written notice of transfer because the transfer was an emergency.
Based on observation, interview, and record review, the facility failed to provide the resident and/or resident's representative a written reason of transfer to a hospital for 2 (Resident #9 and #23) of 2 residents reviewed for transfer/discharge, resulting in the potential of residents and/or family being un-informed of the reason for transfer.
Findings include:
Resident #9
Review of the medical record reflected that Resident #9 (R9) was readmitted to facility 4/28/23 with diagnoses including syncope and collapse, muscle weakness, Parkinson's Disease, and pulmonary fibrosis. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) Of 6/7/23 reflected that R9 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact). Review of the Discharge MDS dated [DATE] reflected that R9 had an unplanned discharge to an acute care hospital and that his return to the facility was anticipated.
In an observation and interview on 8/07/23 at 10:10 AM, R9 was observed in a bedside chair with back of chair reclined and legs elevated. R9 stated that he was originally admitted to the facility toward the end of 2022, had been hospitalized a few months back and then returned to the facility, and did not think that he had received a written notice pertaining to the hospital transfer.
Review of all progress notes dated 4/25/23 indicated that R9 was transferred to the hospital for increased pain with no indication within any of the notes that a written notice of hospital transfer was provided to R9 at the time of his 4/25/23 hospital transfer.
In an interview on 8/8/23 at 11:21 AM, Director of Nursing (DON) B stated that upon transfer a copy of a resident's face sheet, current labs and medication list would be sent to the hospital with the resident and that with a nonemergent transfer, family would be contacted prior to the transfer but that with an emergent transfer, would send the resident out first and then contact the family.
Upon review of R9's medical record surrounding the 4/25/23 hospital transfer, DON B confirmed R9's hospital transfer on that date, stated that verbal communication was provided to the resident and family regarding reason for the transfer but that there was no evidence that a written transfer notice was provided to R9 at the time of transfer as stated unfortunately an agency nurse completed that transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify the resident and/or resident's representative of the facility's policy for bed hold for two (Resident #9 and Resident #26) of two reviewed resulting in the potential of residents and/or representatives to be uninformed of the bed hold policy.
Findings include:
Resident #26 (R26)
Review of the medical record revealed R26 admitted to the facility on [DATE] with diagnoses that included muscle weakness, cellulitis, protein-calorie malnutrition, convulsions, anxiety, pressure ulcer, hypotension, diabetes, and seizures.
Review of the progress note dated 7/4/23 revealed R26 was transferred to the hospital for a blood transfusion. There was no documentation that a bed hold policy was provided upon transfer.
In an interview on 08/08/23 at 11:20 AM, Director of Nursing (DON) B reported R26 did not receive a bed hold notice because the transfer was an emergency.
Resident #9 (R9)
Review of the medical record reflected that Resident #9 (R9) was readmitted to facility 4/28/23 with diagnoses including syncope and collapse, muscle weakness, Parkinson's Disease, and pulmonary fibrosis. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) Of 6/7/23 reflected that R9 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact). Review of the Discharge MDS dated [DATE] reflected that R9 had an unplanned discharge to an acute care hospital and that his return to the facility was anticipated.
In an observation and interview on 8/07/23 at 10:10 AM, R9 was observed in a bedside chair with back of chair reclined and legs elevated. R9 stated that he was originally admitted to the facility toward the end of 2022, had been hospitalized a few months back and then returned to the facility, and did not think that the facility's bed hold policy had been reviewed with him prior to the hospital transfer.
Review of progress notes dated 4/25/23 indicated that R9 was transferred to the hospital for increased pain with no indication within any of the notes that a bed hold policy had been reviewed with or provided to R9 at the time of his 4/25/23 hospital transfer.
During a review of R9's medical record on 8/8/23 at 11:21 AM, Director of Nursing (DON) B confirmed R9's hospital transfer on 4/25/23, stated that verbal communication was provided to the resident and family regarding reason for the transfer but that there was no evidence that the facility's bed hold policy was reviewed with or provided to R9 at the time of transfer as stated unfortunately an agency nurse completed that transfer.
Review of the facility policy titled Bed Hold Policy with a revised/reviewed date of 1/4/2020 stated, Purpose/Objective .Bed Hold for residents requiring hospitalization or leave of absence .Procedure/Guidelines/Protocol .B. A copy of the bed hold policy will be sent with the resident to the hospital .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed complete a comprehensive assessment for one (Resident #139) of 12 reviewed, resulting in the potential for unmet care needs.
Findings include:
Review of the medical record revealed Resident #139 (R139) admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, diabetes, Parkinson's Disease, stage 4 pressure ulcer, and osteomyelitis of vertebra sacral and sacrococcygeal region.
On 8/8/23 at 7:25 AM, R139 was observed asleep in bed with a wound vac in place.
Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/30/23 revealed the MDS was in process, incomplete, and not submitted. R139 did not have a completed MDS assessment since admission.
In a telephone interview on 8/8/23 at 3:27 PM, MDS Coordinator M reported she had completely missed R139's comprehensive admission MDS. MDS Coordinator M reported R139's MDS was due by 5/6/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00132462 and MI00135054.
Based on observation, interview, and record review, the facility failed maintain sufficient staff for one (Resident #2) and Resident Council, resulting in extended call light response times and the potential for unmet care needs.
Findings include:
Review of the Resident Council minutes revealed on 2/21/21, 5/30/23, and 6/27/23, the Resident Council expressed concerns with call light response times.
During a Resident Council meeting on 08/08/23 at 1:35 PM, five of the six residents responded when asked about staffing and call light response time. Four of the five residents who participated in the discussion expressed concerns with staffing and extended call light response times. The Resident Council participants reported waiting up to one hour for staff to respond to their call lights. They reported staff seemed rushed and did not have time to stop and ask if the residents needed anything.
Resident #2 (R2)
Review of the medical record revealed R2 admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, anxiety, and acquired absence of right upper limb. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/11/23 revealed R2 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and was dependent on staff for activities of daily living.
On 08/07/23 at 11:15 AM, R2 was observed lying in his bed. R2 reported he would like to get up in his wheelchair more often. R2 reported he informed staff earlier that morning that he wanted to get up, but staff had still not assisted him.
On 08/08/23 at 09:33 AM, R2 was observed lying in bed. R2 reported he needed to have a bowel movement and had told staff earlier, but he had not heard back from staff yet. R2 then turned on his call light. Continuous observations until 10:10 AM revealed no facility staff were present on R2's end of the hallway. At 10:11 AM, a staff member answered R2's call light. The call light had been on for 38 minutes.
In an interview on 08/09/23 at 08:51 AM, Director of Nursing (DON) B reported the expectation was that call lights were answered immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician received, reviewed and acted upon identified medication regimen irregularities for four residents (Resident #9, 16, 17, and 35) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions.
Resident #16 (R16)
According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident 16 (R16) was an [AGE] year old male admitted to the facility with diagnoses that included heart peripheral vascular disease and diabetes. Review of MDS reflected R16 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. Further review of the medical record including the Pharmacy reviews and revealed the Pharmacist had found irregularities and had made recommendations for the Physician on 5/07/23, 06/01/23 and 07/05/23 .
Resident #17 (R17)
According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident 17 (R17) was an [AGE] year old female admitted to the facility with diagnoses that included heart failure and diabetes. Review of MDS reflected R17 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. Further review of the medical record including the Pharmacy reviews and revealed
the Pharmacist had found irregularities and had made recommendations for the Physician on 03/05/23, 5/07/23 and 06/01/23.
On 08/07/23 at 03:40 PM, during an interview with the Director of Nursing (DON) B she reported she was not aware of where the pharmacy reports were located for R16 and R17 and would have to follow up.
On 08/08/23 at 07:36 AM, DON B reported in an interview that she had to contact pharmacy and the would send the missing reports/recommendations for R16 and R17 later today. DON B stated the former Unit Manager was responsible for this task and has since resigned. DON B elaborated she did not see any progress notes or order changes that may coincide with pharmacy report dates, and could not account for what any of the pharmacists findings were.
Resident #35 (R35)
Review of the medical record revealed R35 admitted to the facility on [DATE] with diagnoses that included fracture of the left shoulder, muscle weakness, multiple myelomoa, and pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/23 revealed R35 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS).
Review of the Physician's Order dated 5/16/23 revealed R35 had an order for Cymbalta for major depressive disorder.
Review of the Pharmacist Drug Regimen Review dated 4/5/23 revealed see report under please take the following action described below.
On 08/08/23 at 07:44 AM, Director of Nursing (DON) B was asked for the report for R35's medication regimen review on 4/5/23. On 08/08/23 at 11:16 AM, DON B reported she was not able to get the recommendation from the pharmacy yet and was still waiting for pharmacy to fax it to the facility. R35's medication regimen review recommendation from 4/5/23 was not received prior to the survey exit.
Resident #9 (R9)
Review of the medical record reflected that Resident #9 (R9) was readmitted to facility 4/28/23 with diagnoses including syncope and collapse, muscle weakness, Parkinson's Disease, Diabetes Mellitus, peripheral vascular disease, chronic anemia, and pulmonary fibrosis. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) Of 6/7/23 reflected that R9 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact).
Review of the medical record revealed Pharmacist Drug Regimen Reviews dated 3/5/23, 5/7/23, and 6/1/23 which indicated see report under please take the following action described below. Further review of R9's medical record included no scanned documents nor nursing or physician progress notes on or around the indicated dates to reflect that the recommendations were addressed by either a nurse or physician.
In an interview on 8/8/23 at 3:43 PM, Director of Nursing (DON) B stated that a prior nurse manager had coordinated the completion of the monthly medication regimen reviews up until her resignation two weeks ago and that the manager would print and forward the recommendations to the nurse assigned to the resident for completion. DON B stated that the expectation was for that nurse to then review the recommendation with the physician and write an order and a corresponding nursing progress note to reflect any changes. Per DON B, the completed recommendation would then be signed by the physician and scanned into the electronic medical record.
Upon review of both R9's electronic medical record and paper chart, DON B confirmed that the pharmacy reviews/recommendations could not be located within the scanned documents or paper chart, verbalized unawareness of where the reports were, and stated that she would have to contact the pharmacy for the prior recommendations. R9's medication regimen reviews dated 3/5/23, 5/7/23, and 6/1/23 were not received prior to survey exit.
Review of the policy titled Organizational Aspects-The Consultant: Medication Regimen Review (Monthly Report) with an effective date of 3/1/2018 stated, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly .Findings and recommendations are reported to the director of nursing and the attending physician .H .Recommendations are acted upon and documented by the facility staff and or the prescriber .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review , the facility failed to ensure as needed psychotopic medication was not prescribed for longer than 14 days for one resident (#16) of 5 reviewed for unnecessary medications, resulting in the potential for unnecessary psychotropic medications and adverse reactions.
According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident 16 (R16) was an [AGE] year old male admitted to the facility with diagnoses that included heart peripheral vascular disease and diabetes. Review of MDS reflected R16 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status.
Review of monthly Physician orders reflected an anti-anxiety medication was ordered on 4/28/23 on an as needed basis, the Physician order did not have a stop date.
On 08/08/23 at 09:06 AM, during an interview with Social Worker/Activity Director C, she reported she worked with the psychiatric group that comes to the facility and Nursing staff. When further questioned about stop dates after 14 days for as needed psychotropic medications Social Worker/Activity Director C stated she was not aware of the regulation. Additional documentation to support the use of as needed antianxiety medication was requested but not received by the survey exit date of 08/09/23.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when two medication errors were observed from a total of twenty-eight opportunities for two residents (Resident #16 and #17) of five reviewed for medication administration, resulting in a medication error rate of 7.14% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects.
Findings include:
Resident #17 (R17)
Review of the medical record revealed that Resident #17 (R17) was readmitted to facility on 6/16/23 with diagnoses including diabetes mellitus. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/20/23 revealed that R17 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 13 (cognitively intact). Section N, of the same MDS, revealed that R17 had received insulin injections on 3 of the days since her 6/16/23 facility readmission. Further review of R17's medical record revealed an order dated 6/21/23 for Novolog FlexPen Insulin four times daily per sliding scale.
On 8/8/23 at 11:47 AM, Licensed Practical Nurse (LPN) L was observed to prepare R17's Novolog Insulin FlexPen for administration which included pen removal from medication cart, cap removal from pen, application of disposable needle after cleansing of the rubber hub at the tip of the pen with an alcohol swab and dialing of the pen to 3 units based on the insulin sliding scale order. LPN L was then observed to enter R17's room, wash hands, place gloves, cleanse R17's right upper abdominal area with an alcohol swab and inject the insulin. At no time prior to R17's insulin administration was LPN L observed to prime (remove the air from the pen vial) the pen. LPN C then proceeded to document the insulin as given on the paper medication administration record (MAR).
Review of R17's MAR dated 8/1/23 through 8/31/23 revealed that LPN L had signed out administration of insulin via Novolog FlexPen two times on 8/3, 8/4, and 8/7 and one time thus far on 8/8.
Resident #16 (R16)
Review of the medical record revealed that Resident #16 (R16) was readmitted to facility 11/18/22 with diagnoses including diabetes mellitus. Review of the MDS with an ARD of 4/12/23 revealed that R16 had a BIMS score of 13 (cognitively intact). Section N, of the same MDS, revealed that R16 received insulin injections on each of the prior 7 days. Further review of R16's medical record revealed an order dated 11/18/22 for Lispro KwikPen three times daily before meals.
On 8/8/23 at 12:09 PM, LPN L was observed to prepare R16's Lispro Insulin KwikPen for administration which included pen removal from medication cart, cap removal from pen, application of disposable needle after cleansing of the rubber hub at the tip of the pen with an alcohol swab and dialing of the pen to 10 units. LPN L was then observed to enter R16's room, wash hands, apply gloves, cleanse R16's left lower abdominal area with an alcohol swab and inject the insulin. At no time prior to R16's insulin administration was LPN L observed to prime the pen. LPN C then proceeded to document the insulin as given on the paper medication administration record (MAR).
Review of R16's MAR dated 8/1/23 through 8/31/23 revealed that LPN L had signed out administration of insulin via Lispro KwikPen two times on 8/3, 8/4, and 8/7 and one time thus far on 8/8.
In an interview on 8/8/23 following the administration of both R16's and R17's insulin, LPN L confirmed that the observed insulin pen preparation was her normal routine, denied ever completing an additional step in between application of the disposable needle and dialing of the pen to the ordered number of units, and denied knowledge of what priming an insulin pen entailed as stated, No one has ever taught me that. I'm sorry. I will find out what that means.
In an interview on 8/8/23 at 1:01 PM, Director of Nursing (DON) B stated that the procedure for insulin pen preparation included removing cap to insulin pen, cleansing the top of the pen with an alcohol swab, applying the disposable needle, priming the needle with 2 units of insulin while holding the pen in an upright position, and then dialing the pen to the ordered number of units.
Review of the facility policy titled Insulin Administration with an effective date of 9/2018 stated, Purpose .To provide guidelines for the safe administration of insulin to residents with diabetes .5. The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use .Insulin Delivery .3. Pens-containing insulin cartridges deliver insulin subcutaneously through a needle.
Further review of the policy was noted to include steps involved in preparing and administering insulin via syringe but was not noted to include steps in preparing an insulin pen for administration. On 8/8/23 at 9:39 AM, Nursing Home Administrator A was requested to provide a facility policy which included the steps for insulin pen preparation and administration with no additional documents provided prior to survey completion.

Based on interview and record review, the facility failed to dispose of expired medications in one of two medication carts and two of two medication rooms reviewed, resulting in the potential for decreased medication efficacy and adverse side effects in a current facility census of 34 residents.
Findings include:
On 8/8/23 at 8:49 AM, Station 3 Medication Room was reviewed in the presence of Director of Nursing (DON) B. During the review, it was noted that the medication refrigerator within the medication room contained a Tuberculin Purified Protein Derivative box with a handwritten open date of 7/6/23. An open, undated Tuberculin vial was noted within the box. DON B confirmed the 7/6/23 open date indicated on the box, stated that Tuberculin was good for thirty days after opening, and therefore would have expired on 8/5/23 and would be disposed of immediately. Station 1 Medication Room was reviewed, also in the presence of DON B, immediately following Station 3 review with a second Tuberculin Purified Protein Derivative box with a handwritten open date of 7/6/23 and an open, undated Tuberculin vial within noted. DON B again confirmed the 7/6/23 open date, reiterated that it was also expired, and would be disposed of.
On 8/8/23 at 9:17 AM, Station 1 Medication Cart was reviewed in the presence of Licensed Practical Nurse (LPN) L. During the review, a Fluticasone Propionate-Salmeterol Inhaler (Advair HFA) was noted with a pharmacy label reflecting R8's name and a handwritten open date of 5/10/23 on both the opened box and the inhaler. LPN L confirmed that R8 had an active order for the Advair Inhaler, stated that she was not positive how long the inhaler was good for after opening, but would be disposing of the current inhaler and ordering a new one from the pharmacy.
Review of R8's medical record revealed an active order dated 4/24/23 for Fluticasone Propionate-Salmeterol Inhaler with twice daily administration. Review of the corresponding Medication Administration Record (MAR) dated 8/1/2023-8/31/2023, reflected twice daily administration on 8/1, 8/2, and 8/7 and once daily on 8/3, 8/4, 8/5, and 8/8.
During the same Station 1 Medication Cart review in presence of LPN L, a Fluticasone Propionate Nasal Spray was noted with a pharmacy label reflecting R16's name and a handwritten open date of 5/11/23 on the box. An open, undated nasal spray bottle was noted within the box. LPN L confirmed that R16 had an active order for the nasal spray and although she did not know how long the nasal spray was good for after opening, would be disposing of the open bottle. An unopened bottle of Fluticasone Propionate Nasal Spray with a pharmacy label reflecting R16's name was noted within the medication cart.
Review of R16's medical record revealed an active order dated 6/5/23 for Flonase Allergy Relief (Fluticasone Propionate) Nasal Spray with daily administration. Review of the corresponding MAR dated 8/1/2023-8/31/2023 reflected daily administration from 8/1/23 - 8/8/23.
Additionally, during the same Station 1 Medication Cart review, a Fluticasone Propionate Nasal Spray was noted with a pharmacy label reflecting R11's name and a handwritten open date of 4/28/23 on both the box and nasal spray bottle. LPN L confirmed that R11 had an active order for the nasal spray, reiterated that she was uncertain how long the opened nasal spray was good for, but would be disposing of and ordering a new bottle from the pharmacy.
Review of R11's medical record revealed an active order dated 5/17/23 for Flonase Allergy Relief (Fluticasone Propionate) Nasal Spray with twice daily administration. Review of the corresponding MAR dated 8/1/2023-8/31/2023 reflected twice daily administration 8/1/23-8/6/23 and the morning dose on 8/7/23.
In an interview on 8/8/23 at 9:42 AM, DON B stated that she was unsure of how long both the Fluticasone Nasal Spray and Advair Inhaler were good for after opening but would check the facility policy for that information. DON B further stated that it was an expectation that every nurse monitor expiration dates prior to that medications administration and dispose of accordingly and that the night shift nurse routinely completed medication cart audits to double check that medications remained within the expiration date.
Review of the facility policy titled Storage of Medications with an effective date of 9/2018 stated, Policy Statement .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Policy Interpretation and Implementation .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .a. The nursing staff will date all inhalers, eye drops, ointments, nasal sprays, and insulin immediately after opening b. Medication is expired after the last day of the designated time frame for each medication .Inhalers-30 days from date of opening or manufacturers expiration date, whichever comes first .Nasal Sprays .30 days from date of opening or manufacturers expiration date, whichever comes first .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer pneumococcal immunizations in accordance with the Center for Disease Control and Prevention (CDC) recommendations for two residents (#1, #23) of five residents reviewed resulting in the potential for server illness and complications from pneumococcal disease
Findings Included:
Resident #1 (R1)
Review of the medical record revealed R1 admitted to the facility on [DATE] with diagnoses that included muscle weakness, hemiplegia and hemiparesis, osteoarthritis, insomnia, anxiety, and pseudobulbar affect. The Minimum Data Set (MDS) with an Assessment Reference Date of 7/9/23 revealed R1 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS).
Review of R1's medical record demonstrated that she had received pneumococcal vaccination, PCV13, on 10/11/2017. No documentation of PCV20 or PPS23 vaccinations were offered or provided to resident R1.
According to CDC (Center for Disease Control and Prevention) guidelines on PneumoRecs Vax Advisor PCV20 or PPS23 at least once year after PCV13. No documentation of PCV20 or PPS23 vaccinations were offered or provided to resident R1.
During observation on 08/09/23 02:29 p.m., R125 observed lying down in bed. Visiting with family.
Resident #23 (R23)
Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed.
Review of R23's medical record demonstrated that she had received pneumococcal vaccination, PPSV23, on 09/20/2017. No documentation of PCV15 or PCV20 had been offered or provided to resident R23.
According to CDC (Center for Disease Control and Prevention) guidelines PneumoRecs Vax Advisor - give one does of PCV 15 or PCV20 at least one year after the last does of PPSV23
During observation and attempted interview on 08/08/2023 at 08:11 a.m. R23 was observed sitting up in her w/c, in her room. During attempted interview with resident responded oh to questions and nodded head. She also would start talking in a foreign language.
In an interview on 08/09/2023 at 11:21 a.m. Infection Control Preventionist (ICP) AA explained that she coordinated the vaccinations for all residents at the facility. She explained that pneumococcal vaccinations are offered to the residents. ICP AA explained that each resident is given or offered pneumococcal immunization based on CDC (Center for Disease Control) guidelines. ICP AA reviewed R1 and R23 pneumococcal vaccination status. She explained that R1 and R23 were in compliance with CDC guidelines. ICP AA was shown guidelines of CDC Pneumovac Vax Advisor for resident R1 and R23. She explained that she did not have those current guidelines for pneumococcal vaccination.

Based on observation, interview, and record review the facility failed to ensure monitoring and inspection of resident bed frames and mattress for one resident (#23) of one resident reviewed for bed safety resulting in the potential for entrapment, injury, or death.
Findings Included:
Resident #23 (R23)
Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed.
During observation and attempted interview on 08/07/2023 at 10:08 a.m. R23 was observed lying in bed. R23 did not respond to verbal questions. R23's left side of the bed was pushed up against the wall and bed had an assist bar visible on both sides of the bed.
During record review, R23's the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, section P (physical restraint) demonstrated that she did not have any physical restraints. According to the MDS physical restraints are any manual method or physical or mechanical devices, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Section G (functional status) of the MDS, with the same ARD, demonstrated that R23 required limited one person assist with bed mobility and limited assistance with transfer. Review of R23's plan of care did not demonstrate the use of bilateral assist bars. No physician order was present for the bilateral assist bars. No therapy evaluation for appropriate use of bilateral assist bars was present in the medical record. No consent for the use of bilateral assist bars was present in the medical record. No documentation regarding the risk and benefits of the bilateral assist bars were present in the medical record.
In an interview on 08/09/2023 at 08:51 a.m. Director of Nursing (DON) B explained that if assist bars were used with a resident it would require an assessment, a consent (that would explain risk and benefits) and would be included in the plan of care. DON B explained that R23 did not have bilateral assist bars present on her bed. DON B was asked to go an observe with surveyor.
During observation and interview on 08/09/2023 at 08:54 a.m. in R23's room, with DON B present, R23's left side of the bed was pushed against the wall and bilateral assist bars were present. DON B explained that bilateral assist bars should not be on the bed. She also explained that the consent was not present, the care plan was not updated, and an assessment of bilateral assist bars was not completed. DON B could not explain why bilateral assist bars were present on R23's bed. DON B was asked to provide copies of the bed monitoring and measurements for R23's bed which had bilateral assist bars present. DON B explained that she could not provide that documentation or demonstrated that they had been conducted as R23 was not suppose to have bilateral assist bars present.

Based on observation, interview, and record review the facility failed to assure safe and appropriate use of bed rail assist bars for one resident (#23) of one resident reviewed for bed safety resulting in the potential for entrapment, injury, or death.
Findings Included:
Resident #23 (R23)
Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed.
During observation and attempted interview on 08/07/2023 at 10:08 a.m. R23 was observed lying in bed. R23 did not respond to verbal questions. R23's left side of the bed was pushed up against the wall and bed had an assist bar visible on both sides of the bed.
During record review, R23's the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, section P (physical restraint) demonstrated that she did not have any physical restraints. According to the MDS physical restraints are any manual method or physical or mechanical devices, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Section G (functional status) of the MDS, with the same ARD, demonstrated that R23 required limited one person assist with bed mobility and limited assistance with transfer. Review of R23's plan of care did not demonstrate the use of bilateral assist bars. No physician order was present for the bilateral assist bars. No therapy evaluation for appropriate use of bilateral assist bars was present in the medical record. No consent for the use of bilateral assist bars was present in the medical record. No documentation regarding the risk and benefits of the bilateral assist bars were present in the medical record.
In an interview on 08/09/2023 at 08:51 a.m. Director of Nursing (DON) B explained that if assist bars were used with a resident it would require an assessment, a consent (that would explain risk and benefits) and would be included in the plan of care. DON B explained that R23 did not have bilateral assist bars present on her bed. DON B was asked to go an observe with surveyor.
During observation and interview on 08/09/2023 at 08:54 a.m. in R23's room, with DON B present, R23's left side of the bed was pushed against the wall and bilateral assist bars were present. DON B explained that bilateral assist bars should not be on the bed. She also explained that the consent was not present, the care plan was not updated, and an assessment of bilateral assist bars was not completed. DON B could not explain why bilateral assist bars were present on R23's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #16 (R16)
According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident 16 (R16) was an [AGE] year old male admitted to the facility with diagnoses that included heart peripheral vascular disease and diabetes. Review of MDS reflected R16 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. Further review of the medical record including the monthly Physician orders reflected R16 was started on an anti-anxiety medication on as as needed basis on April 28, 2023 with no stop date.
Review of R16's care plan dated 7/13/23 reflected R16's problem for the care plan was a diagnosis of anxiety with a goal of stabilize/improve mood and approaches were 1. appropriate referrals 2. encourage activities of interest. 3 explain all procedures of care calmly. 4. identify possible stressors to resident that need to be eliminated . 5. maintain medications as ordered. 6. Offer support and encouragement as needed.
On 08/08/23 at 09:06 AM, during an interview with Social Worker/Activity Director C, R 16's care plan was reviewed and Social Worker/Activity Director C agreed it was not personal or individualized, such as what is an appropriate referral, what are R16's activities of interest, what are R16's triggers/stressors, what medications as ordered.
Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for 7 (Resident #6, #9, #16, #35, #139, #188, and #189) of 12 reviewed resulting in the potential for unmet care needs.
Findings include:
Resident #35 (R35)
Review of the medical record revealed R35 admitted to the facility on [DATE] with diagnoses that included fracture of the left shoulder, muscle weakness, multiple myelomoa, and pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/23 revealed R35 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS).
Review of R35's care plans revealed an intervention dated 5/17/23 for Physical Therapy for 12 weeks and Occupational Therapy for 09 days. An intervention dated 5/12/23 revealed R35 was doing exercises with restorative.
In an interview on 08/08/23 at 08:25 AM, Certified Occupational Therapy Assistant (COTA) O reported R35 was not receiving therapy services, and he believed R35 was receiving restorative services. COTA O reported R35 was evaluated by therapy on 5/17/23, but insurance would not cover skilled services.
In an interview on 08/08/23 at 11:03 AM, Director of Nursing (DON) B reported R35 was not on restorative services.
Review of the Physician's Order dated 5/16/23 revealed R35 had an order for Cymbalta for major depressive disorder.
R35's care plans did not mention that he had major depressive disorder or that he was utilizing a psychotropic medication.
Resident #139 (R139)
Review of the medical record revealed R139 admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, diabetes, Parkinson's Disease, stage 4 pressure ulcer, and osteomyelitis of vertebra sacral and sacrococcygeal region.
On 8/7/23 at 10:25 AM, incontinence care and wound care were observed for R139. R139 had a stage 4 pressure ulcer present on her coccyx. R139 had a wound vac.
Review of R139's care plans revealed there was no mention of a stage 4 pressure ulcer or wound vac.
In an interview on 08/08/23 at 2:48 PM, Licensed Practical Nurse (LPN) P reported she was the facility's wound nurse. LPN P reported R139 had a stage 4 pressure ulcer and a wound vac. LPN P agreed R139's pressure ulcer and wound vac were not care planned.
Resident #6 (R6)
Review of the medical record revealed R6 was admitted to the facility 05/04/2023with diagnoses that included compression fracture of T(thoracic) 6-T7 vertebrae, muscle weakness, age related physical disability, iron deficiency anemia, pain, hypertension, gastro-esophageal reflux, chronic kidney disease, hypokalemia (low potassium), hypomagnesaemia (low magnesium), anxiety, depression, bipolar disorder, stage 3 pressure ulcer of left buttock, protein-calorie insufficiency, atherosclerosis (cholesterol plaque in the walls of arteries), hyperlipidemia (high fat amount in blood), and chronic obstructive pulmonary disease (COPD). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/21/23, revealed R6 Brief Interview of Mental Status (BIMS) was not completed as resident is rarely understood. Section M-Skin Conditions, with the same ARD, demonstrated that R6 had unhealed pressure ulcers.
Review of the medical record revealed wound progress notes, dated 05/09/2023 at 03:22 p.m., that demonstrated, Coccyx with stage 2 open area that measures 1.0 cm (centimeters) length by 0.2 cm width, pink base, scant serosanguinous drainage. Review of R6's plan of care did not demonstrate that she had a pressure wound to her coccyx.
In an interview on 08/08/2023 at 01:11 p.m. Licensed Practical Nurse (LPN) P explained that R6 had a stage 2 pressure wound to her coccyx upon admission. LPN P explained that she was the facility wound nurse at the facility. LPN P explained that it was her responsibility to care plan all resident wounds. LPN P could not demonstrate that a plan of care for R6's coccyx wound had been initiated. LPN P could not explain why a care plan of R6's coccyx wound had not been initiated.
During observation and interview on 08/08/2023 at 03:23 p.m. R6 was observed lying down in bed. R6 explained that the nursing staff was going to complete her dressing change. R6 could not explain what wounds were present. During the observation of LPN P removing R6 coccyx dressing, it was observed that R6 coccyx pressure wound was healed.
Resident #188 (R188)
Review of the medical record revealed R188 was admitted to the facility 12/01/2022 with diagnoses that included displaced fracture of shaft left femur, muscle weakness, multiple sclerosis, pain, hypertension, hyperlipidemia (high fat content in blood), fracture of left calcaneus (heel bone), paraplegia (paralysis of legs and lower body), type 2 diabetes, vitamin deficiency, and constipation.
The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/2023, revealed R188's Brief Interview of Mental Status (BIMS) was 12 (mildly impaired cognition) out of 15. R188 was discharged from the facility 04/03/3023.
During review of R188 medical record demonstrated that R188 was discharged the hospital on [DATE] and readmitted to the facility 1/27/23. R188 medical record demonstrated that she was readmitted with an unstageable pressure ulcer to her coccyx that measured 7.0 centimeters (cm) in width by 7.0 cm in length. Review of R188's plan of care did not demonstrate that R188 had a pressure sore to her coccyx during her stay at the facility. Review of R188 care plan did not demonstrate that R188 had a pressure wound to her coccyx.
In an interview on 08/08/2023 at 01:11 p.m. Licensed Practical Nurse (LPN) P explained that R188 had an unstageable pressure wound to her coccyx upon R118's return from the hospital. LPN P explained that she was the facility wound nurse at the facility. LPN P explained that R188's wound was healed by the time of discharge. LPN P explained that it was her responsibility to care plan all resident wounds. LPN P could not demonstrate that a plan of care for R188's coccyx wound had been initiated. LPN P could not explain why a care plan of R188's coccyx wound had not been initiated.
Resident #189 (R189)
Review of the medical record revealed R189 was admitted to the facility 07/13/2023 with diagnoses that included diabetes, hypertension, end stage renal disease, chronic obstructive pulmonary disease (COPD), muscle weakness, epistaxis, diarrhea, kidney transplant, asthma, constipation, arthritis, angina pectoris, atherosclerotic heart disease, breast cancer, hypothyroidism, hypertension, bipolar disorder, and kidney failure.
During observation and interview on 08/08/2023 at 07:39 R189 was observed standing in the doorway of her room. Resident appeared well groomed. R189 explained that she received hemodialysis three times per week and demonstrated a dressing on her left arm that covered her dialysis port.
During record review of R189's medical record demonstrated that she was to receive dialysis Monday, Wednesday, and Friday at a local dialysis center. Review of R189's care plan did not demonstrate that resident was receiving dialysis services.
In an interview on 08/08/2023 at 10:19 a.m. Director of Nursing (DON) B reviewed R189's medical record and confirmed that R189 was to receive dialysis services. DON B explained that it was the expectation of the facility that dialysis services were to be included in a resident plan of care. DON B could not demonstrate that R189's plan of care included dialysis services. DON B could not explain why R189 did not have a care plan for dialysis services.
Resident #9 (R9)
Review of the medical record reflected that Resident #9 (R9) was readmitted to facility 4/28/23 with diagnoses including syncope and collapse, muscle weakness, Parkinson's Disease, Diabetes Mellitus, peripheral vascular disease, chronic anemia, and pulmonary fibrosis. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) Of 6/7/23 reflected that R9 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact). Section G of the MDS indicated that R9 required one-person extensive assist for bed mobility and transfers, one-person limited assist for toilet use, and was independent with eating after set-up. Section M of the same MDS revealed that R9 was at risk for developing a pressure ulcer, had a pressure reducing device for bed and chair, but was not on a turning/repositioning program.
In an observation and interview on 8/07/23 at 10:10 AM, R9 was observed in a bedside chair with back of chair reclined and legs elevated. R9 stated that he did not have control of his feces or urine and was incontinent of both bowel and bladder, that he had history of recurrent irritation to his bottom even prior to facility admission and that the staff put cream on his buttocks to protect the now intact skin. R9 also stated that although he had developed a sore on his left heel either at the hospital or at the facility, that area was now healed as well.
Skin Treatments Progress Note dated 6/6/23 indicated that R9 and a Grade 1 Diabetic Ulcer (a superficial wound not involving tendon or bone) at left heel with subsequent 6/13/23, 6/21/23, and 6/27/23 notes reflecting gradual wound improvement.
Review of R9's comprehensive care plans included no care plan to reflect that R9 was ever at risk for or had an actual impairment in skin integrity.
In an interview on 8/08/23 at 1:12 PM, Licensed Practical Nurse/Wound Nurse (LPN/WN) P stated that she had been the facility's wound nurse for the past 4 years and that the facility's wound management program included an outside wound team as well. LPN/WN P stated that when a resident was admitted with a wound or when a wound developed within the facility, she would assess the wound either that day or the next day, would coordinate and review wound care orders with the physician, would initiate all needed precautions, and would formulate a care plan to reflect the alteration.
During the same interview, LPN/WN P confirmed familiarity with R9, stated that he had developed a left heel wound after facility admission, physician assessed and diagnosed as a diabetic ulcer, treatment was implemented, wound was monitored weekly and was now healed, and a dry dressing remained in placed for protection. LPN/WN P stated that as R9 was at high risk for skin alterations upon facility admission, an at risk for skin alterations care plan should have been implemented and when R9 was diagnosed with a diabetic ulcer at his left heel, an actual alteration in skin integrity care should have been formulated to reflect. Upon review of R9's comprehensive care plans, LPN/WN P confirmed that R9 did not have an at risk or potential for alterations in skin integrity care plan implemented at facility admission nor was an actual alteration in skin integrity care plan formulated at the time of R9's left heel diabetic ulcer diagnosis. Furthermore, LPN/WN P confirmed that although R9 remained at risk for recurrent skin breakdown, he still did not have a care plan to reflect that risk nor the approaches the staff should have implemented and stated that she would be formulating the at risk care plan at that time.
Review of the facility policy titled Care Planning - Interdisciplinary Team with an effective date of 9/2018 stated, Policy Statement .Our Facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .Policy Interpretation and Implementation .1. A comprehensive care plan for each resident is developed within seven (7) days of the resident assessment (MDS) .2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team .

Based on observation, interview, and record review the facility failed to revise the care plan for one residents (#23) of 12 residents reviewed for care plan timing and revision resulting in the potential for residents that use language other than English to have unmet care needs.
Findings included:
Resident #23 (R23)
Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed.
During observation and attempted interview on 08/07/2023 at 10:08 a.m. R23 was observed lying in bed. R23 did not respond to verbal questions.
During a telephone interview on 08/07/2023 at 11:09 a.m. R23's family member N explained that R23's Alzheimer's disease has progressed to the point that her communication had changed. R23's family member N explained that she speaks Japanese and that was her usual means of communication. She explained that the amount of English spoken or understood had greatly decreased in the last year.
During observation on 08/07/2023 at 04:50 p.m. R23 was observed being transported by wheelchair down the hall, toward the nurse's station, with the assistance of activity aide S. During the time of the observed interaction between R23 and activity aide S R23 was speaking in another language.
In an interview on 08/07/2023 at 04:52 p.m. activity aide S explained that R23 spoke mostly in Japanese. When asked activity aide S how she communicated with R23, she explained that the staff just knows what she likes. She explained that R23 would wiggle and start to shift in her wheelchair if she was uncomfortable. When asked if R23 had a communication device to interpret English to Japanese or a communication board with pictures to interpret English to Japanese, activity aide S explained that she did not know if the facility had those devices. Activity aide S explained that there are sometimes that R23 will respond in English, such as yes or no, but most of the time she just speaks Japanese babble.
During observation and attempted interview on 08/08/2023 at 08:11 a.m. R23 was observed sitting up in her w/c, in her room. During attempted interview with resident responded oh to questions and nodded head. She also would start talking in a foreign language. No communication board or interpretive device was observed in R23's room.
In an interview on 08/08/2023 08:15 a.m. certified nursing assistant (CNA) T explained that R23 speaks Japanese most all the time. She explained that when she provided care to R23, she will occasionally use simple English words such as yes and thank you. CNA T explained that R23 frequently uses one phase in Japanese. CNA T explained that the one phrase was thank you. When asked CNA T if she understood Japanese she explained that she did not understand Japanese but had searched the phrase on an phone application that interpreted Japanese to English. CNA T was asked if she had knowledge if an interpreter had ever been provided to R23 to assist in her care. CNA T explained that she had never seen an interpreter provided.
In an interview on 08/08/23 at 08:17 a.m. Social Worker (SW) 'C explained that if a resident required interpretive services to communicate the facility would ask the family for assistance first. She explained that she was aware that R23 predominately communicated in Japanese and explained that the family had provided some education to the staff in the past. SW C could not provide documentation supporting that education and explained that it had occurred a while ago. When asked how R23 communicated with staff, SW C explained that the staff Just know her routine and needs. SW C explained that an example would be if crosses her arms, R23 would like her baby doll. When asked if this form of communication was listed in R23's plan of care, SW C' explained that she did not think that was explained that specific in the plan of care. SW C explained that R23 currently did not have any communication device but explained it had been tried in the past. SW C could not provide any documentation of communication board attempts by time of exit. SW C was requested to provide a policy that addressed interpretive services for resident that use language other than English.
Record review of R23's plan of care demonstrated a problem statement which state, Resident has occasional behavioral symptoms, behavioral outburst, aggressive behavior, and resistance. One intervention demonstrated provide verbal cues, instruction, handheld direction. No intervention informed the staff that R23 communicated in Japanese. Review of R23's plan of care did not demonstrate any identified concern with communication (speaking and understanding Japanese as her primary form of communication) nor did it demonstrate any interpretive services (interpreter, communication board, or computerized device) that could assist R23 with making her needs known.
No facility policy was provided that addressed interpretive services for resident that use language other than English by the time of exit.

Based on observation, interview, and record review the facility failed to provide interpretive services for one resident (#23) of one resident reviewed for language resulting in the potential for resident that use language other than English to have unmet care needs.
Findings Included:
Resident #23 (R23)
Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed.
During observation and attempted interview on 08/07/2023 at 10:08 a.m. R23 was observed lying in bed. R23 did not respond to verbal questions.
During a telephone interview on 08/07/2023 at 11:09 a.m. R23's family member N explained that R23's Alzheimer's disease has progressed to the point that her communication had changed. R23's family member N explained that she speaks Japanese and that was her usual means of communication. She explained that the amount of English spoken or understood had greatly decreased in the last year.
During observation on 08/07/2023 at 04:50 p.m. R23 was observed being transported by wheelchair down the hall, toward the nurse's station, with the assistance of activity aide S. During the time of the observed interaction between R23 and activity aide S R23 was speaking in another language.
In an interview on 08/07/2023 at 04:52 p.m. activity aide S explained that R23 spoke mostly in Japanese. When asked activity aide S how she communicated with R23, she explained that the staff just knows what she likes. She explained that R23 would wiggle and start to shift in her wheelchair if she was uncomfortable. When asked if R23 had a communication device to interpret English to Japanese or a communication board with pictures to interpret English to Japanese, activity aide S explained that she did not know if the facility had those devices. Activity aide S explained that there are sometimes that R23 will respond in English, such as yes or no, but most of the time she just speaks Japanese babble.
During observation and attempted interview on 08/08/2023 at 08:11 a.m. R23 was observed sitting up in her w/c, in her room. During attempted interview with resident responded oh to questions and nodded head. She also would start talking in a foreign language. No communication board or interpretive device was observed in R23's room.
In an interview on 08/08/2023 08:15 a.m. certified nursing assistant (CNA) T explained that R23 speaks Japanese most all the time. She explained that when she provided care to R23, she will occasionally use simple English words such as yes and thank you. CNA T explained that R23 frequently uses one phase in Japanese. CNA T explained that the one phrase was thank you. When asked CNA T if she understood Japanese she explained that she did not understand Japanese but had searched the phrase on an phone application that interpreted Japanese to English. CNA T was asked if she had knowledge if an interpreter had ever been provided to R23 to assist in her care. CNA T explained that she had never seen an interpreter provided.
In an interview on 08/08/23 at 08:17 a.m. Social Worker (SW) 'C explained that if a resident required interpretive services to communicate the facility would ask the family for assistance first. She explained that she was aware that R23 predominately communicated in Japanese and explained that the family had provided some education to the staff in the past. SW C could not provide documentation supporting that education and explained that it had occurred a while ago. When asked how R23 communicated with staff, SW C explained that the staff Just know her routine and needs. SW C explained that an example would be if crosses her arms, R23 would like her baby doll. When asked if this form of communication was listed in R23's plan of care, SW C' explained that she did not think that was explained that specific in the plan of care. SW C explained that R23 currently did not have any communication device but explained it had been tried in the past. SW C could not provide any documentation of communication board attempts by time of exit. SW C was requested to provide a policy that addressed interpretive services for resident that use language other than English.
Record review of R23's plan of care demonstrated a problem statement which state, Resident has occasional behavioral symptoms, behavioral outburst, aggressive behavior, and resistance. One intervention demonstrated provide verbal cues, instruction, handheld direction. No intervention informed the staff that R23 communicated in Japanese. Review of R23's plan of care did not demonstrate any identified concern with communication (speaking and understanding Japanese as her primary form of communication) nor did it demonstrate any interpretive services (interpreter, communication board, or computerized device) that could assist R23 with making her needs known.
No facility policy was provided that addressed interpretive services for resident that use language other than English by the time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00134426 and MI00136854.
Based on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADLs) for three (Resident #139, #188, #238) of four reviewed, resulting in unmet care needs and the potential for a decline in emotional and physical health.
Findings include:
Resident #139 (R139)
Review of the medical record revealed Resident #139 (R139) admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, diabetes, Parkinson's Disease, stage 4 pressure ulcer, and osteomyelitis of vertebra sacral and sacrococcygeal region.
R139 did not have a Minimum Data Set (MDS) assessment completed since admission.
Review of the Physician's Order dated 4/24/23 revealed EATING: Feeding assistance.
The Physician's Order dated 4/25/23 revealed Diet Order: Regular, thin liquids as tolerated; provide feeding assistance with meals.
Review of the Nutritional assessment dated [DATE] revealed Requires feeding assistance.
Review of R139's nutrition care plan dated 4/25/23 revealed I am on an appetite stimulant and require feeding assistance.
On 08/07/23 at 12:24 PM, R139 was observed in bed. Her lunch tray was on the overbed table, across her bed. There was a care guide on R139's nightstand which read Eating: Feeding assistance.
On 08/07/23 at 12:45 PM, R139 was observed in her bed, feeding herself. The lunch tray card was observed on the tray and revealed R139 needed assistance with feeding.
On 08/07/23 at 03:11 PM, R139's lunch tray was still on the overbed table. R139 had consumed most of the lunch.
In an interview on 08/08/23 at 09:02 AM, Registered Dietitian (RD) Q reported R139 needed assistance with eating. RD Q reported R139 could independently eat some finger foods, but staff were supposed to be with her while she ate to provide supervision.
On 08/08/23 at 09:04 AM and 9:23 AM, R139 was observed asleep in bed. The breakfast tray was still untouched on the overbed table beside her bed. R139's breakfast tray included Greek yogurt, toast, eggs, sausage, and a peanut butter and jelly sandwich. At 9:31 AM, R139 was observed awake. R139 reported she did not eat breakfast yet and reported she was hungry. Continuous observations until 10:11 AM revealed no staff were present on the hallway. R139 was not assisted with eating. At 10:11 AM, Certified Nursing Assistant (CNA) R was observed removing breakfast trays from other rooms. CNA R did not enter R139's room. At 10:31 AM, another staff member walked through the hall, but did not enter R139's room. R139 was observed grabbing the peanut butter and jelly sandwich off the table beside her. R139 began eating the sandwich.
In an interview on 08/08/23 at 10:38 AM, CNA R reported she was an agency staff member and it was her first time working in the facility. CNA R reported she did not have access to the CNA charting and documents yet so the information she knew about residents was obtained in report. When asked about R139's feeding assistance, CNA R reported she was not told that R139 needed assistance with eating.
On 08/08/23 at 10:45 AM, R139 was observed in bed with her napkin across her chest. R139 was holding her silverware and stated, I have breakfast here, but I can't open the lid. The breakfast tray was observed in the same location as earlier and remained untouched except for the peanut butter and jelly sandwich.
On 08/08/23 at 11:16 AM, Director of Nursing (DON) B reported R139 was independent with eating after set-up assistance. DON B reported staff should set up her tray, set R139 upright, and open her drinks.
Resident #188 (R188)
Review of the medical record revealed R188 was admitted to the facility 12/01/2022 with diagnoses that included displaced fracture of shaft left femur, muscle weakness, multiple sclerosis, pain, hypertension, hyperlipidemia (high fat content in blood), fracture of left calcaneus (heel bone), paraplegia (paralysis of legs and lower body), type 2 diabetes, vitamin deficiency, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/2023, revealed R188's Brief Interview of Mental Status (BIMS) was 12 (mildly impaired cognition) out of 15. Section G-Functional Status of the MDS, with the same ARD, demonstrated that R188 required total dependence for toileting needs. Section H-Bladder and Bowel of the MDS, with the same ARD, demonstrated that R188 was frequently incontinent of urine and bowel. R188 was discharged from the facility 04/03/3023.
In a telephone interview on 08/07/2023 at 02:53 p.m. R188's family daughter Y explained that while R188 was at the facility, she was not toileted on a regular basis and that she frequently observed R188 wet and/or soiled of bowel and urine.
During medical record review R188's, Point of Care documentation Toileting Use demonstrated that R188 had not been assisted with toileting during the day shift on 1/18/2023, 1/17/2023, 1/16/2023, 1/15/2023, 1/13/2023, 1/12/2023, 1/11/2023, 1/10/2023, 1/09/2023, 1/08/2023, 1/7/2023, and 1/5/2023. The documentation Toileting Use demonstrated that R188 had not been assisted with toileting during the afternoon shift on 01/7/2023 and 01/6/2023. The documentation Toileting Use demonstrated that R188 had not been assisted with toileting during the midnight shift 01/11/2023, 01/08/2023, and 01/06/2023.
In an interview on 08/09/2023 at 07:10 a.m. Certified Nursing Assistant (CNA) Z explained that incontinent residents are checked on at least every 2 hours and that charting is completed at least once per shift (7-3, 3-11,11-7) for residents.
In an interview on 08/09/2023 at 07:18 a.m. Director of Nursing (DON) B explained that it was the facility expectation that resident that are incontinent of bowel and/or urine would be assisted with toileting every two hours. DON B explained that staff would document these occurrences in the Toileting Use documentation of the medical record. DON B confirmed that Toileting Use documentation was not documented in the medical record as listed above. DON B could not explain why documentation toileting was not completed for R188.
Resident #238 (R238)
Review of the medical record revealed that Resident #238 (R238) was admitted to facility on 12/7/2016 with diagnoses including Alzheimer's Disease, muscle weakness, epilepsy, and dysphagia. Review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/21/23 revealed a staff assessment for mental status that indicated R238 had short term memory problems and severely impaired cognition for decision making. Section G of the MDS revealed that R238 was totally dependent for bed mobility, transfers, eating, bathing, and toilet use. Section H of the same MDS indicated that R238 was always incontinent of bowel and bladder.
In a telephone interview on 8/8/23 at 3:14 PM, Hospital Staff Member (HSM) U confirmed recollection of R238 as well as R238's presentation upon arrival to the hospital with dried snot at nose, debris in mouth, and stool on buttocks and inside of buttock wound.
Review of R238's medical record completed with the following findings noted:
ADL (Activities of Daily Living) Care Plan Problem dated 9/8/2021 indicated the goal, I want to be kept clean, dry, odor free and well groomed and dressed in seasonal attire . with associated Approaches dated 9/8/2021 that included, Please assist me with my bathing needs twice weekly and as needed and Please assist me with my toileting needs daily.
Elimination Care Plan Problem dated 9/8/2021 indicated bowel and bladder incontinency with associated approaches dated 9/8/2021 that included, Check for incontinent episodes at least every 2 hours and Provide incontinence care after each incontinent episode.
Review of order dated 2/9/2023, stated Skin Assessment to be completed on scheduled shower days and shift with scheduled days indicated to be on Mondays and Thursdays.
Review of Point of Care (POC-long term care software used by Certified Nurse Aides to document a resident's activities of daily living at time of care provision) documentation for bathing on R238's ordered/scheduled days (Mondays and Thursdays) from 3/20/23 through 4/21/23 reflected that Activity did not occur on 3/20, 3/23, 3/27, 3/30, 4/3, 4/6, 4/10, and 4/17 (8 of the scheduled 10 bath/shower days). Although POC documentation reflected that bathing activity did not occur on these indicated dates, review of R238's nursing progress notes did reflect that on 2 (3/30 and 4/6) of these 8 days, that a shower had been given. However, review of all combined documentation (POC and nurse progress notes) still only reflected that R238 received a shower/bath on 4 of the 10 scheduled days from 3/20/23 through 4/21/23.
Review of POC documentation for R238's bladder and bowel incontinency care from the same time period (3/20/23 through 4/21/23) reflected the following:
-3/20 11:36 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-3/21 9:31 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-3/22 12:05 AM and 4:27 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-3/23 3:18 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-3/24 3:53 AM and 8:53 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-3/25 4:18 AM Documented as Incontinent of bladder, No Bowel Movement with no additional entries noted to be completed on this date.
-3/26 No entries noted to be completed on this date.
-3/27 4:35 AM Documented as Incontinent of bladder, No Bowel Movement and 6:34 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-3/28 No entries noted to be completed on this date.
-3/29 2:45 AM and 6:30 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-3/30 11:34 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-3/31 No entries noted to be completed on this date.
-4/1 12:43 PM, 5:35 PM, and 11:52 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/2 4:22 PM and 11:46 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/3 11:49 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/4 3:48 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/5 1:18 AM and 4:35 PM Documented as Incontinent of bladder, No Bowel Movement, 2:21 PM and 11:40PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/6 8:02 PM and 11:37 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/7 2:43 PM and 10:32 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/8 11:54 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/9 1:48 PM Documented as Incontinent of bladder, No Bowel Movement with no additional entries noted to be completed on this date.
-4/10 1:33 AM, 2:29 PM, and 10:53 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/11 4:01 AM Documented as Incontinent of bladder, No Bowel Movement; 4:56 PM and 11:48 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/12 2:48 PM Documented as Incontinent of bladder, No Bowel Movement; 5:58 PM and 11:56 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/13 11:46 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/14 2:16 PM Documented as Incontinent of bladder, No Bowel Movement and 5:01 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/15 11:28 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/16 1:40 PM Documented as Incontinent of bladder, No Bowel Movement and 8:30 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/17 1:36 PM Documented as Incontinent of bladder, No Bowel Movement with no additional entries noted to be completed on this date.
-4/18 9:11 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/19 7:31 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/20 9:04 PM Documented as Incontinent of both bowel and bladder with no additional entries noted to be completed on this date.
-4/21 No entries indicated to be documented although 4/21/23 Nursing Progress Note indicated that R238 was not transferred to the emergency room until 5:00 PM.
In summary, although R238's Elimination Care Plan indicated bowel and bladder incontinency with associated approaches to Check for incontinent episodes at least every 2 hours and Provide incontinence care after each incontinent episode over the course of the 33 days reviewed the following was noted:
No bowel/bladder documentation: 4 of 33 days
Bowel/bladder documentation 1 time over the course of the day: 15 of 33 days
Bowel/bladder documentation 2 times over the course of the day: 9 of 33 days
Bowel/bladder documentation 3 times over the course of the day: 4 of 33 days
Bowel/bladder documentation 4 times over the course of the day: 1 of 33 days
Bowel/bladder documentation 5 or more times over the course of the day: 0 of 33 days
In an interview on 8/9/23 at 7:18 AM, Director of Nursing (DON) B stated that when a resident was known to be frequently incontinent of bowel and bladder, that resident should be on an every 2-hour check and change program. Per DON B, the facility had a Two Hour Visual Checks form that the Certified Nurse Aides (CNAs) used to document these every 2-hour checks and would indicate, on that form, whether the resident was dry or needed to be changed with every check. DON B stated that upon completion, these forms were sent to Medical Records so that they could be filed in the individual resident's chart. Per DON B, CNAs also documented every check and change within the POC bowel/bladder task and would expect documentation within POC to be completed every 2 hours for an incontinent resident that was on an every 2 hour check and change program.
In a follow-up interview on 8/9/23 at 9:07 AM, DON B confirmed familiarity with R238, stated that he had a diagnosis of dementia and was alert/oriented to self only, had aphasia with mumbled/unintelligible speech, and was dependent on staff for all care. Additionally, DON B stated that R238 was incontinent of both bowel and bladder, was a heavy wetter, and that the expectation would have been for staff to complete every 1-to-2-hour incontinency checks with documentation completed on both the paper form and in the POC bladder/bowel task to reflect. Upon review of R238's electronic documentation within the bowel/bladder POC task, DON B confirmed that the limited documentation did not reflect at least every 2-hour incontinency checks and stated that she could offer no explanation as to why as stated that if it had been done, it should have been documented. DON B further stated that if CNA documentation was not completed prior to the end of their shift, then it could not be done as the electronic program did not allow back charting. DON B stated that the Two Hour Visual Checks forms that were supposed to be used should also reflect each time that R238 was checked and changed but acknowledged that R238's medical record did not contain any scanned documents to reflect and denied that any of these documents would have been located in the paper chart. DON be stated that the issue the facility had been having was related to agency staffing as their documentation was very poor but admitted that lack of documentation happened with the facility staff as well. DON B confirmed that R238's toileting documentation was inconsistent and lacking and agreed that, per the available documentation, R238 was not checked or changed at the routine every 2-hour interval as was care planned and expected due to the known fact that R238 was frequently incontinent of both bowel and bladder.
During the same interview, upon review of R238's POC bathing task, DON B acknowledged that CNA documentation of baths/showers was inconsistent and lacking, as well, and that based on documentation there was no proof that R238's bathing had been completed on scheduled days. DON B stated that the assigned nurse completed a skin check on the assigned shower days and that the nurse should complete a nursing note to reflect but upon review of R238's progress notes, agreed that she did not see routine nursing entries to indicate that a shower was completed on R238's scheduled days.
Review of the facility policy titled Toileting Residents with an effective date of 9/2018 stated, Policy Statement .All resident should be assisted with appropriate toileting needs. Resident's level of assistance is communicated with staff via the Resident profile .Policy Interpretation and Implementation .1.) .Toileting and Transfer orders are present on resident's profile .6.) .CNAs will document all resident's toileting needs on Visual Checks and in Point of Care charting documentation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #11
According to the clinical record including the Minimum Data Set (MDS) dated [DATE] , Resident 11 (R11) was a [AGE] year old male admitted to the facility with multiple medical issues including a diagnoses of traumatic brain injury. Review of the MDS reflected R11 scored 12 out of 15 on the Brief Interview for Mental (BIMS). Section G of the MDS reflected R11 required extensive assistance from two staff persons for bed mobility and transfers, for dressing and eating R11 coded as requiring extensive assistance from one staff person. Section G 0400 of the MDS reflected upper extremity impairment and bilateral impairment for lower extremity.
Review of R11's Physician order dated 04/05/23 reflected Restorative (3x/wk ) [3 times a week] AROM (active range of motion) exes (exercises) of BUE/BLE (bilateral upper and lower extremities) 10 reps x 1 set. Gentle stretch of BIL (bilateral) hamstrings, as tolerated.
Review of the Restorative Nursing Care Plan dated 4/05/23 revealed R11 was to have restorative therapy 3 times a week with a goal to maintain range of motion. Review of the attendance log reflected R11 received restorative therapy 6 times in June, one time in July and once thus far in August 2023.
On 08/08/23 at 10:46 AM, during an interview with Director of Nursing (DON) B she reported she thought the facility's Restorative program had one resident and that resident was not R11.
On 08/09/23 07:16 AM during a phone Interview with Certified Occupational Therapy Assistant ( COTA) E she stated she was familiar with R11 and wanted restorative 3 days a week as ordered to maintain current status and prevent contractures.
Based on observation, interview, and record review, the facility failed to provide services to maintain, increase, or improve range of motion for three (Resident #11, #27, #35) of three reviewed, resulting in the potential for decreased range of motion, contractures, and worsening contractures.
Findings include:
Resident #35 (R35)
Review of the medical record revealed R35 admitted to the facility on [DATE] with diagnoses that included fracture of the left shoulder, muscle weakness, multiple myelomoa, and pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/23 revealed R35 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS).
Review of R35's care plans revealed an intervention dated 5/17/23 for Physical Therapy for 12 weeks and Occupational Therapy for 09 days. An intervention dated 5/12/23 revealed R35 was doing exercises with restorative.
On 08/07/23 at 10:12 AM, R35 was observed lying in bed. R35 reported he saw a physician two months ago who ordered four additional weeks of therapy but reported he had not received therapy yet. R35 reported sometimes he left arm goes numb and that he needed to work on going up steps to discharge home.
Review of the orthopedic consultation dated 5/31/23 revealed R35 was to work on active and passive range of motion in both shoulders.
Review of the note from the consult visit at the brain and spine clinic on 6/14/23 revealed an order for physical therapy to evaluate and treat three times per week for four weeks. The treatment requested was range of motion and strengthening.
Review of the Progress Note dated 6/14/23 revealed Resident Returned from at appointment .The treatment that is recommended ROM [range of motion] & Strengthening training 3 times per week for four 4 weeks. Resident's paperwork has been scanned in the [Electronic Medical Record] system to be view [sic].
In an interview on 08/08/23 at 08:25 AM, Certified Occupational Therapy Assistant (COTA) O reported R35 was not receiving therapy services. COTA O reported R35 was evaluated by therapy on 5/17/23, but insurance would not cover skilled services. COTA O reported he believed R35 was receiving restorative services.
Review of the Restorative Nursing Care Plan revealed R35's goal was to maintain current functional mobility, range of motion, and transfers and to prevent muscle weakness and atrophy. The treatment plan was for bilateral upper and lower extremity range of motion therapeutic exercises (seated) 15 reps and ambulation with rolling walker for 150 feet twice. The frequency was three times per week and the duration was as tolerated. The documentation revealed R35 received Restorative Nursing services for range of motion on 6/7/23, 6/8/23, 6/13/23, 6/16/23, 6/21/23, 7/28/23, and 8/4/23. The documentation revealed R35 received Restorative Nursing services for ambulation on 6/8/23, 6/16/23, 6/21/23, 7/28/23, and 8/4/23.
In an interview on 08/08/23 at 11:03 AM, Director of Nursing (DON) B reported R35 was not on restorative services. When asked about the order from the brain and spine clinic on 6/14/23, DON B reported she thought R35 was on therapy services at that time. When informed that therapy only evaluated R35 on 5/17/23 and that insurance would not cover services, DON B reported she believed this was during the time when the facility did not have a restorative aide.
Resident #27
Review of the medical record revealed that Resident #27 (R27) was admitted to facility 11/21/2017 with diagnoses including generalized muscle weakness, pain, and difficulty in walking. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/13/23 revealed that R27 had clear speech, was understood by others, and was able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 12 (moderately impaired cognition). Section G of the same MDS reflected that R27 required one-person extensive assist with bed mobility, two-person dependent assist with transfers and toilet use and was independent with eating after set up.
In an observation and interview on 8/07/23 at 10:48 AM, R27 was observed sitting in wheelchair, in room, with right upper arm positioned at side, arm bent at elbow with right forearm and hand resting on abdomen. Right first and second fingers were observed to be extended straight out with third, fourth, and fifth fingers flexed downward with tip of fingers touching palm of hand. R27 was noted with delayed responses to questions but stated that she could not walk, needed staff help to get into her wheelchair, and had a difficult time feeding herself as my hands just don't work right. R27 denied ability to move right third, fourth, and fifth fingers.
Review of R27's medical record completed with the following findings noted:
Document scanned into electronic medical record titled (Name of facility) Range of Motion Screen reflected Limited PROM (passive range of motion)/AAROM (active assisted ranged of motion) to R27's right fingers on 8/17/22, 2/10/23, and 5/10/23 assessments with 8/17/22 assessment indicating 4th & 5th digits flexed.
Order dated 4/7/2023 stated Restorative 3x/week (times per week): PROM of BUEs (Bilateral Upper Extremities) and BLEs (Bilateral Lower Extremities) .
Care Plan Problem dated 4/7/23 stated, I am at risk for decline in rom (range of motion) and functional mobility related to weakness with associated approach also dated 4/7/23 reflecting Restorative 3x/week: PROM of BUEs and BLEs .
Document titled Restorative Nursing Care Plan located within black binder labeled
Restorative Book indicated R27's ROM program to include PROM to bilateral upper and lower extremities 3x/week with goal to maintain ROM and functional status. Separate June, July, and August 2023 calendars on same form reflected completion of R27's restorative treatment plan 6 times in June (6/7, 6/8, 6/13, 6/16, 6/21, and 6/23), one time in July (7/28), and one time in August (8/4).
In an interview on 8/08/23 at 10:46 AM, Director of Nursing (DON) B stated that the facility's restorative nursing team was comprised of herself as the program coordinator and one restorative aide, that the therapy department completed referrals to the restorative nursing program upon completion of skilled therapy in an effort to maintain a resident's functional status, and the resident then received restorative services based on the referral information from therapy. DON B confirmed that R27 had limitations in range of motion to bilateral hands, had an active order for BUE and BLE ROM 3x/week, and that R27 routinely participated in the program. Upon review of R27's restorative nursing calendars, DON B confirmed that based on the documentation contained within the form that R27 was not receiving restorative nursing services consistently or per order and acknowledged that R27 had only received services six times in June, one time in July, and one time thus far in August. DON B stated that the facility's full time restorative aide had been on medical leave and although another aide was filling in, that aide was assigned to work at another facility, as well, and therefore restorative staff was not available to complete R27's restorative program, as ordered.
Review of the facility policy titled Restorative Nursing Program with a revised/reviewed date of 2/2019 stated, PURPOSE: It is the policy of the facility to assist each Resident to attain and or maintain their individual highest most practicable functional level of independence and well-being, in accordance to State and Federal Regulations .PROCEDURE .3. The facility restorative nursing program will include but not be limited to the following programs .b. Mobility-transfer and ambulation, including walking, prosthetic and or splint application with or without active or passive range of motion .4. The above programs will be documented on the facility designated restorative care forms/tools .
Review of the facility policy titled Specialized Rehabilitative and Restorative Services with a revised/reviewed date of 2/2019 stated, PURPOSE .It is the policy of the facility to provide Specialized Rehabilitative and Restorative Services in accordance to State and Federal regulations .PROCEDURE .4. The facility will provide restorative services such as but not limited to walking, transfer training, bowel and or bladder training, bed mobility, Range of Motion .when necessary as indicated by the assessment of the interdisciplinary team .

Based on observation, interview, and record review the facility failed to provide a therapeutic diet that considers the residents clinical conditional condition for one resident (#189) of three residents reviewed for proper diet requirements resulting in the potential of clinical complications for those residents with a clinical condition.
Findings Included:
Resident #189 (R189)
Review of the medical record revealed R189 was admitted to the facility 07/13/2023 with diagnoses that included diabetes, hypertension, end stage renal disease, chronic obstructive pulmonary disease (COPD), muscle weakness, epistaxis, diarrhea, kidney transplant, asthma, constipation, arthritis, angina pectoris, atherosclerotic heart disease, breast cancer, hypothyroidism, hypertension, bipolar disorder, and kidney failure.
During observation and interview on 08/08/2023 at 07:39 R189 was observed standing in the doorway of her room. Resident appeared well groomed. R189 explained that she received hemodialysis three times per week and demonstrated a dressing on her left arm that covered her dialysis port. R189 explained that she was waiting for her breakfast to arrive. During this interview R189 explained that she has been provided foods that she is not supposed to have because she has kidney failure and she received hemodialysis. R189 explained that she has received macaroni and cheese twice during her stay and they keep giving her a banana.
During record review R189's medical record demonstrated that she was order a renal diet/regular texture diet with thin liquids for meals. Review of R189's meal tray card (that was present on her meal trays) demonstrated that she was on a renal diet. In the note section of the meal tray card stated, no cheese, potatoes, tomatoes, or bananas.
In an interview on 08/08/2023 at 07:57 a.m. Registered Dietician (RD) Q explained that the nursing staff pass the dietary trays at the facility and that they should know what cannot be provided to a resident on a renal diet. She explained that R189 was to receive a renal diet with regular texture. She explained that R189's meal tray card would not list the menu items of the day on the meal tray card but would list the items that R189 would not be provided. RD Q explained that audits are not completed regularly on the food trays that are provided to the residents but are only completed once in a while. When asked how the dietary staff would know what R189 was to be provided, she explained that the dietary manager would have a document for each meal that provided information to the dietary staff while preparing meals.
In an interview on 08/08/2023 at 08:46 a.m. Dietary Manager (DM) W explained that R189 was to receive a renal diet that was regular texture. She explained that residents' meal tray cards did not have the exact items list on the card for each meal. DM W explained that she would complete a document for her staff, that listed each food to be provided to resident, in accordance with their diet and provide that to her staff while they prepared the food the food trays of residents. DM W could not provide past instructions to staff, as those documents are not saved after the completion of meals. DM W explained that residents' meal tray cards does not list the food items for each meal. DM W' could not explain how staff, that are passing resident trays, would know if the resident was receiving the proper food that they were allowed. DM W explained that was possible that R189 had received Mac and Cheese, as it was on the facility menu.
In an interview on 08/08/2023 at 09:33 a.m. Certified Nursing Assistant (CNA) X explained that resident meal tray cards listed the type of diet that a resident was to receive. When CNA X was asked if she had knowledge of any document that the facility had provided to her explaining the requirements of each diet type, she explained that she was not aware of any. When asked if a resident that was on a renal diet could receive Mac and Cheese she responded that it would be allowed.
Document review of the facilities menus ( 07/23/2023 through 07/29/2023) demonstrated that the lunch meal on 07/26/23, the facility provided Mac and Cheese.

During the Resident Council meeting on 8/8/23 at 1:35 PM, six of six residents reported they did not know that the State Agency's survey results were available or where the survey results were located.
Based on observation, interview, and record review the facility failed to ensure information within the Survey Book was up to date and maintained to include reports of retrospective surveys and facility plan of correction for identified deficiencies and failed to inform/educate six of six resident who attended the Confidential Group Meeting resulting in the potential for residents, visitors, and families to be uninformed of the facilities deficient practices in a current facility census of 34 residents.
Findings Included:
During facility tour on 08/09/2023 at 07:11 a.m. the facility Survey Book was located steal hanger by the first nurses' station when entering the facility. Review of the Survey Book demonstrated surveys with exit dates of 7/31/2022, 8/8/2022, 2/5/2021, 9/17/2019, and 9/23/2019. The facility had received an abbreviated survey with and exit date of 11/16/2022. The survey with an exit date of 11/16/2022 was not present in the Survey Book.
In an interview on 08/09/2023 at 10:11 a.m. Nursing Home Administrator (NHA) A confirmed that the survey with an exit date of 11/16/2022 was not present in the Survey Book. NHA A could not explain why it was not present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #35 (R35)
Review of the medical record revealed R35 admitted to the facility on [DATE] with diagnoses that included multiple myeloma, major depressive disorder, and heart disease. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/23 revealed R35 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS).
Review of R35's Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions revealed R35 chose Do Not Resuscitate and signed the form on 11/8/22. The form did not have any witness signatures nor was the form compliant with the verbiage required per the Michigan Do Not Resuscitate Act.
Resident #23 (R23)
Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed.
During observation and attempted interview on 08/08/2023 at 08:11 a.m. R23 was observed sitting up in her w/c, in her room. During attempted interview with resident responded oh to questions and nodded head. She also would start talking in a foreign language.
Review of R23's medical record demonstrated that she had a family member who was her Durable Power of Attorney (DPOA) for healthcare. R23's medical record that she had been declared mentally incompetent by one physician on 09/02/2017 and another physician on 09/16/2017. Review of R23's Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions demonstrated Do Not Resuscitate had been checked and dated 02/18/2020. The document entitled Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions was signed by the DPOA and was witnessed by the DPOA's spouse on 02/18/2020. The document entitled Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions did not have another witness documented.
In an interview on 08/07/2023 at 03:58 p.m. Director of Nursing (DON) B explained that the facility does not obtain two witness signatures when completing the document entitled Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions.
Based on observation, interview, and record review, the facility failed to ensure accurate completion of advance directive information for 3 (Resident #23, #27, and #35) of 4 residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility.
Findings include:
Resident #27
Review of the medical record revealed that Resident #27 (R27) was admitted to the facility 11/21/2017 with diagnoses including major depressive disorder, pain, and difficulty in walking. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/13/23 revealed that R27 had clear speech, was understood by others, and was able to understand others. Section C of the same MDS revealed that R27 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 12 (moderately impaired cognition).
In an observation and interview on 8/07/23 at 10:48 AM, R27 was observed sitting in wheelchair, in room, with right upper arm positioned at side, arm bent at elbow with right forearm and hand resting on abdomen. R27 was noted with delayed responses to questions but stated that she could not walk, needed staff help to get into her wheelchair, and had a difficult time feeding herself as my hands just don't work right.
Review of R27's electronic medical record indicated a code status of DNR (Do Not Resuscitate.
Review of advance directive information located within R27's paper chart included a document titled, ACKNOWLEDGEMENT OF RECEIPT ADVANCE DIRECTIVES/MEDICAL TREATMENT DECISIONS. Document reflected Do Not Resuscitate signed and dated by R27 on 12-01-2017. Both witness signature lines within the same form were noted to be blank.
In an interview on 8/07/23 at 3:32 PM, Social Worker (SW) C stated that advance directive paperwork was completed upon admission with a resident who was capable of making his/her own medical treatment decisions, a guardian, or an activated power of attorney. SW C further stated that when a resident opted to be a DNR, a resident completed the facility's Advance Directives/Medical Treatment Decisions form to reflect and that form was then forwarded to the physician to review and sign. Per SW C, the facility did not have witnesses oversee and sign the resident's completion of the DNR form as stated that the facility policy indicated that the facility staff could not witness the completion of the form and therefore the DNR form was not witnessed by anyone. Additionally, SW C stated that the facility's current advance directive form was the same form that the facility had used for the last twenty six years and although the form contained two lines labeled Witness for witness signatures, the forms completion had never been witnessed.
During the same interview, SW C confirmed familiarity with R27, stated that R27 continued to make her own medical treatment decisions, that she reviewed her code status with her at least quarterly, and that she had been and continued to be a DNR. Upon review of the Advance Directives/Medical Treatment Decisions form within R27's chart located behind the nurses' station, SW C confirmed that form signed/dated by R27 on 12-1-17 was the most current form and acknowledged that the form was unwitnessed as both witness signature lines within the form were noted to be blank.
Review of the facility policy titled Advance Directives with a revised/reviewed date of 2/2019 stated, .Guidelines .Resident Code Status Form: The completed and signed Resident Code Status Form (CSF) that is completed pursuant to this Policy that summarizes the resuscitation desires .Witnesses .Individuals who observe the resident place his/her signature on the DPOA-HC (Durable Power of Attorney for Healthcare) signed after December 18, 1990 shall not be the resident's spouse, parent, child, grandchild, sibling .or an employee of this facility (home for the aged, adult foster care facility, hospital, nursing home, or county medical care facility) where the resident resides .Admitting .1.08 .If the Resident has the proper capacity, the Resident will be asked to complete and sign the Resident Code Status Form .1.09 .The Resident Code Status Form is the primary document in the medical record to identify resident code status . Further review of the policy included no guidance pertaining to the completion and witnessing of the facility's code status form.
Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised 3-25-14), revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons:
(a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in
the presence of the declarant and acting pursuant to the directions of the declarant.
(b) The declarant's attending physician.
(c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child,
grandchild, sibling, or presumptive heir.
(3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness
shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of
sound mind and under no duress, fraud, or undue influence.
Further review of this Act revealed, Sec. 4. A do-not-resuscitate order executed under section 3 or 3a shall include, but is not limited to, the following language, and shall be in substantially the following form:
DO-NOT-RESUSCITATE ORDER
This do-not-resuscitate order is issued by _______________________________________, attending physician for _________________________________________. (Type or print declarant's or ward's name)
Use the appropriate consent section below:
A. DECLARANT CONSENT
I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. _______________________________________ _______________
(Declarant's signature) (Date)
_______________________________________ _______________
(Signature of person who signed for (Date) declarant, if applicable)
_______________________________________
(Type or print full name)
B. PATIENT ADVOCATE CONSENT
I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law.
_______________________________________ _______________
(Patient advocate's signature) (Date)
_______________________________________
(Type or print patient advocate's name)
C. GUARDIAN CONSENT
I authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in
effect until it is revoked as provided by law.
_______________________________________ _______________
(Guardian's signature) (Date)
_______________________________________
(Type or print guardian's name)
_______________________________________ _______________
(Physician's signature) (Date)
_______________________________________
(Type or print physician's full name)
ATTESTATION OF WITNESSES
The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the declarant has (has not)received an identification bracelet.
______________________________ ______________________________
(Witness signature) (Date) (Witness signature) (Date)
______________________________ ______________________________
(Type or print witness's name) (Type or print witness's name)
THIS FORM WAS PREPARED PURSUANT TO, AND IS IN COMPLIANCE WITH, THE MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT.

Based on observation, interview and record review the facility failed to promptly make good faith attempts to resolve grievances for members of the Resident Council resulting in the potential for frustration and unmet care needs.
Findings include:
During a Resident Council meeting on 08/08/23 at 1:35 PM, six of six residents reported they did not know how to file a grievance or that it was an option to file a grievance. Resident Council participants reported communication in the building was poor. They reported if a concern was voiced, it was not addressed.
Five of the six residents responded when asked about staffing and call light response time. Four of the five residents who participated in the discussion expressed concerns with staffing and extended call light response times. The Resident Council participants reported waiting up to one hour for staff to respond to their call lights. They reported staff seemed rushed and did not have time to stop and ask if the residents needed anything. One participant expressed there had been an ongoing concern with not receiving restorative therapy services.
Review of the Resident Council minutes revealed on 2/21/21, 5/30/23, and 6/27/23, the Resident Council expressed concerns with call light response times. On 2/21/21, 4/18/23, 5/30/23, 6/27/23, and 7/28/23, the Resident Council expressed they would like restorative therapy.
The facility's grievance log was requested on 8/7/23 during the entrance conference. The facility did not provide a grievance log prior to the survey exit.
Grievances for the last 12 months were requested. The facility provided two Quality Concern Form-Action and four Resident Missing Item forms. The Quality Concern Forms were dated 3/17/23 and 6/2/23. The forms had a section for follow up and signature by the Nursing Home Administrator. Neither form had this section completed.
Review of the Quality Concern Form-Action revealed the Resident Council concerns were not recorded on the forms.
In an interview on 08/09/23 at 8:51 AM, Director of Nursing (DON) B reported Social Worker (SW) C was responsible for grievances. DON B reported if there were any nursing concerns, the nursing department would be notified. When asked if she was aware of Resident Council's concerns with call lights, DON B stated yes. When asked what was being done to resolve the concern, DON B reported the facility tried their best to address the concern with residents and let the residents know that staff might be in another room and not see their call light. DON B reported some residents were satisfied with that response. DON B reported she was also aware of Resident Council's concern with restorative therapy. When asked what was being done to resolve the concern, DON B reported the facility has put out job openings. DON B reported she was verbally notified of Resident Council concerns and that the concerns were not placed on a Quality Concern Form. DON B reported she had only ever witnessed one person use a Quality Concern Form.
In an interview on 08/09/23 at 10:02 AM with Nursing Home Administrator (NHA) A and Regional Director of Operations (RDO) H, RDO H reported the facility's grievance form was not the same as a missing items form. When asked about the ongoing concerns from Resident Council, NHA A reported SW C distributed concerns to each responsible department by providing the Resident Council minutes. When asked how the grievances, follow-up, and resolutions were tracked, NHA A reported they usually reapproached and discussed by following up with managers. When asked about monitoring call lights, NHA A reported the facility tried to keep an eye on call lights but did not have any reports or audit tools. Regarding restorative therapy. NHA A reported the facility had hired multiple people into the position, but they have come and gone. NHA A reported the facility was continuously trying to hire for that position, but in the meantime, one staff member is coming in to assist and CNAs have been doing range of motion and ambulation during care.
On 08/09/23 at 11:23 AM, when asked where the forms were located, DON B went behind the nurses' station and obtained a Resident Concern Form out of the filing cabinet.
In an interview on 08/09/23 at 12:38 PM, SW C reported the Resident Concern form that was found at the nurses' station was not in use and that the facility used the Quality Concern Form. SW C reported Resident Council concerns were not placed on Quality Concern Forms. When asked how she tracked if Resident Council concerns were resolved, SW C reported she followed up at the next resident council meeting. SW C reported she had noticed that Resident Council had continuous concerns with call lights which was first mentioned to administration in February or March 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains To Intake #MI00135054
Based on observation, interview and record review the facility failed to develop and operationalize an abuse policy consistent with regulations for three (Resident #'s 1, 9 and 23) of five reviewed, resulting in allegations of abuse to go unreported to the State Agency, not thoroughly investigated and the potential for further abuse allegations not be reported.
Findings include:
Resident #9
According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 9 (R9) was a [AGE] year old male admitted [DATE] with diagnosis that included Parkinson's disease and depression. Further review of the MDS reflected R9 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status.
On 08/09/23 at 09:00 AM, R 9 was interviewed in his room, R 9 was observed sitting in his recliner. R9 was engaging and articulate when queried about former facility employee Licensed Practical Nurse (LPN) D, R9 winced and made a grimaced facial expression. R9 further reported LPN D was not very nice, he had a very evil attitude and was rough. R9 further reported he had made several complaints to multiple staff members (unable to recall names) about LPN D being mean.
On 08/08/23 at 07:32 AM, during an interview with Director of Nursing (DON) B she confirmed that several residents had complained that LPN D Was not nice. DON B further elaborated that LPN D was terminated due complaints of being too rough with residents. When queried if that was reported to the State Agency, DON B stated that was a question for the Nursing Home Administrator (NHA) A.
On 08/08/23 at 07:50 AM, during an interview with NHA A she reported the Regional Director of Operations (RDO) H would have been the person that reported abuse to the State Agency and she was not certain if that was done.
On 08/08/23 at 01:32 PM , during an interview with NHA A and RDO H, the facility Abuse Prohibition Policy was discussed, RDO H stated R9's allegation was not reported to the State Agency because she had attended a training recently and thought the reporting requirements were going to change.
Resident #1 (R1)
Review of the medical record revealed R1 admitted to the facility on [DATE] with diagnoses that included muscle weakness, hemiplegia and hemiparesis, osteoarthritis, insomnia, anxiety, and pseudobulbar affect. The Minimum Data Set (MDS) with an Assessment Reference Date of 7/9/23 revealed R1 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS).
On 08/08/23 at approximately 1:50 PM, during the Resident Council meeting, R1 was observed sitting in her wheelchair. R1 reported the black girl with red hair grabbed my hand so hard it was black and blue and stated she (the staff member) keeps it a secret. Another resident stated, yeah she is a little rough.
On 08/08/23 at 2:02 PM, Nursing Home Administrator (NHA) A was notified of the allegations. NHA A reported if it was the aide she was thinking of, the aide no longer worked at the facility. NHA A reported the aide was rushing through care and not providing the quality of care the facility expected. NHA A reported the staff member was Certified Nursing Assistant (CNA) I. At that time, all documentation regarding the allegation and investigation was requested.
Review of the facility's investigation revealed written statements from staff. A statement dated 7/31/23 and written by Registered Nurse (RN) J revealed Writer was informed by agency nurse on station one that resident [R1] was c/o [complaining of] abuse, by her CNA [CNA I]. Writer spoke with activities [Activities Aide (AA) K] b/c [because] the resident spoke with [AA K] regarding allegations of abuse by her CNA this AM. Writer then spoke with resident, resident stated her CNA with the black and red hair who is a black woman was mean to her this morning. Resident stated, she didn't smile at all like you do and she was very rough with me getting me out of bed and I don't want her to take care of me anymore. Resident also stated, I like [names of two other CNAs] they don't treat me like a ragdoll and are very nice to me.
Review of a statement dated 7/31/23 and written by AA K revealed On Monday I went to pick up [R1] for activities, she said that the girl was being rough with, just pushing her over. She described a black girl with red hair.
Review of a third written statement by an unknown staff member revealed During medication pass writer appreciated resident to give 9am medications. I spoke to [R1] and stated Good morning [R1] how are you feeling today?' Resident then responded I won't be here longer. I'm leaving and you won't be seeing me. The black lady with the burgundy hair is always so mean. I have bruises all over! Writer attempted to ask resident when did this happen when she screamed She's abusing me. She's always so mean. Writer was accompanied by the activities aide during complaint. Writer made sure resident was safe. Then proceeded to contact the administrator.
Review of CNA I's Corrective Action Form dated 7/31/23 revealed Unacceptable job performance for incident types 012 and 117. Incident type 012 was listed as Unacceptable job performance, including failure to perform in a courteous, conscientious, and caring manner in responding to the needs of patients, visitors, and fellow employees. Incident type 117 was listed as failure to fulfill the responsibilities of the job to an extent that might reasonably or does cause injury to a patient, visitor, or another employee. The action taken was termination.
In an interview on 08/09/23 at 09:45 AM, AA K reported on 7/31/23 at approximately 9:15 AM, R1 reported to her that the CNA was being rough and pushed her over. AA K reported she notified the front office staff and the Social Worker.
On 08/09/23 at 08:42 AM and 11:18 AM, attempts were made to contact RN J via telephone. RN J did not return the call prior to the survey exit.
In an interview on 08/09/23 at 10:02 AM with Nursing Home Administrator (NHA) A and Regional Director of Operations (RDO) H, NHA A reported that R1 reported to a staff member that an aide rushed her, moved her around, and that she didn't like her. NHA A reported CNA I was immediately sent home and an investigation was started. NHA A reported the allegation was not reported to the State Agency because after the investigation, the facility felt it was more of a rushed situation. NHA A reported the investigation took two days to complete. RDO H reported rushing a resident was not abuse. When the staff statements were read, RDO H reported the statements were abuse allegations and it should have been reported to the State Agency.
Review of the facility's Abuse Investigations Policy dated 9/2018 and revised/reviewed 2/2019 revealed 17. Inquiries concerning abuse reporting and investigation will be reported immediately to the Administrator or to the Designee whom will report according to the State of Michigan and federal guidelines and investigations to include the state standardized materials.
18. Incidents will be investigated and the Administrator or Designee will report according to the guidelines. If the resident suffers serious bodily injury, it must be reported within two hours of the event. If there is no serious bodily injury, then a report must be filed within 24 hours of the event. The facility will submit the Facility Incident Report-24 Hours no later than 24 hours after the discovery at https://bhcs.mihealth.org
19. Within 5 working days the facility will submit the Facility Investigation Report.
20.Facility emergencies (fires, loss of water, power or food services for more than 4 hours; the failure of a backup emergency generator, a natural disaster; roof failure; mechanical disaster' unplanned failure of the fire alarm system; evacuation must be reported. Non-business hours [PHONE NUMBER]. Licensing Officer during regular business hours.
Review of facility's Reporting of Abuse to Facility Management policy effective 9/2018 and revised/reviewed 2/2019 revealed.
9. When an incident of resident abuse is suspected or confirmed, the incident must be
immediately reported to Administrator or Designee regardless of the time lapse since the
incident occurred. Reporting procedures should be followed as outlined in this policy. There are two reporting timeframes depending on whether the resident suffers serious bodily injury. Serious bodily injury is defined as an injury involving extreme physical pain: involving substantial risk of death: involving protracted loss or impairment of the function of a bodily member, organ, or mental facility: or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation. If the resident suffers serious bodily injury, it must be reported within two hours of the event. If there is no serious bodily injury, then a report must be filed within twenty-four hours of the event.
On 8/9/23 at 10:02 AM, NHA A and RDO H were asked if there were further facility policies for reporting abuse allegations to the State Agency. NHA A and RDO H reported they would look for a policy. An additional policy was not received prior to the survey exit.
Resident #23 (R23)
Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed.
During observation and attempted interview on 08/07/2023 at 10:08 a.m. R23 was observed lying in bed. R23 did not respond to verbal questions.
During a telephone interview on 08/07/2023 at 11:09 a.m. R23's family member N explained that R23 had a fall at the facility that had occurred within the last year. She explained that fall had resulted in R23 having a broken hip.
During observation and attempted interview on 08/08/2023 at 08:11 a.m. R23 was observed sitting up in her w/c, in her room. During attempted interview with resident responded oh to questions and nodded head. She also would start talking in a foreign language.
Review of R23's facility Event Report, dated 11/22/2022, demonstrated that she had an occurrence on 11/22/2022 at 10:39 a.m. The document entitled Event Report demonstrated that on 11/13/2022 at 01:30 a.m. R23 had been favoring her left thigh/hip during transfers and had not been able to bear her weight on that leg. The Event Report also demonstrate that staff observed R23 to have facial grimacing and holding her left hip. The Event Report demonstrated that an x-ray was ordered. The same Event Report demonstrated that mobile x-ray could not be performed on 11/13/22 at 10:22 p.m. because R23 could not hold still during the attempted x-ray. R23 was sent out to the hospital at that time. The same Event Report demonstrated that on 11/14/23 at 12:56 a.m. that the facility was notified that R23 had a Impact angulated left subcaptial femoral fracture. Review of the investigation file provided by the facility did not demonstrate the cause of R23's fracture and did not indicate that the injury of unknown origin had been reported to the appropriate state agency.
In an interview on 08/09/2023 at 10:01 a.m. Nursing Home Administrator (NHA) A explained that she was aware of R23's Event Report dated 11/12/2022. She explained that she was aware that R23 had a left hip fracture that required hospitalization. When asked if this injury had been reported to the appropriate state agency, she responded No. NHA explained that during the investigation of this incident the facility had determined that the fracture was a result of an unwitnessed fall. NHA A could not provide any documentation supporting that finding. When NHA A was asked why the injury was not report to the appropriate state agency she could not provide an answer. When asked if the facility policy included that injuries of unknown origin are to be reported to the appropriate state agency she responded, I believe so.
During record review of facility policy entitled Abuse Investigation, effective date of 09/2018 and a revision date of 02/19, number 1 stated 18. Incidents will be investigated, and the Administrator or Designee will report according to the guidelines. If the resident suffers serious bodily injury, it must be reported within two hours of the event. If there is no serious bodily injury, then a report must be filed within 24 hours of the event. The facility will submit the Facility Incident Report-24 Hours no later than 24 hours after the discovery .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains To Intake #MI00135054
Based on observation, interview, and record review, the facility failed to report allegations of abuse for three (Resident #1, #9 and #23) of 5 reviewed, resulting in allegations of abuse that were not reported to the State Agency and the potential for further allegations of abuse to go unreported.
Findings include:
Resident #9
According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 9 (R9) was a [AGE] year old male admitted [DATE] with diagnosis that included Parkinson's disease and depression. Further review of the MDS reflected R9 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status.
On 08/09/23 at 09:00 AM, R 9 was interviewed in his room, R 9 was observed sitting in his recliner. R9 was engaging and articulate when queried about former facility employee Licensed Practical Nurse (LPN) D, R9 winced and made a grimaced facial expression. R9 further reported LPN D was not very nice, he had a very evil attitude and was rough. R9 further reported he had made several complaints to multiple staff members (unable to recall names) about LPN D being mean.
On 08/08/23 at 07:32 AM, during an interview with Director of Nursing (DON) B she confirmed that several residents had complained that LPN D Was not nice. DON B further elaborated that LPN D was terminated due complaints of being too rough with residents. When queried if that was reported to the State Agency, DON B stated that was a question for the Nursing Home Administrator (NHA) A.
On 08/08/23 at 07:50 AM, during an interview with NHA A she reported the Regional Director of Operations (RDO) H would have been the person that reported abuse to the State Agency and she was not certain if that was done.
On 08/08/23 at 01:32 PM , during an interview with NHA A and RDO H, the facility Abuse Prohibition Policy was discussed, RDO H stated R9's allegation was not reported to the State Agency because she had attended a training recently and thought the reporting requirements were going to change. NHA A stated the facility investigated R9's allegation of abuse but since they did not substantiate abuse they did not report R9's allegation of abuse to the State Agency.
Resident #1 (R1)
Review of the medical record revealed R1 admitted to the facility on [DATE] with diagnoses that included muscle weakness, hemiplegia and hemiparesis, osteoarthritis, insomnia, anxiety, and pseudobulbar affect. The Minimum Data Set (MDS) with an Assessment Reference Date of 7/9/23 revealed R1 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS).
On 08/08/23 at approximately 1:50 PM, during the Resident Council meeting, R1 was observed sitting in her wheelchair. R1 reported the black girl with red hair grabbed my hand so hard it was black and blue and stated she (the staff member) keeps it a secret. Another resident stated, yeah she is a little rough.
On 08/08/23 at 2:02 PM, Nursing Home Administrator (NHA) A was notified of the allegations. NHA A reported if it was the aide she was thinking of, the aide no longer worked at the facility. NHA A reported the aide was rushing through care and not providing the quality of care the facility expected. NHA A reported the staff member was Certified Nursing Assistant (CNA) I. At that time, all documentation regarding the allegation and investigation was requested.
Review of the facility's investigation revealed written statements from staff. A statement dated 7/31/23 and written by Registered Nurse (RN) J revealed Writer was informed by agency nurse on station one that resident [R1] was c/o [complaining of] abuse, by her CNA [CNA I]. Writer spoke with activities [Activities Aide (AA) K] b/c [because] the resident spoke with [AA K] regarding allegations of abuse by her CNA this AM. Writer then spoke with resident, resident stated her CNA with the black and red hair who is a black woman was mean to her this morning. Resident stated, she didn't smile at all like you do and she was very rough with me getting me out of bed and I don't want her to take care of me anymore. Resident also stated, I like [names of two other CNAs] they don't treat me like a ragdoll and are very nice to me.
Review of a statement dated 7/31/23 and written by AA K revealed On Monday I went to pick up [R1] for activities, she said that the girl was being rough with, just pushing her over. She described a black girl with red hair.
Review of a third written statement by an unknown staff member revealed During medication pass writer appreciated resident to give 9am medications. I spoke to [R1] and stated Good morning [R1] how are you feeling today?' Resident then responded I won't be here longer. I'm leaving and you won't be seeing me. The black lady with the burgundy hair is always so mean. I have bruises all over! Writer attempted to ask resident when did this happen when she screamed She's abusing me. She's always so mean. Writer was accompanied by the activities aide during complaint. Writer made sure resident was safe. Then proceeded to contact the administrator.
Review of CNA I's Corrective Action Form dated 7/31/23 revealed Unacceptable job performance for incident types 012 and 117. Incident type 012 was listed as Unacceptable job performance, including failure to perform in a courteous, conscientious, and caring manner in responding to the needs of patients, visitors, and fellow employees. Incident type 117 was listed as failure to fulfill the responsibilities of the job to an extent that might reasonably or does cause injury to a patient, visitor, or another employee. The action taken was termination.
In an interview on 08/09/23 at 09:45 AM, AA K reported on 7/31/23 at approximately 9:15 AM, R1 reported to her that the CNA was being rough and pushed her over. AA K reported she notified the front office staff and the Social Worker.
On 08/09/23 at 08:42 AM and 11:18 AM, attempts were made to contact RN J via telephone. RN J did not return the call prior to the survey exit.
In an interview on 08/09/23 at 10:02 AM with Nursing Home Administrator (NHA) A and Regional Director of Operations (RDO) H, NHA A reported that R1 reported to a staff member that an aide rushed her, moved her around, and that she didn't like her. NHA A reported CNA I was immediately sent home and an investigation was started. NHA A reported the allegation was not reported to the State Agency because after the investigation, the facility felt it was more of a rushed situation. NHA A reported the investigation took two days to complete. RDO H reported rushing a resident was not abuse. When the staff statements were read, RDO H reported the statements were abuse allegations and it should have been reported to the State Agency.
Resident #23 (R23)
Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed.
During observation and attempted interview on 08/07/2023 at 10:08 a.m. R23 was observed lying in bed. R23 did not respond to verbal questions.
During a telephone interview on 08/07/2023 at 11:09 a.m. R23's family member N explained that R23 had a fall at the facility that had occurred within the last year. She explained that fall had resulted in R23 having a broken hip.
During observation and attempted interview on 08/08/2023 at 08:11 a.m. R23 was observed sitting up in her w/c, in her room. During attempted interview with resident responded oh to questions and nodded head. She also would start talking in a foreign language.
Review of R23's facility Event Report, dated 11/22/2022, demonstrated that she had an occurrence on 11/22/2022 at 10:39 a.m. The document entitled Event Report demonstrated that on 11/13/2022 at 01:30 a.m. R23 had been favoring her left thigh/hip during transfers and had not been able to bear her weight on that leg. The Event Report also demonstrate that staff observed R23 to have facial grimacing and holding her left hip. The Event Report demonstrated that an x-ray was ordered. The same Event Report demonstrated that mobile x-ray could not be performed on 11/13/22 at 10:22 p.m. because R23 could not hold still during the attempted x-ray. R23 was sent out to the hospital at that time. The same Event Report demonstrated that on 11/14/23 at 12:56 a.m. that the facility was notified that R23 had a Impact angulated left subcaptial femoral fracture. Review of the investigation file provided by the facility did not demonstrate the cause of R23's fracture and did not indicate that the injury of unknown origin had been reported to the appropriate state agency.
In an interview on 08/09/2023 at 10:01 a.m. Nursing Home Administrator (NHA) A explained that she was aware of R23's Event Report dated 11/12/2022. She explained that she was aware that R23 had a left hip fracture that required hospitalization. When asked if this injury had been reported to the appropriate state agency, she responded No. NHA explained that during the investigation of this incident the facility had determined that the fracture was a result of an unwitnessed fall. NHA A could not provide any documentation supporting that finding. When NHA A was asked why the injury was not report to the appropriate state agency she could not provide an answer. When asked if the facility policy included that injuries of unknown origin are to be reported to the appropriate state agency she responded, I believe so.
During record review of facility policy entitled Abuse Investigation, effective date of 09/2018 and a revision date of 02/19, number 1 stated 18. Incidents will be investigated, and the Administrator or Designee will report according to the guidelines. If the resident suffers serious bodily injury, it must be reported within two hours of the event. If there is no serious bodily injury, then a report must be filed within 24 hours of the event. The facility will submit the Facility Incident Report-24 Hours no later than 24 hours after the discovery .