Every finding on record at Grand Valley Health & Rehab

Based on record review and interview, the facility failed to ensure medication were administered per the physician's orders for 2 of 5 residents reviewed for unnecessary medications. (Resident 71, Resident 33) Findings include: 1. On 6/12/25 at 11:35 a.m., Resident 71's clinical record was reviewed. The diagnoses included, but were not limited to, congestive heart failure and atrial flutter. A Physician's Order for metoprolol (a medication used to slow the heart rate) 50 mg (milligrams) oral tablet extended release daily, initiated 4/6/25. The medication was to be held if the resident's pulse was below 60 beats per minute. The Medication Administration Record indicated on the following dates, the medication was administered when the resident's pulse was below 60 beats per minute: - On 5/725, 57 beats per minute. - On 5/8/25, 52 beats per minute. - On 5/12/25, 57 beats per minute. - On 5/13/25, 57 beats per minute. - On 5/19/25, 57 beats per minute. - On 5/21/25, 55 beats per minute. - On 5/22/25, 58 beats per minute. - On 5/27/25, 53 beats per minute. - On 6/2/25, 52 beats per minute. - On 6/4/25, 52 beats per minute. - On 6/5/25, 55 beats per minute. - On 6/7/25, 57 beats per minute. - On 6/9/25, 53 beats per minute. 2. On 6/11/25 at 11:05 a.m., Resident 33's clinical record was reviewed. The diagnoses included, but were not limited to, hypertension, atrial fibrillation, and respiratory failure. The Physician Order Report indicated metoprolol tartrate 25 (mg) milligrams administer half tablet by mouth twice a day. Hold the medication if heart rate was less than 60 or the systolic (the top number in a blood pressure reading) blood pressure was less than 110 (order start date 12/27/24). The May 2025 Medication Administration Record (MAR) indicated to administer metoprolol tartrate 25 mg half tablet twice a day. Hold the medication if heart rate was less than 60 or the systolic blood pressure was less than 110. The MAR indicated the following: - On 5/21/25 at 6:30 a.m. - 10:30 a.m. the medication was administered. The pulse was 57. The clinical record lacked documentation of medication being held. The June 2025 Medication Administration Record indicated to administer metoprolol tartrate 25 mg half tablet twice a day. Hold the medication if heart rate was less than 60 or the systolic blood pressure was less than 110. The MAR indicated the following: - On 6/1/25 at 6:30 p.m. - 10:30 p.m. the medication was administered. The blood pressure was 103/76. The clinical record lacked documentation of medication being held. - On 6/7/25 at 6:30 a.m. - 10:30 a.m. the medication was administered. The blood pressure was 100/56. The clinical record lacked documentation of medication being held. - On 6/9/25 at 6:30 a.m. - 10:30 a.m. the medication was administered. The blood pressure was 101/43. The clinical record lacked documentation of medication being held. During an interview on 6/12/25 at 1:35 p.m., the Director of Nursing indicated per physician order, the medication should not have been administered to the resident on the aforementioned dates. On 6/12/25 at 2:01 p.m., the Corporate Administrator provided the facility's policy, Medication Administration, revised date 4/17, and indicated it was the policy being used. A review of the policy indicated, .To safely administer medications as per physicians' order .20. Always take pulse and B/P as indicated if ordered prior to giving certain cardiac or antihypertensive drugs. Notify the physician if the vital signs are not within the acceptable range . 3.1-35(g)(1)

Based on interview and record review, the facility failed to ensure designation of a certified Infection Preventionist (IP). The IP did not currently dedicate at least part time hours to the role of IP for 2 of 2 staff members reviewed for IP (Director of Nursing and RN 1). Findings include: On 6/8/25 at 11:30 a.m., the Administrator provided documentation which indicated the Director of Nursing (DON) was the facility's Infection Preventionist (IP) nurse. During an interview on 6/12/25 at 2:05 p.m., RN 1 indicated she was responsible for the infection tracking and monitoring. She had not received certification in Infection Prevention and Control. During an interview on 6/12/25 at 2:05 p.m., the DON indicated she was currently responsible for the infection prevention quality and assurance. She indicated she also worked full time in the facility as the DON and was unable to show she devoted 20 hours each week to infection prevention. She confirmed RN 1 did not have infection prevention certification. During an interview on 6/12/25 at 2:26 p.m., the Corporate Administrator indicated he was aware the facility needed to have a staff member devoted to the IP nurse role which was not the DON. On 6/12/25 at 2:26 p.m., the Corporate Administrator provided the IP job description, Infection Preventionist, dated 2023, and indicated it was the job description currently being used. A review of the job description indicated, . Reports To: Director of Nursing . 5. Infection prevention and control (IPC) training must be sufficient to perform the role of the IP . 6. An IP must have obtained specialized PIC training beyond initial professional training or education prior to assuming the role . On 6/12/25 at 2:26 p.m., the Corporate Administrator provided the DON job description, Director of Nursing, dated 2023, and indicated it was the job description currently being used. A review of the job description indicated, . Summary: . He/she assumes responsibility for nursing service compliance in accordance to facility policy and procedure as well as Federal Regulations and State Rules governing the facility .

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was labeled and dated for 5 of 5 residents reviewed for respiratory care. (Resident 6, Resident 47, Resident 60, Resident 51, and Resident 44). Findings include 1. On 4/23/23 at 12:05 p.m., Resident 6 was observed in bed in her room. She was receiving oxygen via oxygen tubing and a nasal cannula. The oxygen tubing had no label indicating the date it was changed. On 4/25/23 at 9:40 a.m., Resident 6 was observed in bed in her room. She was receiving oxygen via oxygen tubing and a nasal cannula. The oxygen tubing had no label indicating the date it was changed. On 4/26/23 at 10:00 a.m., Resident 6 was observed in bed in her room. She was receiving oxygen via oxygen tubing and a nasal cannula. The oxygen tubing had no label indicating the date it was changed. On 4/25/23 at 2:30 p.m., Resident 6's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction and chronic obstructive pulmonary disease. A current physician's order with a start date of 8/30/22 indicated the resident was prescribed supplemental oxygen at 2 liters per minute. 2. On 4/23/23 at 12:05 p.m., Resident 47 was observed in bed in his room. On the floor, beside the bed was a nasal cannula and oxygen tubing attached to an oxygen delivery machine. The oxygen tubing had no label indicating the date it was changed. On 4/25/22 at 9:45 a.m., Resident 47 was observed in bed in his room. On the floor, beside the bed was a nasal cannula and oxygen tubing attached to an oxygen delivery machine. The oxygen tubing had no label indicating the date it was changed. On 4/26/23 at 10:05 a.m., Resident 47 was observed in bed in his room. On the floor, beside the bed was a nasal cannula and oxygen tubing attached to an oxygen delivery machine. The oxygen tubing had no label indicating the date it was changed. On 4/25/23 at 2:40 p.m., Resident 47's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease and chronic obstructive pulmonary disease. A current physician's order with a start date of 8/30/22 indicated the resident was prescribed supplemental oxygen at 2 liters per minute. 3. On 4/23/23 at 12:15 p.m., Resident 60 was observed in her chair in her room. She was receiving oxygen via oxygen tubing and a nasal cannula. The oxygen tubing had no label indicating the date it was changed. On 4/25/23 at 9:50 a.m., Resident 60 was observed in her chair in her room. She was receiving oxygen via oxygen tubing and a nasal cannula. The oxygen tubing had no label indicating the date it was changed. On 4/26/23 at 10:10 a.m., Resident 60 was observed in her chair in her room. She was receiving oxygen via oxygen tubing and a nasal cannula. The oxygen tubing had no label indicating the date it was changed. On 4/25/23 at 3:05 p.m., Resident 60's clinical record was reviewed. The diagnoses included, but were not limited to, chronic respiratory failure and chronic obstructive pulmonary disease. A current physician's order with a start date of 8/31/22 indicated the resident was prescribed supplemental oxygen at 2 liters per minute. 34848 4. On 4/25/23 at 11:51 a.m., Resident 51 was observed in her bedroom receiving concentrated oxygen via nasal cannula. No date was observed on the oxygen tubing nor concentrator. The resident indicated staff change the tubing when they replace the water (concentrator). On 4/26/23 at 10:15 a.m., Resident 51's clinical record was reviewed. The diagnoses included, but were not limited to, asthma, Chronic Obstructive Pulmonary Disease (COPD), obstructive hypertropic cardiomyopathy (a condition in which the heart muscle becomes abnormally thick), and heart failure. Review of the resident's current, April, 2023, physicians orders indicated on 2/10/23, the resident was ordered continuous supplemental oxygen via nasal cannula flowing at 1 liter per minute. 35318 5. On 4/24/23 at 10:51 a.m., Resident 44 was observed to be lying in bed with an oxygen nasal cannula in her nostrils. The tubing for the oxygen and the humidification bottle were undated. On 4/26/23 at 9:42 a.m., Resident 44 was observed to be lying in bed with an oxygen nasal cannula in her nostrils. The tubing for the oxygen was undated. On 4/27/23 at 11:25 a.m., Resident 44 was observed to be lying in bed with an oxygen nasal cannula in her nostrils. The tubing for the oxygen was undated. On 4/28/23 at 10:23 a.m., Resident 44 was observed to be lying in bed with an oxygen nasal cannula in her nostrils. The tubing for the oxygen was undated. Resident 44's clinical record was reviewed on 4/26/23 at 11:07 a.m. The diagnosis included, but was not limited to, chronic respiratory failure. Physician orders, dated 4/27/23, indicated Resident 44 utilized supplemental oxygen via nasal cannula at 2 L (liters) as needed. During an interview on 4/26/23 at 10:25 a.m., the DON indicated the oxygen tubing and humidifiers had no labels as they should have had that indicated when they were changed and Resident 47's tubing and cannula should not have been on the floor. On 4/28/23 at 11:00 a.m., the DON provided the facility policy, Oxygen Therapy, dated 10/2014, and indicated this was the policy currently being used by the facility. A review of the policy did not indicate putting a date on the oxygen tubing or the humidification bottle. 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for residents who transferred to the hospital was provided for 1 of 4 residents reviewed for hospitalization . (Resident 57) Finding includes: On 4/27/23 at 10:15 a.m., Resident 57's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease, cholecystitis (inflammation of the gall bladder), and diabetes mellitus. Resident 57's progress notes indicated the following: - On 12/31/22 at 8:30 a.m., Resident 57 was sent to the emergency room . There was no documentation that a written notice that specified the facility's bed-hold policy was provided to the resident or the resident's representative. - On 1/13/23 at 9:45 a.m., Resident 57 was sent to the the emergency room . There was no documentation that a written notice that specified the facility's bed-hold policy was provided to the resident or the resident's representative During an interview on 4/28/23 at 12:25 p.m., the Director of Nursing (DON) indicated Resident 57's bed-hold policy lacked the resident or resident's representative notification in writing. On 4/28/23 at 12:51 p.m., the DON provided the facility policy, Bedhold, revision date 7/2018, and indicated this was the policy currently being used by the facility. A review of the policy indicated .At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident to the resident or resident representative written notice which specifies the duration of the bed-hold policy 3.1-12(a)(25) 3.1-12(a)(26)

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was given to the resident or the resident representative for 1 of 4 residents reviewed for hospitalization . (Resident 57) Finding includes: On 4/27/23 at 10:15 a.m., Resident 57's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease, cholecystitis (inflammation of the gall bladder), and diabetes mellitus. A progress note, dated 12/31/22 at 8:30 a.m., indicated Resident 57 was sent to the emergency room . The Notice of Transfer or Discharge, dated 12/31/22, lacked documentation the resident or the resident's representative had been notified of the transfer in writing and provided the appeal rights information in writing including the contact information of the the Office of the State LTC (Long Term Care) Ombudsman after the resident was sent out to the hospital. A progress note, dated 1/13/23 at 9:45 a.m., indicated Resident 57 was sent to the the emergency room . The Notice of Transfer or Discharge, dated 1/12/23, lacked documentation the resident or the resident's representative had been notified of the transfer in writing and provided the appeal rights information in writing including the contact information of the the Office of the State LTC (Long Term Care) Ombudsman after the resident was sent out to the hospital. During an interview on 4/28/23 at 12:25 p.m., the Director of Nursing (DON) indicated the Notice of Transfer or Discharge for Resident 57 lacked the resident or resident's representative notification in writing. On 4/28/23 at 12:51 p.m., the DON provided the facility policy, Transfer/Discharge, dated 1/2015 and indicated this was the policy currently being used by the facility. A review of the policy indicated .(A) Notify the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner that the resident understands. The health facility must place a copy of the notice in the residents' clinical record and transmit a copy to the following: (i) The resident .(iii) The resident's legal representative 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(iii)

Based on observation and interview, the facility failed to ensure resident wheelchair arm pads were in good repair and a resident wheelchair was clean for 5 of 24 residents reviewed for environment (Resident 6, Resident 26, Resident 45, Resident 240, Resident 241) Findings include: 1. On 6/28/22 at 2:45 P.M., the right arm pad of Resident 6's wheelchair was observed to have cracks in the covering, revealing the underlying white padding. 2. On 6/28/22 at 2:55 P.M., the right and left arm pads of Resident 26's wheelchair were observed to have cracks in the covering, revealing the underlying white padding. 3. On 6/28/22 at 3:20 P.M., the right and left arm pads of Resident 45's wheelchair were observed to have cracks in the covering, revealing the underlying white padding. 4. On 6/29/22 at 11:55 A.M., the right arm pad of Resident 241's wheelchair were observed to have cracks in the covering, revealing the underlying white padding. 5. On 6/28/22 at 2:30 P.M., 7/1/22 at 3:05 P.M., and 7/5/22 at 10:45 A.M., Resident 240's wheelchair was observed to have food crumbs in the seat, the seat back folds, and the cloth beneath the seat. On 7/5/22 at 11:38 A.M., the Director of Nursing indicated the damaged wheelchair arm pads were in need of repair and Resident 240's wheelchair was in need of cleaning. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure a urinary drainage bag attached to an ostomy (an artificial opening in an organ of the body) was positioned off the floor for 1 of 1 residents reviewed for a [MEDICATION(S)]. (Resident 30) Finding includes: On 6/29/2022 at 9:49 a.m., Resident 30 was observed to be propelling herself using the handrail while sitting in a wheelchair on the 400 unit. A drainage bag used for urine was observed to be attached to the wheelchair and was dragging on the floor. On 6/29/2022 at 1:53 p.m., Resident 30 was observed to be in bed asleep with the urine drainage bag touching the floor. On 6/29/2022 at 2:54 p.m., Resident 30 was observed to be in bed asleep with the urine drainage bag touching the floor. On 6/30/2022 at 2:20 p.m., Resident 30 was observed to be in bed asleep with the urine drainage bag touching the floor. Resident 30's clinical record was reviewed on 6/30/2022 at 12:28 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders, dated 6/1/2022 through 6/30/2022, indicated . Change ostomy pouch weekly on Monday, Thursday and as needed . A care plan, initiated on 2/12/2021, and revised on 4/26/2022, for Resident 30 indicated: . FOCUS: The resident requires the use of a urinary ostomy due to [CONDITION(S)] bladder . GOAL: The resident will be free from signs and symptoms of infection through next review . INTERVENTIONS: Position catheter tubing and drainage bag in such a way to avoid contact with the floor . A review of the nursing progress notes indicated Resident 30 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/30/2022 at 2:22 p.m., Registered Nurse 1 indicated the urinary drainage bag should be positioned off the floor. During an interview on 6/30/2022 at 11:35 a.m., the Director of Nursing indicated the urinary drainage bag should not have been touching the floor. On 6/30/2022 at 3:41 p.m., the Nurse Consultant provided the facility's policy,Urinary Drainage Bag Maintenance, with a revised date of 1/2020, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Purpose: Closed urinary drainage will provide a reservoir to continuously collect urine from the bladder via an indwelling catheter . Urinary drainage bag should not be allowed to touch the floor . 3.1-47(a)(3)

Based on observation, interview, and record review, the facility failed to ensure food was prepared to conserve nutritive value, flavor and appearance for 11 of 24 residents reviewed for food services. (Resident 3, 18, 27, 29, 31, 35, 36, 51, 66, 72, and 80). Findings include: During an interview, on 7/13/21 at 2:40 p.m., Resident 3 indicated the facility had a problem with food. The meals were always the same, usually some type of Italian food, and the food did not taste good. I have tried and tried to get them to do something about the food, but no one will do anything. Their quarterly MDS (Minimum Data Set) assessment, dated 4/4/21, indicated they were cognitively intact. During an interview, on 7/15/21 at 2:22 p.m., Resident 29 indicated the food was not good in taste and texture. The resident's admission MDS assessment, dated 5/19/21, indicated the resident was cognitively intact. During an interview, on 7/13/21 at 12:02 p.m., 51 indicated the room trays were not delivered until 2:00 p.m., and the food was often cold and did not taste good. On 7/19/21 11:10 a.m., the resident indicated they were served raw eggs for breakfast, and most of the time the food was so terrible they wouldn't feed it to my hogs. The resident's quarterly MDS, dated [DATE], indicated the resident was moderately cognitively impaired. During an interview, 7/13/21 at 12:03 p.m., Resident 18 indicated lunch trays were not delivered until 2:00 p.m., it is cold, and does not taste good. On 7/19/21 at 11:12 a.m., the resident indicated the food remained poorly cooked and tasted terrible. The resident's quarterly MDS assessment, dated 4/8/21, indicated the resident was cognitively intact. During an interview, on 7/14/21 at 9:30 a.m., Resident 36 indicated the food was terrible and they do not get their meal tray until after 1:30 p.m. on most days. The resident's quarterly MDS, dated [DATE], indicated the resident was cognitively intact. During an interview, on 7/15/21 at 10:06 a.m., Resident 31 indicated the food did not taste good. The resident's significant change MDS, dated [DATE], indicated the resident was cognitively intact. On 7/19/21 at 10:13 a.m., a Resident Council meeting was conducted. Each resident who attended the meeting indicated the food did not taste good, was frequently cold, was not good in texture, and lacked variety. The following residents participated in the meeting: -Resident 3. Their quarterly MDS assessment, dated 4/4/21, indicated they were cognitively intact. -Resident 27. Their annual MDS assessment, dated 4/21/21, indicated they were moderately cognitively impaired. -Resident 35. Their change in status MDS assessment, dated 5/7/21, indicated they were cognitively intact. -Resident 66. Their change in status MDS assessment, dated 6/9/21, indicated they were cognitively intact. -Resident 72. Their change in status MDS assessment, dated 6/16/21, indicated they were moderately cognitively impaired. -Resident 80. Their admission MDS assessment, dated 6/20/21, indicated they were cognitively intact. A review of the Resident Council minutes indicated the following: July: meals were frequently cold, meals were frequently late, and there was little attention paid to residents' food preferences. June: no attention was paid to resident preferences and meals lacked variety May: residents received the same menu without variety, food was not warm, and meals were served late. On 7/16/21 at 12:10 p.m., a lunch test tray was sampled. The meal was observed to consist of a hot dog on a bun, potato chips, and baked beans. The baked beans lacked flavor and the hot dog bun was dry in texture. On 7/20/21 12:15 p.m., a lunch test tray was sampled. The meal was observed to consist of a polish sausage, mashed potatoes with brown gravy, and sauerkraut. The polish sausage's outer skin was rubbery and split apart down the middle. The alternate meal was beef chili with beans and forest pears. The forest pears were grainy in texture. During an interview, on 7/19/2 at 11:27 a.m., the Administrator indicated the meal service menu comes from the corporate office, however, the facility was able to alter the menu to accommodate resident requests. The listed menu food is served to the resident and if the resident did not care for it, they could order something from the alternative menu. The resident would have to wait until the meal service was passed out to other residents before they could get the alternative option. During an interview, on 7/19/21 12:20 p.m., CNA (certified nursing assistant) 1 indicated staff was not always able to provide adequate assistance to residents who eat in their rooms because they are sometimes short-staffed and have to pass out all of the hall trays before they can provide assistance to the residents. During an interview, on 7/19/21 at 12:30 p.m., CNA 2 indicated the food was frequently cold, had to be reheated, and the residents complained about the menu options and taste of food. 3.1-21(a)(1) 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such group concerning issues of resident care and life in the facility for 6 of 6 residents reviewed during Resident Council meeting (Resident 3, 27, 35, 66, 72, and 80). Findings include: On 7/19/21 at 10:13 a.m., a Resident Council meeting was conducted. Each resident who attended the meeting indicated the food did not taste good, was frequently cold, was not good in texture, and lacked variety. The following residents participated in the meeting: -Resident 3. Their quarterly MDS (Minimum Data Set) assessment, dated 4/4/21, indicated they were cognitively intact. -Resident 27. Their annual MDS assessment, dated 4/21/21, indicated they were moderately cognitively impaired. -Resident 35. Their change in status MDS assessment, dated 5/7/21, indicated they were cognitively intact. -Resident 66. Their change in status MDS assessment, dated 6/9/21, indicated they were cognitively intact. -Resident 72. Their change in status MDS assessment, dated 6/16/21, indicated they were moderately cognitively impaired. -Resident 80. Their admission MDS assessment, dated 6/20/21, indicated they were cognitively intact. A review of the Resident Council minutes indicated the following: -May, 2021, .Dietary: Too much pasta dinners, knifes [sic] don't cut food, portions are small, same menu over and over, hot food is cold and all meals are served late . There was no follow-up documentation in regard to the resident council's concerns which were brought up during the meetings. -June, 2021, .Dietary: too much pasta. Food is cold . Not paying attention to dislikes. Meals are late/cold . There was no follow-up documentation in regard to the resident council's concerns which were brought up during the meetings. On 7/16/21 at 12:10 p.m., a lunch test tray was sampled. The meal was observed to consist of a hot dog on a bun, potato chips, and baked beans. The baked beans lacked flavor and the hot dog bun was dry in texture. On 7/20/21 12:15 p.m., a lunch test tray was sampled. The meal was observed to consist of a polish sausage, mashed potatoes with brown gravy, and sauerkraut. The polish sausage's outer skin was rubbery and split apart down the middle. The alternate meal was beef chili with beans and forest pears. The forest pears were grainy in texture. During an interview, on 7/19/2 at 11:27 a.m., the Administrator indicated the facility began Resident Council meetings in May, 2021. On 7/20/21 the clinical nurse consultant provided the facility policy, RESIDENT COUNCIL, revised August, 2013, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .6. The Administrator will review reports submitted by the Council and will make recommendations and/or take appropriate action. All problem areas will be addressed on the Resident Council Minutes as well as the Resident Council Feedback . 3.1-3(l)

Based on observation, interview, and record review, the facility failed to ensure drugs were stored in locked compartments, and controlled drugs were stored in a separate locked and permanently affixed compartment for 1 of 4 treatment carts, 1 of 2 respiratory treatment carts, 1 of 8 medication carts, and 1 of 8 controlled drug compartments. Findings include: On 7/12/21, from 11:10 A.M. to 11:30 A.M., the treatment cart on the 300 unit hall was observed to be unattended by staff, with resident medications sitting on top of the cart. On 7/12/21, from 11:10 A.M. to 11:30 A.M., the respiratory treatment cart on the dining room hallway was observed to be unlocked and unattended by staff. Inside the cart were resident respiratory medications. On 7/15/21, from 10:50 A.M. to 11:15 A.M., a medication cart on the 200 unit was observed to be unlocked and unattended by staff. Inside the cart were resident medications and an unlocked controlled drug compartment containing resident controlled drugs. On 7/15/21, from 10:50 A.M. to 11:15 A.M., the treatment cart on the 300 unit was observed to be unlocked and unattended by staff. Inside the cart were resident medications. During an interview, on 7/12/21 at 11:31 A.M., the Director of Nursing indicated the 300 unit treatment cart was unattended by staff and had resident medications on top of the cart. The respiratory treatment cart on the dining room hallway was unlocked and unattended by staff. During an interview, on 7/15/21 at 11:17 A.M., the facility Administrator indicated the medication cart on the 200 unit was unlocked and unattended by staff. The controlled drug compartment in the unlocked medication cart was unlocked. On 7/20/21 at 10:15 A.M., the Director of Nursing provided the Storing Drugs policy, dated 4/2021, and indicated this was the policy currently used by the facility. A review of the policy indicated, .drugs .will be stored in a safe, secure .manner .when a permitted person is not in a drug storage area, the drug storage areas and devices must be kept locked .controlled drugs are subject to special storage that is only accessible to authorized personnel .must be stored by a double lock in a separate area . 3.1-25(m) 3.1-25(n)

Based on observation, interview, and record review, the facility failed to ensure residents' call lights were answered in a timely manner by any staff member for 5 of 5 residents reviewed for timely answered call lights. (Resident B, C, D, E, F). Findings include: Observation of call light responses began, on 3/5/2020 at 3:30 p.m., at main nurses station in front of 1 of 2 call light systems. During the 20 minute observation, Resident E's call light was observed to not be responded to until 17 minutes after the call light was first turned on. During that time, 7 staff members were observed to be standing and talking without any response to the call light. Observation of LPN 1 (Licensed Practical Nurse), on 3/5/2020, at 3:30 p.m., on hall 200 indicated she walked back and forth to the first section of the hall and back to nurses station, without acknowledging the call light on at the end of the 200 hall (Resident E). Observation of call lights, on 3/6/2020 10:00 a.m., call lights began to go off and staff (four) stood in front of halls 200 and 100. No staff member was observed to respond to any of the call lights for 7 minutes (Resident C) . Observation of a red call light, on 3/6/2020 at 12:15 p.m., indicated the light was on for 7 minutes (Resident D). Interview, at that time, the DON (Director of Nursing) indicated the red light was for the bathroom and had been on approximately 7 minutes prior to being answered. Observation of the call light system, on 3/5/2020 at 3:00 p.m., indicated there were 2 call light boxes, one on each side of the main nursing station, the system showed room number, type of light (white or red) and how long the call light had been on. Resident B's clinical record was reviewed on 3/5/2020 at 10:55 a.m. [DIAGNOSES REDACTED]. The admission cognitive assessment, dated 1/31/2020, indicated Resident B was cognitively intact. Resident C's clinical record was reviewed on 3/5/2020 at 11:15 a.m. [DIAGNOSES REDACTED]. The admission cognitive assessment, dated 2/26/2020, indicated Resident C was cognitively intact. Resident D's clinical record was reviewed on 3/5/2020 at 11:30 a.m. [DIAGNOSES REDACTED]. The quarterly cognitive assessment, dated 2/26/2020, indicated Resident D was cognitively intact. Resident E's clinical record was reviewed on 3/5/2020 at 11:40 a.m. [DIAGNOSES REDACTED]. The quarterly cognitive assessment, dated 12/23/2019, indicated Resident E was cognitively intact. Resident F's clinical record was reviewed on 3/5/2020 at 11:50 a.m. [DIAGNOSES REDACTED]. The quarterly cognitive assessment, dated 12/28/2019, indicated Resident F was cognitive intact. Interview with Residents C, on 3/5/2020 at 3:00 p.m., indicated staff answering of call lights was slow, up to 1 hour. The wait time was higher during the day. Interview with Resident D, on 3/6/2020 at 30:15 p.m., indicated staff were slow to when responding to call lights. The response time was between 30-40 minutes and were more prevalent in the day. Interview with Resident E, on 3/5/2020 at 3:45 p.m., indicated she had to wait sometimes to be assisted with toileting and/or other requests. On 3/5/2020 at 12:34 p.m., the DON provided the facility call light policy, dated 10/2014, and indicated the policy was the one currently being used by the facility. A review of the policy indicated .resident's call light is to be within reach and answered promptly by facility personnel, answer the call light promptly and all facility personnel are expected to respond to call lights . This Federal tag related to Complaint IN 390. 3.1-19(u)

Based on interview and record review, the facility failed to develop a discharge plan which addressed the resident's need for oxygen therapy for 1 of 3 residents reviewed for discharge plan. (Resident B). Findings include: The clinical record of Resident B was reviewed on 1/16/2020 at 11:30 a.m [DIAGNOSES REDACTED]. A respiratory therapy adult evaluation, dated 12/14/2019, indicated Resident B had orders from a local hospital for oxygen (02) at 2 liters per minute (lpm) continuously via nasal cannula (nc), with an oxygen saturation of 96%. On 12/18/2019, no time given, physician orders [REDACTED]. A PA (Physician Assistant) discharge summary, dated 12/19/2019, no time given, indicated Resident B was medically stable and appropriate for discharge to home on 12/19/19. A home 02 evaluation for 2 L (liter) nasal cannula continuously was needed Interview with RT (respiratory therapy), on 1/17/2020 at 11:25 a.m., indicated they had not discontinued Resident B's oxygen. Resident B's discharge summary dated 12/19/19, no time given, indicated Resident B was on 2 liters of oxygen via nasal cannula, with no indication of oxygen being discontinued. Interview with Social Service, on 1/17/2020 at 11:15 a.m., indicated she went into Resident B's room on the morning of 12/18/2019, after respiratory therapy indicated Resident B wanted to go home the morning of 12/19/2019. Social Service set up home health evaluations with Resident B's preference. On 12/19/2020, at discharge, Resident B's daughter asked social service if home oxygen had been set up. Social service had not seen Resident B wearing any oxygen, was not aware of the need for oxygen, and she had not set up services for home oxygen. On 1/17/2020 at 11:50 a.m., the DON (Director of Nursing) provided the Discharge Planning policy, revised (MONTH) 9 (YEAR), and indicated the policy was the one currently being used by the facility. A review of the policy indicated the discharge planning process shall begin on admission and involve each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluate them throughout the residents's stay to ensure a successful discharge. This Federal tag relates to Complaint IN 879. 3.1-12(a)(18)

Based on interview and record review, the facility failed to provide a resident discharge instructions to ensure a safe and orderly discharge to home for 1 of 3 residents reviewed for discharge. (Resident D) Findings Include: On 11/26/2019 at 11:00 a.m., Resident D's closed clinical record was reviewed. [DIAGNOSES REDACTED]. Current (MONTH) 2019, physician orders [REDACTED]. Trazadone 50 mg by mouth at bedtime [MEDICATION NAME] eye drops 6 times a day [MEDICATION NAME] folic acid 100 mg daily [MEDICATION NAME] 50 mg once daily [MEDICATION NAME] 50 mg every 6 hours as needed [MEDICATION NAME] 200 mg 3 times a day. Clinical records lacked documentation of discharge instructions, for returning home, provided to Resident D. No discharge instruction sheet was located in Resident D's clinical record. Interview with the DON (Director of Nursing), on 11/26/19 at 2:30 p.m., indicated she checked with the LPN (Licensed Practical Nurse) who indicated she did complete the form, but neither the LPN or the DON could locate the information prior to survey exit. This Federal tag relates to Complaint IN 923. 3.1-12(a)(21)

Based on interview and record review, the facility failed to provide a resident with a written discharge notice that included the reason for discharge, the effective date of discharge, and the location to which the resident was to be transferred for 1 of 3 residents reviewed for discharge notice (Resident D). Findings include: On 11/26/2019 at 11:00 a.m., Resident D's closed clinical record was reviewed. [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 11/08/2019, indicated Resident D was cognitively intact. Resident D's insurance letter, dated 11/6/19, indicated Resident D's rehabilitation would end on (MONTH) 14, 2019. At that time, social services initiated a discharge care plan meeting with Resident D and his family dated for 11/19/19. A coverage timeline paper, dated 11/14/19, indicated when Resident D was informed his insurance company would stop coverage, he requested an appeal of the stop coverage decision. Resident D's appeal denial letter, dated 11/16/19, indicated coverage would end on 11/18/19. His appeal was denied. A progress note, dated 11/15/19 at 2:00 p.m., indicated the Assistant Administrator informed Resident D of his appeal being denied. Resident D indicated to the Assistant Administrator he wanted to stay until his doctor's appointment on 11/18/19, so the facility could take him, and once he had seen the doctor he would go back home. Social Services notes, dated 11/19/19 with no time given, indicated Resident D was waiting for his daughter to discharge from the facility. Clinical records lacked documentation of discharge notification form that indicated Resident D was provided a reason for discharge, the effective date of discharge, and the location to which the resident would be transferred. During interview, dated 11/26/19 at 11:15 a.m., the Administrator indicated the facility did not feel a 30 day discharge letter was indicated due to the fact Resident D wanted to discharge to home. No discharge notice had been provided to Resident D. On 11/26/19 at 12:15 p.m., the DON (Director of Nursing) provided the Transfer/Discharge policy, revised date of 1/2015, and indicated the policy was the one currently used by the facility. A review of the policy indicated a discharge notice may be made as soon as practical before discharge when a resident had not resided in the facility for 30 days. This Federal tag relates to Complaint IN 923. 3.1-12(a)(8)(E) 3.1-12(a)(9)(A) 3.1-12(a)(9)(B) 3.1-12(a)(9)(C)

Based on interview and record review, the facility failed to ensure develop of a discharge summary that included a recapitulation of a resident's stay, a final summary of a resident's status and a reconciliation of all pre and post discharge medications for 1 of 3 residents reviewed for discharge from the facility. (Resident D) Findings Include: On 11/26/2019 at 11:00 a.m., Resident D's closed clinical record was reviewed. [DIAGNOSES REDACTED]. Current (MONTH) 2019 physician orders [REDACTED]. Trazadone 50 mg by mouth at bedtime [MEDICATION NAME] eye drops 6 times a day [MEDICATION NAME] folic acid 100 mg daily [MEDICATION NAME] 50 mg once daily [MEDICATION NAME] 50 mg every 6 hours as needed [MEDICATION NAME] 200 mg 3 times a day Resident D's records indicated a discharge summary sheet with date of discharge documented of 11/19/2019. There were no recapitulation of the resident's stay, no post discharge plan of care, or reconciliation of medications pre-and post-discharge. The form was blank except for the date of discharge. Interview with the DON (Director of Nursing), on 11/26/19 at 2:30 p.m., indicated she checked with the LPN (Licensed Practical Nurse) who indicated she had completed the form, but neither the LPN or the DON could locate the information prior to survey exit. On 11/26/19 at 12:15 p.m., the DON (Director of Nursing) provided the Discharge of Resident/Discharge Summary policy, revised date of 9/2017, and indicated the policy was the one currently used by the facility. A review of the policy indicated, When a discharge is anticipated, a resident shall have a Discharge Summary that includes, but is not limited to, the following: A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy . This Federal tag relates to Complaint IN 923. 3.1-36(a)(1) 3.1-36(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident who received a medication prescribed for chronic pain was monitored for effectiveness of the routine medication for 1 of 5 residents reviewed for unnecessary medication use. (Resident 52) Findings include: On 6/6/19 at 10:52 a.m., Resident 52 was observed to be sitting in her wheelchair at the nurses station. She was conversing with staff and other residents. On 6/7/19 at 10:45 a.m., Resident 52's clinical record was reviewed. The [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment, dated 4/28/19, indicated Resident 52 had severe cognitive impairment and had no pain. Resident 52's physician orders, dated (MONTH) 2019, indicated [MEDICATION NAME] (pain medication) 5-325 mg (milligrams) twice a day for pain (start date 2/8/19). Resident 52's Medication Administration Record [REDACTED] -April 2019, Resident 52 received [MEDICATION NAME] 5-325 mg twice a day for pain from 4/1/19-4/30/19. -May 2019, Resident 52 received [MEDICATION NAME] 5-325 mg twice a day for pain from 5/1/19-5/31/19. -June 2019, Resident 52 received [MEDICATION NAME] 5-325 mg twice a day for pain from 6/1/19-6/10/19. A care plan, initiated on 5/10/19 and current through next review, indicated; F[NAME]US: The resident has the potential for pain .GOAL: The resident will have no signs of symptoms of pain or discomfort daily through next review or pain severity will be managed per resident satisfaction through next review .INTERVENTIONS: 1. Monitor for non-verbal signs of pain such as facial grimacing, moaning, restlessness, increased heart rate, increased blood pressure, increased behaviors, crying, tearfulness, guarding/rubbing area 6. Administer/offer pain medication as ordered and monitor for efficacy. 7. Document efficacy of approaches . Resident 52 physician progress notes [REDACTED]. The clinical record lacked documentation of monitoring the effectiveness of the routine pain medication. During an interview, on 6/7/19 at 12:04 p.m., Registered Nurse (RN) 1 indicated Resident 52 takes routine pain medication, and there is no monitoring of effectiveness of routine pain medications. During an interview, on 6/7/19 at 1:21 p.m., the Director of Nursing indicated Resident 52 had no monitoring of effectiveness of routine pain medication. On 6/7/19 at 1:12 p.m., the Director of Nursing provided the facility's policy, Pain Assessment, dated 10/2014, and indicated it was the policy currently being used by the facility. A review of the policy lacked documentation of monitoring of effectiveness of routine pain medications. 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident's portable oxygen tank was filled with oxygen for 1 of 1 randomly observed resident. (Resident 40) Findings include: On 6/3/2019 from 12:30 to 12:57 p.m., Resident 40 was observed sitting in the dining room with an empty portable oxygen tank. An interview, at the time, with Resident 40 indicated he was not getting any air through the nasal cannula tubing. On 6/3/2019 at 12:58 p.m., the Marketing and Admissions person indicated Resident 40's portable oxygen tank was empty. The Marketing and Admissions person was observed to remove Resident 40 from the dining room and return a few minutes later with a filled portable oxygen tank. Resident 40's clinical record was reviewed on 6/4/2019 at 11:30 a.m. [DIAGNOSES REDACTED]. Physician orders, dated 6/1/2019 through 6/30/2019, indicated Oxygen (O2) at 3 liters per minute (LPM) via nasal cannula (N/C) continuously for [MEDICAL CONDITION] . A care plan, initiated on 1/19/2018 and revised on 7/17/2018, for Resident 40 indicated: . F[NAME]US: . Requires oxygen use continuous . GOAL: Resident will be free of respiratory distress daily through next review . INTERVENTIONS: Administer O2 as per physician order [REDACTED].>On 6/7/2019 at 2:53 p.m., the Director of Nursing provided the facility policy titled, Oxygen Therapy, dated 10/2014, and indicated it was the one currently being used by the facility. A review of the policy indicated, . Oxygen therapy is administered by licensed personnel per physician's orders [REDACTED]. 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure residents who were continent of bowel and bladder were provided activities of daily living (ADL's) assistance in a timely manner to maintain continence for 2 of 4 residents reviewed for continence (Resident 1 and Resident 56) and failed to ensure the Foley catheter tubing (flexible tube which passed through the urethra and into the bladder to drain urine) and drainage bag were position off of the floor for 1 of 2 residents reviewed for urinary catheter care (Resident 44). Findings include: 1.a. On 6/4/2019 at 10:33 a.m., during an interview, Resident 1 indicated they do not have enough staff. She was continent of bladder and bowel, but she is required by the staff to wear a brief. It takes staff a long time to answer the call light and sometimes she has had to go in her brief. It makes her feel really bad, because she wants to use the restroom. A confidential interview was conducted during the course of the survey. The interview indicated Resident 1 does not want to wear a brief. She wears it at the convenience of the staff, because they cannot get to the resident in time for her to be continent of bladder and bowel. Resident 1's clinical record was reviewed on 6/6/2019 at 2:30 p.m. [DIAGNOSES REDACTED]. The Admissions Minimum Data Set (MDS) assessment, dated 2/26/2019, indicated Resident 1 was continent of bowel and bladder and needed extensive assist of one person for toilet use. A review of the Bowel and Bladder assessment, dated 2/22/2019, indicated Resident 1 was continent. During an interview, on 6/10/2019 at 10:13 a.m., Certified Nursing Assistant 1 (CNA) indicated Resident 1 was usually continent, but sometimes had already gone in the brief by the time staff got to her. On 6/10/2019 at 12:23 p.m., the Assistant Director of Nursing was asked to provide a policy related to Activities of Daily Living for residents who are continent of bladder and bowel. A policy was not provided by the exit date of 6/10/2019. 1.b. On 6/7/2019 at 10:41 a.m., during an interview, Resident 56 indicated the facility is short staffed. He used a urinal for urine, but has had to wait for staff to take him to the restroom for a bowel movement. It takes staff a long time and sometimes he has had to go in his pants. It makes him feel bad. Resident 56's clinical record was reviewed on 6/7/2019 at 11:30 a.m. [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment, dated 5/3/2019, indicated Resident 56 was frequently incontinent of bladder, always continent of bowel, and needed extensive assist of one person for toilet use. A review of the Bowel and Bladder assessment, dated 1/28/2019, indicated Resident 56 was continent. During an interview, on 6/10/2019 at 9:54 a.m., Qualified Medication Aide 1 (QMA) indicated Resident 56 was continent of bladder and bowel, but will have an accident of bowel if they cannot get there soon enough. On 6/10/2019 at 12:23 p.m., the Assistant Director of Nursing was asked to provide a policy related to Activities of Daily Living for residents who are continent of bladder and bowel. A policy was not provided by the exit date of 6/10/2019. 2. On 6/3/19 at 12:40 p.m., Resident 44 was observed to be sitting in his wheelchair in the dining room. Resident 44's Foley catheter tubing and drainage bag was observed to be laying on the floor. On 6/4/19 at 2:25 p.m., Resident 44 was observed to be laying in bed. The Foley catheter drainage bag was observed to be touching the floor. Interview, at that time, Resident 44 indicated he had a recent hospital stay with [DIAGNOSES REDACTED]. On 6/6/19 at 11:45 p.m., Resident 44 was observed to be sitting in the dining room. The Foley catheter bag was observed to be hanging from the handles on the back of his wheelchair which was above his bladder. On 6/7/19 at 11:42 a.m., Resident 44 was observed to be sitting in the dining room. The Foley catheter tubing was observed to be laying on the floor. On 6/6/19 at 2:36 p.m., Resident 44's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident 44's, (MONTH) 2019, physician orders [REDACTED]. Resident 44's urinalysis, dated 5/9/19, indicated many bacteria. Resident 44's physician progress notes [REDACTED]. Resident 44 was admitted to the hospital [MEDICAL CONDITION]ly due UTI and pneumonia. Resident 44's (MONTH) 2019 Medication Administration Record [REDACTED]. A care plan, initiated on 5/10/19 and current through next review, for Resident 44 indicated: F[NAME]US: .The resident requires the use of a Foley catheter due to [MEDICAL CONDITION] bladder, [MEDICAL CONDITIONS] and is at risk for infection .GOAL: The resident will be free from signs of symptoms of infection through next review .APPROACH: 6. Position catheter tubing and drainage bag below the level of the bladder to minimize the risk of urinary reflux. 7. Position catheter tubing and drainage bag in such a way to avoid contact with the floor . During an interview, on 6/6/19 at 2:12 p.m., Certified Nursing Assistant (CNA) 2 indicated Resident 44 gets UTIs due to having a Foley catheter. The Foley catheter tubing is long and it is hard to keep the tubing off the floor. The Foley drainage bag and tubing had to be changed on this day, because the Foley tubing had a hole in the tubing from being ran over with the wheelchair. The Foley drainage bag was to be placed below the bladder to assist with drainage. During and interview, on 6/7/19 at 12:02 p.m., Registered Nurse (RN) 1 indicated Foley catheter drainage bag and tubing should not touch the floor. On 6/10/19 at 11:35 a.m., the Social Services Director (SSD) provided the facility's policy, Urinary Drainage Bag Maintenance, dated 10/14, and indicated it was the policy currently being used by the facility. A review of the policy indicated, Urinary drainage bag should not be at a level above the bladder when drainage bag tubing is not clamped. Urinary drainage bag should not be allowed to touch the floor . 3.1-38(a)(2)(C) 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure staff locked a medicine preparation room on the 100 unit which contained hazardous materials for 1 of 2 medicine preparation rooms observed. This had the potential to affect 9 residents who were cognitively impaired and independently ambulatory of 65 who reside in the facility. Findings include: On 6/3/2019 at 12:36 p.m., during the initial tour, the medicine preparation room on the 100 unit was observed to be unlocked. The medicine preparation room contained various hazardous materials including medications, [MEDICATION NAME], eliquis, [MEDICATION NAME], cetirizim, Cipro, [MEDICATION NAME], pantoprazole, [MEDICATION NAME], nasal sprays, along with [MEDICATION NAME] syringes, lab tubes and sharps containers On 6/3/2019 at 2:15 p.m. the same medicine preparation room on the 100 unit remained unlocked. During an interview, on 6/3/2019 at 2:17 p.m., Registered Nurse 1 indicated the door to the medicine preparation room should always be locked. The facility occupancy rate, on 6/3/2019 at 2:00 p.m., included 9 residents who self ambulated and had a Brief Interview for Mental Status (BIMS) score which indicated they were cognitively impaired. On 6/7/2019 at 2:53 p.m., the Director of Nursing provided the facility policy titled, Storing Drugs dated 4/2016, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Drugs and biologicals will be stored in a safe, secure, and orderly manner . and accessible only to licensed nursing and pharmacy personnel or staff members lawfully authorized to administer medications . 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure the privacy and confidentiality of residents' personal and medical information for 1 of 1 random observation. Findings include. On 6/3/19 from 12:10 P.M. to 12:20 P.M., the facility's medical records room was observed to be unlocked and unattended. Inside the room were clinical records for current residents and discharged residents. Two independently mobile residents were observed to pass by the medical records room during this time period. During an interview, on 6/3/19 at 12:20 P.M., the facility Administrator indicated the medical records room was unlocked, unattended, and should have been locked while unattended. On 6/7/19 at 2:45 P.M., the Director of Nursing indicated there were 42 residents in the facility who were independently mobile and able to move about the facility unattended. 3.1-3(o)