Every finding on record at Omni Continuing Care

Based on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 06/23/2026 at 7:53 PM observed a janitor sink with a chemical pre-dispensing system in place and the cold water faucet on in the [NAME] Hall janitor closet. This set up puts undue back pressure on the faucet's Hose Bib vacuum breaker, which can compromise the integrity of the mechanism.On 06/23/2026 at 8:02 PM observed chipped paint on the toilet base and along the interior surface of the bowl in the [NAME] Hall shower room. [NAME] discoloration was visible on the interior of the bowl in areas where paint was missing. Caulking was missing around the base and showed brown discoloration in some areas.On 06/23/2026 at 8:03 PM observed an approximate one by one foot section of tile missing on the wall at the shower controls in the [NAME] Hall shower room. A wood slab and the water line were visible through the wall. Further observation in the adjacent shower stall found the shower head with paint peeling. On 06/23/2026 at 8:11 PM observed eight one by one inch floor tiles missing near the tub in the [NAME] Hall bathroom. On 06/23/2026 at 8:19 PM observed chipped paint on the toilet bowl interior surface and areas of brown discoloration where paint was missing. Hair was observed on the seat, around the rim, and in the bowl in the [NAME] Hall shower room. The caulking around the base of the toilet was observed missing in some areas. On 06/23/2026 at 8:26 PM observed a connecting piece missing on the shower control, leaving a space and the screw head protruding from the control in the Gratiot Hall shower room. Further observation found the toilet seat and internal bowl with areas of paint missing and brown spots consistent with corrosion. The shower bed mat was also observed to be creased throughout the entire surface with black residue spots present on the mat.On 06/23/2026 at 8:30 PM observed the ceiling light partially detached and hanging from the ceiling in the Gratiot Hall soiled utility room. On 06/23/2026 at 8:40 PM observed a hopper with the hot water release only as a trickle in the Gratiot Hall soiled utility room. On 06/23/2026 at 8:47 PM observed a trickle of water released from the tub hot water faucet in the Gratiot Hall bathroom. Black buildup was observed accumulated around the rim of the tub faucet. Further observation found the hand sink slow to drain.On 06/23/2026 at 9:00 PM observed chipped paint on the interior surface of the toilet bowl and brown discoloration on the inside of the bowl where paint was missing in the [NAME] Hall shower room. Hair and debris were around the surface of the toilet seat.On 06/23/2026 at 9:06 PM observed brown stained and bulging ceiling tiles with evidence of water damage in the [NAME] Hall ice machine room.On 06/23/2026 at 9:23 PM observed a bed sheet covering the top half of a portable clean linen cart in hall.On 06/24/2026 at 9:05 AM in an interview, Nursing Home Administrator (NHA) indicated there is no maintenance director currently and indicated they are serving as the maintenance director. On 06/24/2026 at 9:25 AM in an interview with Housekeeping and Laundry Supervisor (HLS) G, when asked about the portable laundry carts, HLS G indicated the carts are used for easy access.On 06/24/2026 at 9:28 AM in an interview regarding cleaning, HLS G indicated housekeeping cleans shower rooms and equipment two to three times a day. On 06/24/2026 at 9:35 AM observed the floorboard pulled away from the adjoining board and partially peeling with circular indentation marks in the Gratiot Hall day room.On 06/24/2026 at 9:39 AM observed a portable clean linen cart with the cover open in the Gratiot Hall exposing the linens inside. In an interview at this time, HLS G indicated it should be closed.On 06/24/2026 at 9:43 AM observed chipped paint on the interior surface of the toilet bowl and brown discoloration on the inside of the bowl where paint was missing in the [NAME] Hall shower room. In an interview at this time HLS G indicated staff clean the toilets and it looks like rust.On 06/24/2026 at 9:59 AM observed an accumulation of wood shavings in the utility sink basin along with a bucket in the [NAME] Hall soiled utility room. The other basin of the two compartment sink contained a bucket and had brown particulate matter floating in water at the bottom of the sink. In an interview with HLS G at this time when, asked what housekeeping cleans in the room, HLS G indicated they clean floors and take out trash. On 06/24/2026 at 10:10 AM observed a portable clean linen cart with two disposable cups filled with wrappers among the linen in the [NAME] Hall.On 06/24/2026 at 10:45 AM an interview was conducted with Maintenance Assistant (MA) J. When asked about the Maintenance director, MA J indicated the facility had been without a maintenance director for about three weeks to a month.On 06/24/2026 at 10:47 AM an interview was conducted with MA J. When asked about the hole in the shower room wall, MA J indicated they did know about it but cannot fix it and have to call someone to help. When asked about general repairs around the facility, MA J indicated there is an online service that requests can be uploaded. MA J indicated they do not have access and the NHA hands them requests. On 06/24/2026 at 11:01 AM observed a janitor sink with chemical pre-dispensing system in place and the water on in the maintenance office/storage room in the basement. This set up puts undue back pressure on the faucet's Atmospheric Vacuum Breaker, which can compromise the integrity of the mechanism.On 06/24/2026 at 3:41 PM observed the baseboard peeled away from the wall and black buildup present behind and around the baseboard in the area beneath the sink in resident room [ROOM NUMBER]. Further observation found raised and missing paint along the walls at the entrance of the room as well as the emergency pull cord box partially attached and not secure. On 06/24/2026 at 3:43 PM observed a portable clean linen cart with the cover open and facing out in the [NAME] Hall.Record review of the facility provided document titled Laundry Services last dated 8/26/2025, includes the proper storage of linen, Linen is stored in separate rooms, closets, or other designated spaces with a closing door or cover to assist in reducing the risk of accidental contamination.

Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 06/23/2026 at 6:31 PM observed the sink hot water faucet nonfunctional in the [NAME] Hall nourishment room.On 06/23/2026 at 7:52 PM observed the hot water handle missing from the janitor sink in the [NAME] Hall janitor closet.On 06/23/2026 at 7:58 PM observed the hot and cold water faucets off and the foot pedals intact at the sink fixture in the [NAME] Hall soiled utility room, indicating possible stagnant water in the line.On 06/23/2026 at 8:10 PM observed the top cold and hot water handles missing on the tub in the [NAME] Hall bathroom.On 06/23/2026 at 8:32 PM observed a utility sink with the hot and cold water faucets nonfunctional and the foot pedals intact in the Gratiot Hall soiled utility room. Further observation found no drain line in one compartment of the sink.On 06/23/2026 at 8:50 PM in an interview regarding the hoppers, Nurse H indicated the hoppers are not used. On 06/23/2026 at 8:53 PM observed orange discolored water coming from the hopper hot and cold spray hose controlled by foot pedals for a few seconds before running clear in the Gratiot Hall hopper room.On 06/23/2026 at 9:05 PM observed a water line coming from the wall with approximately three feet of exposed piping, leading to a valve and followed by an additional approximate four feet of piping. The line was not connected to any fixture or equipment indicating possible stagnant water in the line located in the [NAME] Hall ice machine room.On 06/23/2026 at 9:07 PM observed a utility sink with a faucet and the handles missing in the [NAME] Hall soiled utility room. On 06/24/2026 at 9:05 AM in an interview, Nursing Home Administrator (NHA) indicated there is no maintenance director currently and they are serving as the maintenance director. On 06/24/2026 at 9:08 AM in an interview, Housekeeping and Laundry Supervisor (HLS) G indicated they are not on the water management team. On 06/24/2026 at 9:58 AM observed a water fixture with the hot and cold handles missing in the [NAME] Hall soiled utility room. On 06/24/2026 at 9:59 AM observed an accumulation of wood shavings in the utility sink basin along with a bucket in the [NAME] Hall soiled utility room. The other basin of the two compartment sink contained a bucket and had brown particulate matter floating in water at the bottom of the sink.On 06/24/2026 at 10:03 AM observed brown water run from the spray hose of the hopper for several seconds in the [NAME] Hall hopper room. HLS G confirmed the discolored water.On 06/24/2026 at 10:31 AM an interview with Floor Tec (FT) I was conducted regarding water management. When asked if they are on the water management team, FT I indicated no. When asked what flushing entails, FT I indicated they flush the hoppers in the facility, and do not turn on water or use the spray hose. When asked about the hoppers in the utility room, FT I indicated they do not bother with them. When asked if there are any other areas they flush, FT I indicated no.On 06/24/2026 at 10:45 AM an interview was conducted with Maintenance Assistant (MA) J. When asked about the Maintenance director, MA J indicated the facility had been without a maintenance director for about three weeks to a month. When asked if they are on the water management team, MA J indicated no. On 06/24/2026 at 12:36 PM an interview with NHA was conducted regarding water management. When asked if they are a part of the team, NHA indicated yes as well as maintenance, Director of Nursing (DON), and they believe housekeeping. When asked if there has been an annual review of the plan, NHA stated not yet. When asked when the last one was, NHA indicated probably last year. When asked about control measures to reduce the growth of legionella, NHA indicated they push the flush apparatus on the [NAME] and run janitors sinks.On 06/24/2026 at 12:56 PM in an interview with NHA, when asked if there are eye wash stations in the facility, NHA indicated there is one in the kitchen. When asked if it is flushed, NHA indicated they are not sure who is doing that.On 06/24/2026 at 1:10 PM observed the tub with the top two handles missing in the [NAME] Hall bathroom. NHA indicated they do not use the tub. Record review of the facility provided binder titled Water Management Program 2025 includes a list of the water management team including Administrator, DON, Maintenance staff, and Unit managers. Listed under plan of action to limit Legionella states, Maintenance staff detach shower heads clean them and spray them with bleach, Maintenance staff take off aerators and clean them as well as faucets spraying both with bleach. The program includes work online orders regarding water management, Faucet Aerators and Shower Wants, Flush eye wash stations, Flush Low Flow Fixtures, Inspect eyewash stations. The last log recorded under Inspect eyewash stations was on 12/08/2025. No annual review date of the plan was listed or identified areas where Legionella could grow and spread.Record review of the facility provided document titled Water Management Program last revised 2/1/2024 included activities that are performed in a water management program, Establish a water management program team. Identify areas where Legionella could grow or spread.Decide where control measures should be applied and how to monitor them. Establish ways to intervene when control limits are not met. Make sure the program is running as designed (verification) and is effective (validation). Document and communicate all the activities. The program also states, The water management program team will meet quarterly in conjunction with the infection control committee to validate and verify the water management program.According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Eliminate dead legs, which are sections of no- or low-water flow.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 06/23/2026 beginning at 5:31 PM a tour of the kitchen was conducted with Dietary Manager (DM) E.On 06/23/2026 at 5:32 PM an interview with DM E was conducted regarding date marking. When asked about date marking, DM E indicated a receive date, an open date and a use by date are placed on items. On 06/23/2026 at 5:35 PM observed an opened bag of salad mix with a date of 6/19/26 on the bag.On 06/23/2026 at 5:39 PM observed an open bag of spinach with no date on the bag.On 06/23/2026 at 5:40 PM observed an open package of hot dogs with no date. In an interview at this time, when asked if this item is usually dated, DM E stated yes.On 06/23/2026 at 5:42 PM observed an open package of sliced meat with a date of 5/12/26 on the package. DM E indicated they did not know if a staff member meant to put a five or six.On 06/23/2026 at 5:51 PM observed flour, sugar, and oats in a bin with a plastic bag liner. In an interview at this time when asked if the bags are food safe, DM E indicated they were not sure.On 06/23/2026 at 6:06 PM observed the kitchen microwave with chipped paint and brown areas consistent with corrosion in the back bottom corners. DM E indicated they were trying to get a new unit, and stated it is not dirty just worn.On 06/23/2026 at 6:20 PM observed food splatter on the inside walls of the microwave in the [NAME] Hall nourishment room. In an interview at this time, DM E indicated the microwave is used for staff.On 06/23/2026 at 6:22 PM observed brown buildup along the inside wall of the ice machine in the [NAME] Hall. In an interview with DM E at this time regarding cleaning, DM E indicated maintenance cleans the ice machine monthly and dietary cleans the ice scoops. The drain line from the ice machine was connected directly into a pump and the discharge line from the pump terminated below the flood rim of the drain creating an improper air gap. Further observation found black residue build up on the interior of the drain line covering approximately two feet from the point where the drain exited the pump.On 06/23/2026 at 6:33 PM observed paint peeling and corrosion on the inside side of the microwave in the [NAME] Hall nourishment room.On 06/23/2026 at 6:36 PM observed splatter and food debris inside the microwave in the Gratiot Hall nourishment room.On 06/23/2026 at 6:39 PM observed areas of corrosion and paint flaking and peeling from the top of the microwave in the [NAME] Hall nourishment room. In an interview with Licensed Practical Nurse (LPN) N at this time, when asked who uses the microwave, LPN N indicated it is used for residents. On 06/23/2026 at 7:42 PM observed brown spots of corrosion on the front metal panel of ice machine where the door rests in [NAME] Hall.On 06/23/2026 at 8:15 PM in an interview with LPN F regarding the microwave, LPN F indicated the microwave on the unit is for resident use.On 06/24/2026 at 10:19 AM an interview with Housekeeping and Laundry Supervisor (HLS) G was conducted regarding the ice machine. When asked who is responsible for cleaning the ice machine, HLS G indicated housekeeping cleans the outside and they are not sure who is responsible for cleaning the inside.On 06/24/2026 at 10:47 AM an interview was conducted with Maintenance Assistant (MA) J, when asked who cleans the ice machine, MA J indicated housekeeping cleans it.On 06/24/2026 at 12:51 PM an interview with Nursing Home Administrator (NHA) was conducted regarding cleaning of the ice machine. When asked who cleans the internal components of the ice machine, NHA indicated they were unsure.On 06/24/2026 at 2:34 PM in an interview, DM E indicated they clean the microwaves on the units every morning.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.According to the 2022 FDA Food Code section 4-101.11 Characteristics, Materials that are used in the construction of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: P (A) Safe; P (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.According to the 2022 FDA Food Code section 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).

Based on observation, interview, and record review the facility failed to adequately address one resident (R59) of one resident identified to possess smoking paraphernalia, resulting in the potential for unidentified and unsafe smoking practices within the facility that did not comply with the facility's smoking policy.Findings include:On 6/23/26 at 6:51 p.m. during the entrance conference, it was confirmed with the Nursing Home Administrator (NHA) that the facility was non-smoking. On 6/23/2026 at 9:39 p.m. R59 was observed walking independently in the halls of the unit ([NAME]). R59 appeared alert, oriented to person, place, and situation. R59 did not voice any concerns regarding care. On 6/25/26 at 12:37 p.m. R59 was interviewed in the bedroom regarding the allegations of smoking and having smoking material in the facility. R59 denied smoking in the facility or having possession of smoking material, Naw, it wasn't me. R59 concluded the interview. Review of the clinical record documented R59 was initially admitted into the facility on 9/25/25 and readmitted on [DATE] with diagnoses that included traumatic brain injury, alcohol abuse, and seizures. According to the quarterly Minimum Data Set assessment dated [DATE], R59 had severe cognitive impairment (BIMS-4) and was independent in all activities of daily living. Review of the Social Service progress notes documented the following occurrences with smoking and/or possessing smoking material:5/7/2026 08:03 Social Services Note- SW Tech was informed by nursing staff that the resident had a cigar at bedside table. Nurse told SW Tech that she confiscated cigar and disposed of it. SW Tech went to resident's bedroom to address and educate the resident on the risks of smoking in the room. SW Tech also explained to the resident that this is a smoke free/drug free facility. Resident seemed upset and stated that: He was not smoking, he was holding it for when left the facility. SW Tech searched resident's room and found additional smoking contraband: a lighter, a vape pen and an empty pack of blunt (cigar) wrappers. 4/22/2026 15:36 Social Services Note- SW Tech was informed by nursing staff that resident was smoking inside of his bedroom. SW Tech went to resident's bedroom. SW Tech asked resident was he smoking? Resident stated No. Resident also stated that: I had a visitor that was smoking in the room while chillin with me. SW Tech asked resident did he have any smoking contraband on him? Resident stated: No. SW Tech explained to resident that the facility is a smoke free facility, and a drug free facility. SW Tech searched the resident's room and did not find any smoking contraband. Review of the physician's order consented to R59 leaving the facility for LOA (Leave of Absence). There were no care plans with interventions that addressed the incidents of smoking and having smoking material in the facility. There was no evidence of the facility evaluating R59 smoking safety after the reported incidents of smoking. On 6/25/26 at 12:59 p.m. Social Service Director (SSD) D was interviewed about R59 not complying with the facility's smoking policy. SSD D said they were not aware R59 smoked or possessed smoking material in the facility. SSD D also said per the facility's policy, residents smoking in the facility would be educated and all materials would be confiscated. On 6/25/26 at 1:20 p.m. SSD D confirmed there was no smoking care plan or assessment for R59, however acknowledged both should have been done. SSD D said R59 was only given a verbal warning for both incidents. Placement to a smoking facility was not offered to R59 or other interventions to address smoking. On 6/25/26 at 2:03 p.m. the NHA was interviewed and acknowledged being aware that R59 used vapes. The NHA said R59 should have been assessed for smoking, and a care plan should have been developed after the very first incident was reported. The NHA also said discharge plans to a smoking facility should have been considered and discussed with R59. Review of the facility's policy titled Non-Smoking Policy last revision date 6/10/24 documented in part the following: This facility is a non-smoking facility. For new admissions review the Resident Non-Smoking policy with the resident or responsible party upon admission and as part of the care planning process. The nursing facility will provide information regarding education and options for smoking- cessation activities to residents who were smokers. If a resident wishes to smoke the facility will assist them to find other placement to meet their needs. The first violation of this non-smoking policy by a resident who smokes will result in a warning (verbal or written) to the resident and their resident representative and documented in the medical record. All smoking paraphernalia will be given to the facility staff. A second violation by a resident who smokes will result in Involuntary Discharge procedures being initiated and pursued to completion. The Social Worker/designee will document in the record that the Resident Non-Smoking Policy.

Based on observation, interview, and record review the facility failed to provide timely communication for a change in health status for one (R49) of one hospice resident resulting in the missed opportunity to coordinate care to provide sufficient continuity and collaboration to address the R49's needs. Findings include:On 6/23/2026 at 8:40 p.m. R49 was observed in bed resting. R49 did not respond to name called. Although R49 was leaning to the left side of the bed unsupported, there were no signs of pain. The nurse on shift reported R49 was nonverbal and on hospice services.Review of the clinical record documented R49 was initially admitted into the facility on [DATE] with diagnoses that included Parkinson's disease, degenerative disease of nervous system, cerebral infarction, Alzheimer's disease, and dementia. According to the quarterly Minimum Data Set assessment dated [DATE], R49 had severely impaired cognition (BIMS-0) and was dependent on all activities of daily living. R49 was admitted to hospice services on 12/3/25 for decline in health status related to Parkinson's Disease.Review of the Hospice care plan dated 12/8/26 documented in part: (R49) is at risk for decline in condition, pain, depression, weight loss and other symptoms R/T terminal prognosis. (R49) receives hospice services. Hospice RN visits weekly and PRN for symptom management and care coordination. Goal: Comfort will be maintained. Interventions: Work with nursing staff to provide maximum comfort for the resident. Work cooperatively with hospice team so that the resident's spiritual, emotional, intellectual, physical and social needs are met. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Observe for adverse reactions & symptoms of end of life such as N/V, difficulty breathing, agitation. Report findings to Hospice and physician.Review of the physician's order documented the following orders and medications:-12/3/25- Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate) *Controlled Drug*. Give 0.25 ml by mouth every hour as needed for pain.-12/3/25- Ropinirole HCl Oral Tablet 1 MG (Ropinirole Hydrochloride). Give 1 tablet by mouth one time a day for Parkinson's.-12/3/25- Consult to (Name of Hospice).-12/3/25- Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate). Review of the Behavior Note dated 6/11/2026 documented in part the following: This patient refuses to allow for assigned nurse or writer to assess pain in her left leg. The patient is grimacing and rubbing leg and will state she's in pain, however, refuses for writer to assess leg for pain. Pain medication was offered, however, patient refused. The patient refused to allow for adl care to be performed. Patient continues to refuse. Further review of the progress notes did not provide evidence that hospice was notified. There were no progress notes that supported the facility nurse adequately addressed R49's pain or refusal of medications. The hospice binder that documented hospice-to-facility communication, located at the nurse's station was reviewed and did not document R49's change in condition. Review of June Medication Administration Record did not document pain medications that were refused or administered.On 6/24/26 at 3:47 p.m. LPN K confirmed being the writer of the progress note dated 6/10/26 however, was not the attending nurse but assisted with medication administration. LPN K said R49 complained on leg pain but refused pain medications. LPN K said they were not aware R49 was a hospice patient and was unsure if hospice was contacted by the attending nurse (LPN L).On 6/25/26 at 1:44 p.m. R49 was observed in bed resting and did not arouse to name being called.On 6/25/26 at 1:50 p.m. LPN L was interviewed as queried was hospice notified of R49 having leg pain and refusing pain medications. LPN L said hospice was not notified because R49 gets confused about having pain. LPN L also said R49 had not eaten breakfast or lunch and refused all medications. At that time, hospice had not been contacted about the changes in condition. On 6/25/26 at 1:57 p.m. the Clinical Care Manager O for hospice was interviewed via telephone and said it is the expectation for the nursing facility to notify and inform hospice staff when patients have a change in condition such as refusing medication, change in appetite, and pain and should not wait for unaddressed changes to continue to occur. Constant communication is essential for welfare of the patient. On 6/25/26 at 209 p.m. the Director of Nursing (DON) was interviewed and said consistent communication between the facility and hospice should always occur to maintain the continuity of care. Review of the facility's policy titled Hospice Care revision date 8/3/24, documented in part the following: When a facility resident elects to receive hospice care, the facility staff communicates with the hospice agency to establish and agree upon a coordinated plan of care that is based on an evaluation of the resident's needs and living situation in the facility.

Based on observation, interview, and record review the facility failed to maintain dignity by not providing a foley catheter bag cover for one resident (R123) to maintain dignity out of two residents reviewed for dignity, resulting in the potential for impaired mental and psychosocial well-being.Findings include:On 6/23/2026 at 7:46 p.m., R123 was observed lying in bed, non-verbal with a foley catheter hanging on the left side of the bed frame. R123' catheter bag was visible from the hallway without a foley catheter bag cover. Observed at this time was 450 milliliters (cc's) of amber colored urine in the foley catheter bag. Several staff members and visitors entered R123's room providing care and visiting resident, and roommate. On 6/23/2026 at approximately 8:00 p.m., R123's assigned Licensed practical nurse (LPN) M was asked during an interview should foley catheters bag have covers? LPN M stated, Yes, the resident should have a dignity bag on the foley catheter.According to the Electronic Health Record, R123 was admitted on [DATE] with diagnoses of sequelae of non-traumatic intracerebral hemorrhage, neuromuscular dysfunction of bladder, tracheostomy status, gastrostomy status, dependence of respiratory (ventilator) status. R123's admission Minimum Data assessment dated [DATE] revealed no documented BIMS (brief interview for mental status) score.According to the Activity Daily Living (ADLs) care plan dated 6/12/2026 documented, (R123) has a functional ability deficit and requires assistance with self-care/mobility related to weakness, impaired balance, impaired cognition, impaired mobility, pain. SOB (short of breath), and cerebral vascular accident. Interventions: Dressing: Resident is dependent on one to two helpers to dress.According to the Foley Catheter care plan dated 6/24/2026, (second day of SA survey) documented Ensure the drainage bag is secured properly with a dignity cover in place.On 6/25/2026 at approximately 1:30 p.m. the Director of Nursing (DON) was interviewed regarding R123 not having a foley catheter bag cover. The DON verified that R123 foley catheter bag should have had a privacy cover. The DON was asked what was the importance of having a foley catheter bag cover? The DON stated, the reason is a dignity issue, that's their personal business, that their body fluid, and they don't want no one else to see. According to the facility's 3/28/2024 Resident Dignity & Personal Privacy Policy: The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy.

Based on observation, interview, and record review the facility failed to follow the Physician order for administering medications through a Percutaneous tube (Peg Tube), a flexible tube surgically inserted directly into the stomach through the skin of the abdomen to deliver nutrition, hydration, and medication, for one resident (R87) of twenty eight residents reviewed for medication administration, resulting in residents not receiving the full amount of their prescribed medications and water, and the potential for PEG tube malfunction due to clogging. Findings include: On 7/1/2025 at 8:26 a.m. during medication administration, Licensed Practical Nurse (LPN) H was observed at the medication cart preparing eight cups of R87's medications individually. LPN H was observed to pour water from a large cup into each cup of individually crushed medication cup without measuring the amount of water poured in each. LPN H was asked how much water would be given with each medication? LPN H said I just use ten milliliters of water with each medication. The Surveyor then observed LPN H attempt to administer R87 mediation through the peg tube without attempting to flush the peg tube. LPN H said the R87's peg tube is clogged. LPN H used an opened tubing from R87 nightstand to unclog R87's peg tube without cleaning the tubing prior to use. LPN H successfully unclogged R87 peg tube and then continued to use an unmeasured amount of water in a calibrated piston syringe to flush the peg tube afterward. LPN H was unable to provide the amount of water used in the syringe. LPN H then used ten milliliters of water to flush the peg tube and continued to administer medications. LPN H was asked how much water will be used to flush the peg tube afterward. LPN said R87 gets water already all during the shifts without giving any water flushes afterward. LPN H was observed placing the tubing back in the resident's nightstand without cleaning the tubing. LPN H was asked should the tubing be cleaned before and after use due to the package was already opened. LPN H said yes, because I didn't know where it's been before I used it and it could cause infection. On 7/1/2025 at 8:40 a.m. the surveyor interviewed LPN H at the medication cart while reviewing R87 medications. LPN H was asked was R87 med pass completed. LPN H said yes. LPN H was asked why R87 multivitamin was not administered. LPN H said the medication is not in the med cart and did not know whether it was available in the med room. LPN H stated, I will check later if it's in there I will give it later and if it's not there I can't give it. Review of the morning medications were as follows: 1- Prostat two times a day 30ml via PEG. 2- Prochlorperazine Maleate Tablet 10 MG Give 1 tablet via PEG-Tube two times a day. 3- Norvasc Oral Tablet 10 MG Give 1 tablet via PEG-Tube two times a day. 4- Amantadine HCl Oral Solution 50 MG/5ML Give 5 ml via PEG-Tube every 12 hours. 5- Keppra Oral Solution 100 MG/ML Give 5 ml via PEG-Tube every 12 hours. 6- Insulin Glargine Subcutaneous Solution Inject 35 unit subcutaneously every 12 hours. 7- Sertraline HCl Oral Tablet 50 MG Give 1 tablet via PEG-Tube one time a day.8- Losartan Potassium Oral Tablet 25 MG Give 1 tablet via PEG-Tube one time a day. 9- Metoprolol Tartrate Oral Tablet 100 MG Give 1 tablet via PEG-Tube every 12 hours. 10- . Multivitamin & Mineral Oral Liquid Give 15 ml via PEG-Tube one time a day. LPN H was asked should the peg tube be checked for placement and residual before administering medications. LPN H said yes, I should have checked it first. LPN H was unable to provide documentation of the resident's peg tube being checked for placement and residual amount. The physician's orders were reviewed with LPN H and asked why ten milliliters of water was given with each medication instead of at least fifteen milliliters per the physician orders. LPN H stated, I thought it was ten milliliters and that's what I been using. LPN H acknowledged fifteen milliliters per the physician order should have been given. Physician's orders revealed as follows: Enteral Feed every shift Flush Peg Tube with at least 15cc of water before and after medication administration and at least 15cc of water in between each medication active date 5/21/2025. -every shift Check resident for residual, if greater than 250cc hold tube feeding for 1 hour and recheck, if still greater than 100cc call the physician. -every shift Check Peg Tube for placement by aspirating stomach contents and patency by instilling at least 15cc of water. On 7/2/2025 at 1:09 p.m. the Director of Nursing (DON) was asked about the facility's policy for administering medications through a PEG tube and stated, The nurses are supposed to check placement by using air in the syringe before med pass and the nurse should have cleaned the tubing used to unclog the peg tubing before it was inserted because it's a risk for infection. According to the facility's 10/17/2023 Medication Administration policy: Physician's orders- medication is administered in accordance with written orders of the attending physician.

Based on observation, interview and record review the facility failed to ensure respiratory care equipment was stored in a sanitary manner for one resident (R8) out of four residents reviewed for storage of respiratory equipment, resulting in the potential for a decline in of respiratory health. Findings include: On 6/30/25 at 10:48 A.M., R8 was observed in the resident's room. On the resident's bedside tables a CPAP machine (a continuous positive airway pressure device used for treating sleep apnea disorders), face mask and assorted tubing were observed among the resident's personal care items. The resident's face mask was uncovered positioned on the table among the assorted, used/unused tubing, one gallon container of open, undated sterile water and plastic covers. R8's visitor who interjected during the observation stated, They leave that mask and oxygen tubing like that, its not clean. R8 stated, I am supposed to use it twice a day, but they take it off and just throw it there. Throughout the interview and observation R8 indicated when her favorite nurse returned from vacation, he would clean off the table and put the mask and other equipment like it should be. On 7/1/2025 at 8:34 A.M. during an observation R8's CPAP machine, face mask and tubing was stored among used paper towels/napkins, personal care items, and an opened gallon container of water the face mask was uncovered and stored on top of the used paper towels/napkins. On 7/2/25 at 1:12 P.m. while checking the filter of the oxygen canister with nurse E the nurse was made aware of the storage of the resident's respiratory equipment. Nurse E acknowledged the equipment was not stored properly and the face mask should not be left in the manner observed. Review of the Physician Orders dated 10/23/24 documented: BiPAP 14/5 5 Liters oxygen 02 @ HS (bedtime) and naps once a day. Review of the Physician Orders and care plans did not identify any method, frequency of cleaning, or storage of the respiratory equipment. Review of the Care Plan documented: R8 has a potential, SOB and risk for respiratory complications R/T h/o respiratory failure, COPD, Obstructive Sleep Apnea. Interventions .Administer medication and treatment per physician order .provide supplemental oxygen via nasal cannula to maintain oxygen saturation greater than 92% PRN, BPAP at night. Review of the clinical record documented R8 was readmitted to the facility on [DATE], with pertinent diagnoses: chronic obstructive pulmonary disease, chronic respiratory failure, obstructive sleep apnea and dependence on supplemental oxygen. According to the Minimum Data Set (MDS) dated [DATE], R8 had a BIMS (Brief Interview for Mental Status of 14, was cognitively intact, required one to two person assist for Activities of Daily Living (ADL'S) and was always incontinent of bowel and bladder. The facility's policy was requested and provided, referenced: AARC Clinical Practice Guidelines Policy 1:8 was provided, titled: Small volume nebulizer (SVN) Handheld Nebulizer: After treatment rinse equipment with tap water and dry. Place in storage bag that is labeled with resident's name, and the date equipment was issued (do not seal damp equipment in a plastic bag).

Based on observation, interview, and record review the facility failed to ensure routine dental services were provided to one resident (R16) of one resident reviewed for routine dental services, resulting in unmet oral health needs and discomfort. Findings include: On 6/30/25 at 12:00 p.m. R16 was observed in the room, sitting at the bedside. R16 presented as alert and oriented to person, place, situation, and makes all needs known verbally. During the resident interview, R16 had a complaint about mouth discomfort due to teeth pain and needed to see a dentist. R16 asked staff to see the dentist and has waited for quite some time now. R16 was edentulous apart from a few back teeth. The resident opened the mouth, and the back teeth were discolored. The gums appeared swollen and red. R16 stated, There's certain things I like to eat but can't, so I eat soft things like Jello and mash potatoes. I am tired of it. R16 said the dentist removed most of the top teeth months ago but has not come back to remove the rest for unknown reasons. Review of the electronic medical record documented R16 was admitted into the facility on 7/20/23 with diagnoses that included seizures, obesity, benign prostatic hyperplasia without lower urinary tract symptoms, dysarthria and anarthria, major depressive disorder, and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. According to the annual Minimum Data Set (MDS) dated [DATE], R16 was cognitively intact (BIMS-14) and required assistance activities with daily living. The MDS also documented mouth or facial pain, discomfort or difficulty with chewing. Review of the physician order, dated 1/24/25 documented: Consult to dentist. The dental care plan was not in the medical record or available for review. Review of the social service progress notes documented in part the following: 1/21/2025- Social Services Note: SW informed by unit medical records that resident's insurance only covers oral surgery at (named dental office), requires (named in-house dental company) to fax referral directly to them. SW informed dental company who stated they would send referral. Writer was notified that referral was sent and medical records can schedule an appointment. SW provided medical records with contact to schedule appointment . SW will continue to assist as needed. 1/15/2025- Social Services Note: SW sent referral to dental company for an emergency dental visit. Dentist scheduled to come to facility 2/4/25. Resident states he is having tooth pain. Referral for emergency dentist sent to np. SW will continue to assist as needed. Review of the Emergency Dental Care Request dated 1/10/25 documented in part the reason for the referral was for right sided facial swelling and right upper tooth pain with visible decay . Issues with teeth and gums to top right . Evidence of pain (constant) . Swelling of the face (signs of infection). Antibiotic and pain medication was prescribed . Review of the following dental consult dated 2/4/25, documented in part the following: 2/4/2025- Doctors note summary: room visit, teeth, 15 and 16 are now hurting him, add those to the refer to be extracted by outside dentist. Next visit plan: exam, possibly future partial denture when teeth are extracted. Next visit: dental recall based on pay source frequency . 2/4/2025- X-rays not taken. X-rays were not taken because the resident was seen in their room. Recommend the resident be taken to the dental clinic on their next visit. Review of the nurse progress notes dated 3/14/25 documented in part: .dental services on 3/4/25. There was no record of the dental service provided to R16. On 7/2/25 at 11:27 p.m. Medical Records Clerk B was interviewed and asked the reason R16 has not had a follow up dental appointment for teeth pain in four months of the last referral. Medical Records Clerk said the dental appointment for March did not occur due to the dental company that services the facility needed to send a referral to the only dental office that would accommodate the resident which did not have any available appointments due to having a backlog. Medical Records Clerk B also said the one specific dental office was the only office that could accommodate the resident's wheelchair. The last call to the dental office was at the end of March. There have been no recent inquiries. On 7/2/25 at 11:45 a.m. the dental company that provides in house dental services, Care Coordinator D was contacted via telephone and stated, We provide referrals to any dental office. We don't refer to just one office. Residents can go to any dental office. On 7/2/25 at 12:00 p.m. Social Worker (SW) A was interviewed. SW A and stated, We usually use the one dental office because they accept Medicaid insurance. We have tried other places, but the resident would have to pay out of pocket. SW A was asked how they were notified when residents need dental services. SW A stated, I don't know when residents need dental services unless the MDS department tells me after they do their assessment. On 7/2/25 at 12:10 p.m. the Nursing Home Administrator (NHA) and Medical Records Clerk B was interviewed. Medical Records Clerk B was asked was R16 referred to another dental office that would see the resident immediately contacted. Medical Records Clerk B said another dentist office was called but the resident was not seen because the resident did not have the money to pay for services. The NHA stated immediately, If I would have known the resident needed to be seen, the facility would have paid for it. Review of the facility's policy titled Dental Services dated 10/25/23 documented in part the following: The facility will provide, or obtain from an outside resource, routine and twenty-four (24) hour emergency dental to meet the needs of the resident and when requested by the resident. The facility will assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the state plan . Follow up visits will be scheduled as needed.

Based on observation, interview, and record review, the facility failed to ensure Preadmission / Screening (PAS)/Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms (DCH-3877 and/or DCH-3878) documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for intellectual/ developmental disability needs in a timely manner for two residents (R32 and R54) of seven residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs. Findings include: R32 Record review of R32's electronic medical records (EMR) revealed admission into the facility on [DATE] with a pertinent diagnosis of undifferentiated schizophrenia (mental illness). Further review of Brief Interview for Mental Status (BIMs) dated 3/12/25 revealed R32 scored 0 out of 15 (severe cognitive impairment). Record review of R32's PASSAR-ARR (Annual Record Review) revealed completion on 11/21/24 at 2:47 PM. A Level II Determination (an evaluation to verify mental illness, nursing home placement, and specialized services) was not documented in R32's EMR. An interview was conducted on 7/2/25 at 11:00 AM with Social Worker (SW) A, and was reported that although Form-3877 had been submitted, Form 3878 had not been completed by the physician, which 'was causing a delay' in the process. An interview was conducted on 7/2/25 at 11:15 AM with Physician G. Physician G reported being unaware that R32's 3878 form needed to be signed. An interview was conducted on 7/2/25 at 1:15 PM with the Nursing Home Administrator (NHA). The NHA reported that it was the responsibility of both the Social Work Department and the Nursing Department to notify the physician when Form 3878 needs to be completed in the system. It was further reported that this responsibility was not carried out in a timely manner. R54 On 6/30/25 at 12:17 p.m. R54 was observed throughout the day walking independently around the facility. R54 was pleasant and calm but did not engage much with staff or other residents. On 7/1/25 at 11:38 a.m. review of the electronic medical record documented R54 was initially admitted into the facility on 3/3/23 with a recent readmission from the hospital crisis unit on 6/3/25 with diagnoses that included dementia with behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, psychotic disorder with delusions and adjustment disorder with depressed mood. According to the quarterly MDS assessment dated [DATE], R54 had severe cognitive impairment (BIMS-4) and was independent with activities of daily living. Review of the Preadmission Screening (Level I Screen, 3877) dated 2/27/24, documented the following were checked Yes: 1. Mental illness and dementia were checked for current diagnoses and received treatment. (Dementia Psychotic Disorder with delusions) 2. The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. (Seroquel) 3. There is presenting evidence of mental illness or dementia, including significant disturbances in thought, conduct, emotions, or judgment. Further record revealed there was no annual 3877 in the medical record. Review of the Mental Illness/Intellectual Disability/ Related Condition Exemption Criteria Certification (3878) dated 3/5/24, documented R54 had Dementia Exemption checked Yes: 1.Has demonstrable evidence of impairment in short-term or long-term memory as indicated by the inability to learn new information or remember three objects after five minutes, and the inability to remember past personal information or facts of common knowledge. 2. Exhibits at least one of the following: Impairment of abstract thinking, as indicated by the inability to find similarities and differences between related words, has difficulty defining words, concepts and similar tasks. -Impaired judgment, as indicated by inability to make reasonable plans to deal with interpersonal, family and job-related issues. Other disturbances of higher cortical function, i.e., aphasia, apraxia and constructional difficulty. -Personality change: altered or accentuated premorbid traits. Disturbances in items 1 or 2 above significantly interfere with work, usual activities or relationships with others. Further record revealed there was no annual 3878 in the medical record. On 7/2/25 at 11:52 a.m. SW A was interviewed about the absence of the annual 3877 and 3878 in the medical record and the person responsible to ensure they are completed timely. SW A stated, The Corporate Social Worker has been doing since I'm not full time, but the social worker is responsible for completing them. I am waiting for the physician to sign the 3878. SW A was asked to provide evidence the annual 3878 was waiting for the physician's signature and was not able to. Review of the facility's policy titled Pre-admission Screening and Guest/Resident Review- PASRR Michigan dated 11/12/21 documented in part the following: The PASRR process was established in 1987, as part of the OBRA ruling, to screen all individuals admitted for nursing care to ensure that needs are met to assist the individual in reaching their highest potential. All persons seeking admission to a nursing facility, who are seriously mentally ill and/or have an intellectual/developmental disability, are required to be evaluated to determine if a nursing facility is the appropriate place to receive services . A Level 1 3877 is completed annually for all guests/residents and maintained in the electronic medical record . As of September 20,2021, all Level 1 screenings are to be electronically received and submitted.

Based on observation and interview, the facility failed to maintain equipment in good repair and clean condition, properly store refuse, and maintain physical facility, resulting in contamination of equipment and a non-homelike environment, affecting all residents, staff, and visitors in the facility. Findings include: During an environmental tour on 7/10/24, assisted by Housekeeping Supervisor (HS) F, the following observation were made: 1:11 PM, the Gratiot Hall shower room was observed to have a light out over the sink, resulting in the shower room being dim. 1:31 PM, a box of wound dressing, a box of saline solution, a box of gloves, and a box of abdominal pads were observed to be stored on the floor in the respiratory supply room on the [NAME] Hall. At this time, HS F instructed staff to remove the boxes from the floor. 1:32 PM, the shower bed, located in the [NAME] Hall shower room, was observed to be soiled with discolored water. At this time, HS F stated that showers were done earlier in the day and staff are supposed to clean the shower room after use. 1:35 PM, the 2nd floor guest bathroom was observed to have water steadily leaking from the ceiling onto the floor. At this time, torrential rains were occurring. HS F stated that a company has come out to attempt to repair the leak but could not find where water was entering the building. 1:39 PM, three safety razors were observed on the floor of the Mac Hall shower room in the middle of the shower enclosure. Additionally, the foam shower bed was observed to have a tear in the head pad area exposing the interior foam. At this time, HS F stated he will order more shower beds. 1:42 PM, the soiled utility room, located on the Mac Hall, was observed to have two full trash containers, resulting in three full trash bags stored on the floor. At this time, HS F stated that a porter removes the trash from the soiled utility rooms twice a day. 1:48 PM, the ice machine, located on the Mac Hall, was observed to have mildew-like accumulation on the deflector plate. 1:54 PM, the hand rail, located in the hall near room [ROOM NUMBER], was observed to have a crack, leaving approximately a four inch hole. At this time, HS F stated he can order more hand rail parts to repair the hole. 2:12 PM, the boiler room, located in the basement, was observed to have water steadily dripping from the ceiling on to the floor and equipment. At this time, HS F stated the rooms with leaking ceilings are all sourcing from the same leak. 3:00 PM, the guest bathroom, located on the 1st floor, was observed to have water steadily leaking from the ceiling onto the floor.

Based on observation, interview, and record review, the facility failed to maintain physical facilities, install backflow prevention, date mark food, and properly cool potentially hazardous foods, resulting in the potential for increased risk of food borne illness, affecting all residents that consume food from the kitchen. Findings include: On 7/10/24 at 9:57 AM, the floor tile grout, located in the dish washing area and the cookline, was observed to be dissolving and worn, resulting in gaps for water accumulation. Additionally, the hose under the dish machine drain board was observed to not be provided with a backflow protection device (a device commonly used in plumbing to prevent contaminated water from backflowing into the potable water system). At this time, Registered Dietician E queried staff who stated the hose is used for cleaning the floor. According to the 2017 FDA Food Code Section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. According to the 2017 FDA Food Code Section 5-203.14 Backflow Prevention Device, When Required. A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under S 5-202.13 P; or (B) Installing an APPROVED backflow prevention device as specified under S 5-202.14. P On 7/10/24 at 10:05 AM, a pan labeled diced pork in the walk-in cooler, tightly covered with aluminum foil, was observed to feel warm to the touch. The diced pork temperature was measured with a digital probe thermometer and was observed to be holding at 121 degrees F. At this time, Dietary Staff G stated the pork was cooked this morning by Dietary Staff H During an interview on 7/10/24 at 10:30 AM, Dietary Staff H was queried on their preparation process of the dice pork and stated the pork was finished cooking around 8:00 AM, then say on the counter for a short period of time, then was covered and placed in the walk-in cooler. Dietary Staff H was then queried on the proper cooling process of cooked potentially hazardous foods and couldn't recite the proper cooling method or procedure. According to the 2017 FDA Food Code Section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); P and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. P (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna. P (C) Except as specified under (D) of this section, a TIME/TEMPERATURE CONTROL FOR SAFETY FOOD received in compliance with LAWS allowing a temperature above 5oC (41oF) during shipment from the supplier as specified in 3-202.11(B), shall be cooled within 4 hours to 5oC (41oF) or less. P (D) Raw EGGS shall be received as specified under 3-202.11(C) and immediately placed in refrigerated EQUIPMENT that maintains an ambient air temperature of 7oC (45oF) or less. P According to the 2017 FDA Food Code Section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; Pf (2) Separating the FOOD into smaller or thinner portions; Pf (3)Using rapid cooling EQUIPMENT; Pf (4) Stirring the FOOD in a container placed in an ice water bath; Pf (5) Using containers that facilitate heat transfer; Pf (6) Adding ice as an ingredient; Pf or (7) Other effective methods. Pf (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. 47964 During initial tour of the kitchen on 7/9/2024 at 11:15 AM with Dietary Assistant (DA) D the following was observed: -the three compartment sink had an active leak dripping directly onto the floor. DA D ackowlwedged the sink was leaking and needed repair. -undated desserts were found in the freezer: three pound cakes, three fruit pies and one round cake with no label. DA D agreed the desserts should be dated. Record review of the facility policy titled Food Purchasing and Storage revised 11/11/2021 revealed in part .all food items will be dated with the in date or delivery date, all frozen foods will be dated, labeled, and wrapped or sealed. According to the 2017 FDA Food Code Section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair.

Based on observation, interview, and record review the facility failed to follow the standards of infection control for proper PPE use (mask, gloves, gown) and proper hand hygiene, for one resident (R68) out of three residents reviewed for tracheostomy care, resulting in the increased potential for cross-contamination of diseases which place a vulnerable population at high risk for infections. Findings include: In an observation on 7/9/24 at 11:37 a.m., R68 laid in bed and had a tracheostomy. The suction tubing laid on the floor. R68's door had an Enhanced Barrier sign which read, . Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities . Device care or use: tracheostomy . Review of an Admission Record revealed, R68 admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included chronic respiratory failure with hypoxia and tracheostomy status. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R68 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15 and required a tracheostomy. In an observation on 7/11/24 at 9:43 a.m., Respiratory Therapist (RT) C prepared to perform trach care for R68. RT C entered R68's room and did not put on a gown or gloves. Trach care supplies laid on R68's bedside table and not on a barrier. RT C applied gloves after washing hands in R68's bathroom. RT C then removed R68's inner cannula and inserted a new one. RT C did not remove gloves after the removal of the old inner cannula. In an interview on 7/11/24 at 9:54 a.m., RT C reported changing an inner cannula requires clean technique. In an interview on 7/11/24 at 9:58 a.m., RT C reported she should have put on a gown before entering R68's room and should be worn during trach care. In an interview on 7/11/24 at 1:11 p.m., the Director of Nursing (DON) reported gloves should be changed after the old inner cannula is removed and the new one is put in. The DON then reported if staff is providing care longer than 10 minutes they should put on a disposable gown and supplies should be placed on a barrier and not on the bedside table. Review of a Enhanced Barrier Precautions (EBP) policy revised 3/26/24 documented, It is the intent of this facility to use Enhanced Barrier Precautions (EBP) in addition to Standard Precautions for preventing the transmission of CDC targeted multidrug-resistant organisms (MDROs) . Gloves, Gowns and Hand Hygiene A. Health care personnel caring for residents on Enhanced Precautions should wear gloves and gowns during high-contact resident care. Examples of high contact resident care activities requiring gown and glove use . Device care or use; central line, urinary catheter, feeding tube, tracheostomy/ventilator .

This citation pertains to Intake number MI000144806. Based on interview and record review the facility failed to obtain a Physical Therapy (PT) and Occupational Therapy (OT) evaluation upon admission for one (R345) of one resident reviewed for physical rehab, resulting in delayed Physical and Occupational Therapy treatment. Findings include: Review of an Admission Record revealed, R345 readmitted to the facility on [DATE] and discharged [DATE] with pertinent diagnosis which included tracheostomy status and gastrostomy status. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R345 had severely cognitive impairment. Review of Physician orders revealed R345 had orders for physical therapy evaluation- treat as indicated and occupational therapy evaluation- treat as indicated dated 5/24/24. Review of an interdisciplinary therapy screen assessment dated [DATE] revealed, PT/OT evaluation recommended for R345. Review of R68's electronic medical record revealed, R68 did not have a PT or OT evaluation. In an interview on 7/11/24 at 2:15 p.m., Rehab Manager A reported therapy evaluations were not completed as recommended on 5/24/24 and stated, Looks like we just missed it.

Based on observation and interview the facility failed to provide timely ADL (Activities of daily living) care to include nail care and shaving, for three residents (R21, R53, and R56) of six residents reviewed for ADL care resulting in dissatisfaction with care. Findings include: On 7/9/24 at 11:40 AM R21 was observed upright in bed, alert and able to participate in an interview. According to record review R21 was admitted [DATE]. According to a Minimum Data Set (MDS) assessment completed 6/26/24, R21 had a Brief Interview for Mental Status (BIMS) of 15/15 indicating intact cognition. R21's nails, on the fingers of both hands, were observed to be long to the point of curving over enough to partially obscure the underside of the nails. R21 was queried about the condition of the nails and said nail clipping had been requested and commented, Two days ago I asked and today someone came and said it will be done. R21 demonstrated that it was hard to pick items up off the bedside table due to the length of the nails and said, It's a problem. On 7/10/24 at 4:00 PM R21 was observed upright in bed, alert and able to participate in an interview. Nails were observed to be in the same condition as the previous day. No one showed up yet R21 said. On 7/11/24 at 11:35 AM an interview was held with the Director of Nursing (DON). During discussion about the condition of R21's nails and resident's statement about the inability to pick certain items up because of the length of the nails, the DON responded by saying that resident had . never said anything about it and that it hadn't been noticed. When asked about the risks involved the DON said, It is a risk for infection to have nails that long. 39465 R56 R56 was observed on 7/9/2024 at 10:31 and 7/10/2024 at approximately 11:30 a.m. with long facial hair and dirty long untrimmed fingernails. R56 was nonverbal and unable to be interviewed. According to the electronic medical record, R56 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses of chronic respiratory failure, tracheotomy status, dependence on respirator ventilator status, diabetes type two, and major depressive disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R56 BIMS (brief interview for mental status) score was not documented. R56's Functional ability care plan, dated 5/13/2024, revealed, Resident has a functional ability deficit requires assistance with self-care/mobility related to impaired balance, impaired cognition, impaired mobility, pain, and diagnoses of chronic respiratory failure, persistent vegetative state. Interventions: Bathing: Resident is dependent with two helpers to bathe/shower two times a week and as needed. 50634 R53 On 07/09/2024 at 10:19 AM, R53 was observed lying in bed alert and interview able. R53 was observed with long, untrimmed and dirty fingernails. R53 had food particles in beard. R53 was nonverbal but able to nod head when queried about care. R53 nod head indicating Yes, when asked if they would like nails cleaned and trimmed. Record review revealed R53 was admitted into the facility on [DATE] with Traumatic hemorrhage of cerebrum. According to R53's quarterly Minimum Data Set (MDS), with reference date of 04/23/2024, they have a BIMS score of 2 (severely impaired cognition). according. Review of the ADLs care plan documented R53 needs maximum assistance with and with personal hygiene, toileting and turning. On 07/11/2024 at 11:00 AM, the Director of Nursing (DON) said during an interview, the residents should have showers twice a week and it consists of being cleaned from head to toe and their nails to be cleaned and cut.

Based on interview and record review, the facility failed to complete an OBRA (Omnibus Budget Reconciliation Act) Level II Evaluation for one (R40) of one residents reviewed for PASARRs (Preadmission Screen and Resident Review), resulting in the potential for unmet mental health services. Findings include: Review of the clinical record revealed R40 was initially admitted into the facility on [DATE] and readmitted on [DATE]. R40's diagnoses included seizures, unspecified convulsions, bipolar disorder, and major depressive disorder. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. The date of R40's most current Level II PASARR was 11/16/2023. On 7/10/2024 at 10:36 AM, a review of R40's most recent Level II PASARR, dated 11/16/2023, was conducted with Social Worker (SW) B. SW B said based on the Level II PASARR from 11/16/2023 a new Level II evaluation was needed by March 15th, 2024. SW B said R40 does not have a current Level II PASARR evaluation. I should have submitted a Level II request by March 15th, 2024. On 7/10/2024 at 10:53 AM, the Director of Nursing (DON) stated she expected PASARRs to be completed per OBRA requirements. A review of the facility document titled, Pre-Admission Screening and Guest/Resident Review-PASRR Michigan, revised 11/12/2021, documented in part the following: for residents who screen positively for a mental illness/intellectual/developmental disability the facility submits the annual Level 1/3877 screen to the local community mental health program for comprehensive screening (level 2).

Based on interview and record review the facility failed to ensure complete and accurate documentation was maintained in an Electronic Health Record (EHR) for one resident (R139) of 20 residents reviewed resulting in inaccurate and incomplete medical records with the the potential for inadequate care delivery. Findings include: A review of R139's EHR revealed 16 consecutive progress notes from 11/7/22 through 4/17/23 written by Nurse Practitioner (NP) A with the exact same documentation that included; Hematuria (blood in the urine), continue to flush foley. UA (urinalysis) and cultures (C&S) reviewed, negative, (11/7/22, 11/9/22, 11/14/22, 11/16/22, 11/25/22, 11/28/22, 12/8/22, 12/15/22, 12/19/22, 12/22/22, 1/5/23, 1/23/23, 2/20/23, 3/20/23, 4/5/23, and 4/17/23). Review of R139's progress notes written by the physician and other nursing staff did not reveal any documentation to indicate the resident had hematuria during this time. A Urinalysis result for R139 collected 10/26/22 and reported on 10/27/22 indicated it was a 'Partial Report, Final to Follow. There was no additional Final Report of R139's urinalysis in his EHR as of 6/22/23. According to the EHR, R139 admitted to the facility on [DATE] with multiple diagnoses that included quadriplegia and required a supra pubic catheter (s/p catheter is a hollow flexible tube surgically inserted through the abdomen into the bladder) to drain urine. - On 10/26/22, NP A documented, hematuria and a UA and C&S was ordered. - On 10/28/22 NP A documented hematuria follow-up. UA and C&S pending results. Continue to flush foley. - On 11/2/22, NP A documented R139's hematuria was resolved. During an interview on 6/22/23 at 9:34 AM the Director of Nursing (DON) reviewed R139's EHR. The DON said, I reviewed all her (NP A) notes. They all say the exact same thing. Its looks like she just copied and pasted her progress notes from 10/28/22 through 4/17/23. The DON continued to review R139's EHR and said, There is no note from nursing that indicates resident had hematuria since October 27th. The resident's UA was from October and it's inconclusive. I don't know why we do not have the final report on this. I will call the lab. It (the final UA report) should be in there. On 6/22/23 at 12:15 PM during a phone interview with NP A she said, I reviewed his (R139)'s medical record. I had been accidentally pasting an old note in his record. It's a mistake on my end. I wrote a note today indicating it was an error. The resident did not have any hematuria or UA since 10/26/22. I don't know why the final report of his UA isn't in his EHR. It should be. A review of R139's EHR revealed a progress note written by NP A on 6/22/23 as follows; inaccurate documentation in regards to hematuria. Also UA and culture was never ordered, also wrong documentation. Please call our team with questions or concerns. On 6/22/23 at 12:30 PM the DON provided R139's final Urinalysis report dated 10/27/22. The report indicated 'Negative for infection. The DON said, I'll have this uploaded into the resident's medical record. It should have been there earlier. According to the facility's policy for Documentation Expectations last revised 11/1/2017; Healthcare personnel will complete documentation requirements as outlined by the company and recorded in the medical record using accepted principles of documentation. Be Specific. Entries should reflect factual statements. Be Complete. All facts and pertinent information related to an event, course of treatment, resident condition, response to care, and deviation from standard treatment (including the reason for the deviation) must be documented. If an original entry is incomplete, follow guidelines for making a late entry, addendum, or clarification. Procedure General 1. Chart events as they occur and maintain chronological order. 6. Preprinted forms: Only approved forms are to be used. Do NOT copy forms. All areas of the form are to be completed fully according to each form's instructions. If a field is not applicable, MN/A should be entered to show that the question was reviewed and answered.

Based on observation, interview and record review, the facility failed to ensure proper anchoring/securing of an indwelling urinary catheter for one (R73) of four residents reviewed for urinary catheters, resulting in pain and the potential for infection and skin trauma. Findings include: In an observation on 6/21/23 at 10:35 a.m., Resident #73 (R73) laid in bed and had a urinary cathete. Tea colored urine was observed in the tubing. Review of an admission record revealed, R73 admitted to the facility 11/4/22 and readmitted on [DATE] with pertinent diagnosis which included Obstructive and Reflux Uropathy (the backup of urine into the kidneys) and Benign Prostatic Hyperplasia (prostate pushes against the urethra and the bladder). Review of a Minimum Data Set (MDS) assessment, with a reference date of 5/10/23 revealed R73 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14 out of 15 and required an indwelling catheter. In an observation on 6/26/23 at 8:58 a.m., Certified Nursing Assistant (CNA) B prepared to perform ADL care for R73. CNA B performed hand hygiene and applied gloves. R73's catheter tubing hung to the right side and did not have a device to secure the indwelling catheter. R73's head of the penis was red and a yellowish substance near the base of penis was present. R73 complained of pain when CNA B touched the catheter. In an interview on 6/26/23 at 9:30 a.m., CNA B reported R73 should have an anchor or leg strap on the catheter. In an interview on 6/26/23 at approximately 9:33 a.m., Licensed Practical Nurse (LPN) C reported R73 should have a leg strap and had a history of urinary tract infections. Review of a care plan revealed R73 had focus, (R73) is at risk for urinary tract infection and catheter-related: has a Foley Catheter r/t (related to) obstructive uropathy with a revised date of 5/2/23. Interventions include provide catheter care per policy. Review Physician orders revealed R73 had an order, Secure Foley Catheter with Anchor/Leg strap with a start date of 6/7/23. Review of a progress note with a date on 6/19/23 at 12:20 p.m. revealed R73 had a blood in urine and pain. In an interview on 6/26/23 at 11:06 a.m., the Director of Nursing (DON) reported applying an anchor for the catheter depends on the resident's needs. The DON then reported an anchor is required most of the time for a resident with a catheter. Review of an Catheter Associated Urinary Tract Infection (CAUTI) Prevention policy with a revised date of 8/17/21 revealed To ensure appropriate technique in the care and maintenance of indwelling catheters . 5. Secure catheter properly to prevent movement. A leg strap or tape may be used .

Based on observation and interview, the facility failed to maintain a sanitary environment and the physical facility in good repair (Room #'s 225-228, 232, 231, 222, 109, 108, 216, 207, 134, and 2nd floor shower room) resulting in a non-homelike environment and potential respiratory distress. Findings Include: On 3/22/22 at 11:16 AM, the bathroom exhaust ventilation grids for room #'s 227-228 and 225-226 were observed to be caked with dust. On 3/22/22 at 11:22 AM, the bathroom faucet for room # 232-231 was observed to have pink biofilm around the base. On 3/22/22 at 12:53 PM, the shower room, near resident room 222, was observed to have two dusty exhaust vents. Additionally, the shower gurney pad was observed to have multiple cracks/rips exposing the internal foam, which can harbor bacteria. On 3/22/22 at 1:19 PM, the foot board of Bed 1 was observed to be loosely fastened and crooked in Room #222. Additionally, the footboard from Bed 2 was removed completely and leaning against the wall in the room. On 3/22/22 at 1:23 PM, unfinished drywall patches were observed on the wall behind Bed 1 in Room # 109. At this time, Maintenance Director Q stated that the wall patches were there before they started working at this building. On 3/22/22 at 1:24 PM, approximately five feet of baseboard underneath the wall register, near Bed 2 of Room # 108, was observed to be detached from the wall and laying on the floor. On 3/22/22 at 2:10 PM, the wall register, located in Room # 216, was observed to be loose from the wall and was resting on Bed 2. Additionally, Bed 2 was not level; the front left of the bed was lower than the rest of the bed. On 3/22/22 at 2:12 PM, the wall behind Bed 2 in Room # 207 was observed to be largely etched/scratched, covering approximately a 3 foot by 2 foot area. On 3/22/22 at 2:48 PM, the wall behind Bed 1 in Room # 134 was observed to have significant etching on the wall, exposing drywall.

This citation pertains to intake MI 913 Based on observation, interview, and record review the facility failed to provide 3 dependent residents (R 29, R 38, R52) out of 6 dependent residents reviewed for ADL's (activities of daily living), with the option of receiving showers as opposed to wash ups in bed; resulting in the residents expressing verbal and nonverbal expressions of surprise and annoyance when informed showers were an available care option. Findings include: R29 A review of the medical record for R29 on 3/23/22 at 2PM indicated the resident was admitted to the facility on [DATE] with relevant diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS (minimum data set) with a reference date of 1/20/22, R 29 scored 9/15 on the BIMS (brief interview for mental status) indicating moderate cognitive (thought process) functioning. R32 required total 2-person assistance with transfers, and 2- person total assistance with dressing, toileting, personal hygiene, and bathing. The care plan interventions for bathing indicated the need for staff assistance to take showers twice weekly and as needed. An interview was conducted with R29 on 3/24/22 at 03/25/22 8:15AM. R29 was observed lying in bed when asked by the surveyor if she had been receiving assistance in the mornings with getting washed up the resident stated yes. R 29 stated, I get a bed bath. When asked if she ever got a shower R29 stated no. When asked if she would like a shower she stated, Yes. I did not know I could get a shower. A review of the March 2022 shower sheet for R 29 was conducted on 3/25/22 at 1PM. The shower sheet did not specify a particular day for baths/showers, nor did it differentiate between a bed bath or a shower. In the month of March 2022 there were a total of seven baths/showers from March 1, 2022, to March 24,2022 documented for R29. R38 A review of the medical record for R38 was conducted on 3/25/22 at 12:00 PM. The medical record indicated R38 was admitted to the facility on [DATE], with relevant diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS (minimum data set) with a reference date of 2/7/2022, R 38 scored 10/15 on the BIMS (brief interview for mental status) indicating moderate cognitive (thought process) functioning. R 38 required limited 1- person limited assistance with transfers and personal hygiene, extensive 1- person assistance with dressing, toilet use, and one person assistance with part of bathing. The care plan interventions for bathing indicated the need for staff assistance to take showers twice weekly and as needed. An interview was conducted with R 38 on 03/25/22 at 12:30PM. R38 was observed lying in bed, when asked by the surveyor if he has been receiving assistance in the mornings with getting washed up the resident stated Yes. The resident also stated, I get washed up in the mornings, they even put deodorant under my arms. When asked by the surveyor if he would like to get showers on some of the wash up days, R38 stated, You know I can't walk, that is why they don't take me to the showers. R38 stated, If I could get taken to the shower sometime, I would want to. A review of the March 2022 shower sheet for R 38 was conducted on 3/25/22 at 1:15 PM. The shower sheet did not specify a particular day for baths/showers, nor does it differentiate between a bed bath or a shower. In the month of March 2022 there were a total of seven baths/showers from March 1, 2022, to March 24,2022 documented for R38. R 52 A review of the medical record for R52 was conducted on 3/25/22 at 1:30PM. The medical record indicated R52 was readmitted to the facility on [DATE] with relevant diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS with a reference date of 2/14/22, the BIMS was unscored. R52 required total 2-person assistance with transfers, and extensive 1-person assistance with toilet use and personal hygiene. R 52 is totally dependent on 2 staff for bathing. The care plan interventions for bathing indicated the need for staff assistance to take showers twice weekly and as needed. An interview was conducted with R 52 on 3/25/22 at 1:45PM. R52 was observed lying in bed, when asked by the surveyor if he has been receiving assistance in the mornings with getting washed up, the resident had no response. When asked if would like to get out of bed and taken to get a shower, R52 responded Yes. A review of the March 2022 shower sheet for R 52 was conducted on 3/25/22 at 2PM. The shower sheet did not specify a particular day for baths/showers, nor does it differentiate between a bed bath or a shower. In the month of March 2022 there were a total of five baths/showers from March 1, 2022, to March 24,2022 documented for R52. An interview was conducted with DON B on 3/25/22 at 4:15 PM regarding R29, R38, and R 52 stating they have not received showers and did not know they could receive anything other than a bed bath. DON B, stated, Residents are scheduled for showers twice weekly and as needed at this facility. The DON provided the surveyor with the March 2022 shower/bath sheets for R 29, R38, and R32.

Based on observation, interview and record review, the facility failed to provide devices to assist and maintain mobility and proper positioning for two (#s 72, 103) of six sampled residents reviewed for range of motion (ROM), resulting in the development of a contracture (permanently fixed, immobile joint) and the potential for further development or decline in ROM and mobility. Findings include: Resident #72- On 12/03/19 at 12:06 PM and 2:30 PM, on 12/4/19 at 10:05 AM, 12:30 PM, 2 PM and 4:15 PM, the resident was observed lying in bed, totally immobile, non-verbal and with bilateral forearms held tightly up to the chest with elbows flexed (bent) and hands tightly clenched. The resident's minimum data set in the clinical record dated 10/23/19 noted: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/17/19, the resident was prescribed Occupational Therapy (OT) five times a week for 12 weeks including, splint/orthopedic management/training and functional management program development following the completion of an OT evaluation. On 12/05/19 at 9:53 AM, the resident's forearms and hands remained in the same position. A gloved finger was inserted into the right hand, the fingers were very stiff and the palm contained a brown, foul smelling coating and a small area of impaired skin (breakdown). A gloved finger was inserted into the left hand, which the resident was easily able to relax and open (had more ROM), but also had a foul smell. Nurse Unit Manager B was called to the room and began cleaning the right palm and between the fingers. The fingers were able to loosen (extend) slightly as they were being manipulated. Nurse B then placed rolled wash clothes into the palms attempting to keep the hand opened and absorb moisture in the palms. When asked, she could not explain why the resident's hands appeared to have been neglected of care. Therapy staff was then called to the room. Therapy manager D said the resident had received skilled OT at one time, but was discharged from care by OT staff. She then assessed the resident's upper extremities by attempting to extend the elbows and fingers. The elbows were stiff, but the forearms could be extended away from the chest. The fingers on the left hand could to be extended. The fingers of the right hand were stiff, could barely be extended and appeared contracted. Manager D said, He could use bilateral elbow extenders and a hand splint on the right. He doesn't really need anything for the left hand. I will get the therapist (OT C) who worked with him to look at him. The resident's therapy records were requested. At 12:39 PM, therapy records were reviewed and revealed the following: 10/17/19 initial OT Evaluation-Goal: Patient will improve tolerance for ROM full elbow extension and hand open 50% in order to prevent contractures and decreased skin integrity. (Target (date) 10/30/2019); The resident was right-handed, ambulatory, had no contractures and able to perform activities of daily living (ADL) before the stroke occurred around 8/21/19; Bilateral hands closed, requires gentle extensor tactile stimulation/therapeutic touch to relax for active hand opening to 75% (meaning after massage and ROM exercises to hands); Right upper extremity muscles are tight, not rigid; Risk factors: .the patient is at risk for further decline in function, immobility, increased tone (stiffness/rigidity), limited functional movement contracture(s) Per an OT progress report, on 10/30/19 the resident was able open both hands to 75% with gentle stretch. The resident was discharged from skilled OT on 11/20/19. The discharge summary dated 11/20/19 noted: Bilateral hands opened to 75% with gentle stretch, and patient is tolerating resting hand splint (a splint used to maintain the hand in a neutral position of rest to prevent contracture) for 3 or more hours at a time to the right hand; Interventions provided during therapy included orthotic (hand splint) management and training, including design and fitting patient's response to wearing orthotic adjustments to device to ensure proper body alignment prevent decline from current level of skilled performance .; Prognosis for maintaining current level of functioning=good with consistent staff follow-through; Discharge recommendations: refer to restorative nursing program. The instructions for the restorative nursing staff to continue care of the right hand with ROM exercises and splint application, were to be provided by OT C and made accessible via computer program, however, there was no documented indication the instructions were provided. At 12:45 PM, when asked why there were no splints/positioning devices for the resident's upper extremities, manager D said, (OT C) made a mistake. (The resident) should have been referred to restorative therapy. At 1:15 PM, OT C said, There was a mistake. There was no documented referral to restorative (staff) for them to put on the splint. There should have been. I looked for it (in the computer), but it wasn't there. She was carrying a right hand splint and said, He had the splint in his drawer but it is no longer appropriative for him to use because now he has a contracture. He didn't before. She indicated the hand could no longer open enough to place the splint. She said, He has a hand roll, but that won't work (the rolled wash cloth placed by nurse B, which was too soft to maintain proper positioning). I'm not sure if the right orthotic is in house. I may be able to put together something or have to order one. At 2:05 PM, when made aware splints/positioning devices were not being provided for the resident and a contracture had developed, the Director of Nursing said, If restorative (staff)didn't get the order, how would they know? She did not comment as to why nursing staff did not notify and confer with therapy staff about devices. The resident's OT care plan initiated 10/17/19 noted: (Resident) will increase bilateral upper extremity ROM enabling him to tolerate splint device per schedule to prevent further contractures The ADL care plan initiated 10/16/19 noted: Provide gentle ROM as tolerated with daily care. On 12/6/19 at 8 AM, per review of the facility's Brace and Splint Program policy dated 1/2012: The facility will ensure that any resident with a limited ROM receives treatment and services to increase ROM and prevent further decrease in ROM. The facility will ensure that the resident reaches and maintains his or her highest level of ROM and to prevent avoidable decline in ROM Staff has a scheduled program of applying and removing the appliance that include: scheduled hours to be worn Communicate individualized interventions to the direct care providers. Provide specific directions and training as needed (e.g. correct splint application, ROM ). Per the facility's Contracture Prevention and Management Program policy dated 1/2012: Purpose: Assisting a resident to attain and/or maintain joint mobility prevents or reduces contractures, preserves ROM for use of prosthesis A resident requiring splints/brace application and removal are considered for this restorative program Communicate individualized interventions to the direct care providers. Provide specific directions and training as needed (e.g. correct splint application, ROM ). Resident #103 During an observation on 12/03/19 at 10:29 AM, R103 was laying in bed with his head slightly elevated. The resident had obvious bilateral foot drop (a dropping of the forefoot caused from nerve damage, inability to lift the foot) and left hand contracture. The resident did not have any splint on, nor did he have an 'over-the-bed' trapeze (a metal apparatus above a resident's bed used to help move and support weight during during a transfer or position change). At 12:18 PM and again at 2:08 PM, the resident remained in bed without any splint on his left hand or feet/ankles. According to the resident's medical record, he admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident had a [DIAGNOSES REDACTED]. The last Minimum (MDS) data set [DATE] indicated the resident had limited range of motion for both extremities on one side. On 9/29/19 there was an order for [REDACTED]., 3 time a week for 8 weeks. The 'tasks' section of R103's chart had the following task identified on 10/9/19: position resident in bed and chair and assist with the use of pillows and wedges. Left hand/wrist splint and both feet ankle splints for 4 hours daily. Left arm PROM 2 sets of 10 reps to each joint and plane as tolerated for 8 weeks. There is no documentation to indicate that any of these tasks were performed, not once. On 11/8/19 and 11/11/19 there is a documentation that indicated this task as not applicable. On 12/4/19 at 9:03 AM, R103 is observed in his bed without any splints on his left hand, or feet/ankles. There are no pillows or positioning wedges in the residents bed. CNA N was asked about R103's splints. CNA N said, I don't know of any splints. He hasn't worn any splints that I know of. A search of R103's room revealed a left hand/wrist splint only, no foot/ankle splints. On 12/04/19 at 11:17 AM , the facility's therapy director reviewed R103's medical record and confirmed that he was suppose to have an 'over-bed' trapeze. She said, he is no longer on our case load, and was placed on restorative therapy on 10/1/19. On 10/1/19 we did an education with nurse M, the restorative nurse, for a splint schedule and PROM exercises to prevent any further loss of mobility. At this time the medical record was reviewed and confirmed that both the therapy manager and nurse M had participated and documented in the restorative therapy plan. A care plan and task was initiated by nurse M in the R103's medical record. On 12/04/19 at 12:30 PM, R103 is sitting up in his bed and eating his lunch, independently with built up utensil. There is no over-bed trapeze and no splints on the residents feet/ankles or left hand/wrist. At 2:00 PM the resident is asleep in bed without any splints in use. During an interview with the restorative nurse M, on 12/04/19 at 2:20 PM, he said the facility was in the process of getting a over-bed trapeze for R103. Nurse M did not know if it had been ordered as of yet. Nurse M was unaware that R103 had not been wearing his splints, and could not be certain if the PROM had been conducted since there was no documentation to support that the therapy had ever been done. During an interview with the Administrator on 12/04/19 at 2:37 PM, she said the resident was not going to get the 'over-bed' trapeze because she was told by staff that R103 was placing himself on the floor when he had a trapeze before. Upon review of the medical record, the resident was documented to have had no falls in the past year. There was no documentation or care plan to support this, nor was there any previous orders to indicate that R103 had an 'over-bed' trapeze in the past. During an interview with the Director of Nursing (DON) on 12/04/19 at 2:59 PM, she said, If he had an over-bed trapeze it had to be years ago, I don't remember ever seeing him with one. On 12/05/19 at 8:40 AM, R103 did not have any splints in use. On 12/05/19 at 10:23 AM, the restorative CNA G was asked about R103's splints, he said; He refuses to have the hand splint put on, so I haven't been doing it. He has not had any feet/ankle splints for months, since he switched rooms. I don't know what happened to them. On 12/05/19 at 11:17 AM, CNA N placed the left hand/wrist splint on R103 without any difficulty.