**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) were provided accurately and timely to two Residents (R#25 and R#107) of three reviewed. Findings include: Resident #25 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident 25 (R25) was a [AGE] year old admitted to the facility on [DATE] utilizing Medicare part A benefits. Review of the NOMNC for R25 reflected a last covered day under Medicare A would be 4/16/25. The NOMNC was signed by R25 on 4/15/25, thus not giving the required time frame for the notice . Review of the SNF ABN, also signed by R25 on 4/15/25 revealed R25 would be billed privately starting 4/18/25. Resident #107 Review of the clinical, including the Minimum Data Set (MDS) record reflected Resident 107 (R107) was admitted to the facility on [DATE]. Review of the NOMNC for R107 reflected a last covered day under Medicare A would be 2/19/25 the form was signed by R107 and dated 2/19/25. On 06/03/25 at 03:28 PM, during an interview with the facility Social Worker (SW) K she reported being responsible for issuing NOMNC and SNF ABN and always issued them with 3 days notice to ensure residents had adequate time to appeal. Review of R25's and R107's NOMNC, SNF ABN was completed with SW K whom offered no explanation for why the notices were issued late and inaccurate.

Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for one resident (#49) of 14 resident reviewed. Findings included: Resident #49 (R49) Review of the medical record demonstrated R49 was admitted to the facility 04/16/2025 with diagnoses that included fracture of right tibia (the larger of the two bones in the lower leg), infection at surgical site, cellulitis (bacterial infection) of left upper limb, chronic pain, osteoarthritis (degenerative joint) of right knee and right hip, hypertension, atrial fibrillation, malnutrition, depression, prediabetes, gastro-esophageal reflux, neurocognitive disorder with Lewy Bodies (Lewy Body Dementia), anxiety, and schizoaffective disorder. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2025, revealed R49 had a Brief Interview for Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. During observation and interview on 06/02/2025 at 11:26 a.m. R49 was observed sitting up in a recliner chair at bedside. R49 explained that she was bored at the facility. It was inquired of R49 if the facility provided her with an activity calendar with activities that she could possibly attend. R49 explained that she was unaware of any Calander of activity programs. No activity Calander was observed posted in R49's room. Review of R49's medical record did not reveal any listed plan of care demonstrating what activity programs R49 may have been interested in attending or completing while at the facility. Review of R49's Life Enrichment Assessment, dated 04/17/2025, listed her activities as passive, centered almost entirely family activities, and solitary activities. R49's Life Enrichment Assessment , dated 04/17/2025 also revealed Will Activities- functional status be addressed in the care plan?, was answered yes. During observation and interview on 06/03/2025 at 01:31 p.m. R49 was observed sitting up in her recliner at bedside. R49 was asked if anyone invited her to facility activity? R49 explained that no one has ever invited her to any activities. R49 denied again that she had ever been provided an activity calendar. No activity calendar was observed in her room. R49 again expressed concern that she was bored at the facility. Review of R49's activity participation, in the medical record, for the last 30 days revealed an activity entitled conversation/reminiscing and documented participation 21 times. R49's activity participation for the last 30 days also revealed that seven times out of those 21 times were only conducted with R49 participating, not staff. The activity record did not demonstrate any group activity being offered to R49. In an interview on 06/03/2025 at 01:53 p.m. Nursing Home Administrator (NHA) A explained that it was her expectation that the Life Enrichment (Activity) Department provide a monthly activity Calender, of list activity programs, to all residents. NHA A also explained that it was her expectation that all residents plan of care included activity preferences. NHA A confirmed that R49 did not have a plan of care demonstrating her activity preferences. NHA A could not explain why no care plan was present for R49's activity preferences. In an interview on 06/04/2025 at 12:54 p.m. Activity Assistant (AA) L explained that activities are documented in the resident's records for each activity that residents are invited to attend or that the resident participates in. AA L explained that all residents are provided an activity calendar that is usually placed on the bathroom door of the residents' room. During observation and interview on 06/04/2025 at 01:08 p.m. R49 was observed sitting up in recliner chair. She was observed coloring with colored pencils. It was also observed that an activity calendar was hanging on the exterior of her bathroom door. R49 explained that someone from the activity program at the facility had come into her room and discussed June's activity calendar and hung it on her bathroom door. R49 also explained that the same person had given her colored pencils and coloring books at that time. R49 explained that she was happy and excited that she was able to color and had been given the option to attend other activities.

During observation, interview, and record review the facility failed to provide failed to provide meaningful, individualized activities for one resident (#49) of one resident reviewed for activities. Findings included: Resident #49 (R49) Review of the medical record demonstrated R49 was admitted to the facility 04/16/2025 with diagnoses that included fracture of right tibia (the larger of the two bones in the lower leg), infection at surgical site, cellulitis (bacterial infection) of left upper limb, chronic pain, osteoarthritis (degenerative joint) of right knee and right hip, hypertension, atrial fibrillation, malnutrition, depression, prediabetes, gastro-esophageal reflux, neurocognitive disorder with Lewy Bodies (Lewy Body Dementia), anxiety, and schizoaffective disorder. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2025, revealed R49 had a Brief Interview for Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. During observation and interview on 06/02/2025 at 11:26 a.m. R49 was observed sitting up in a recliner chair at bedside. R49 explained that she was bored at the facility. It was inquired of R49 if the facility provided her with an activity calendar with activities that she could possibly attend. R49 explained that she was unaware of any Calander of activity programs. No activity Calander was observed posted in R49's room. Review of R49's medical record did not reveal any listed plan of care demonstrating what activity programs R49 may have been interested in attending or completing while at the facility. Review of R49's Life Enrichment Assessment, dated 04/17/2025, listed her activities as passive, centered almost entirely family activities, and solitary activities. R49's Life Enrichment Assessment , dated 04/17/2025 also revealed Will Activities- functional status be addressed in the care plan?, was answered yes. During observation and interview on 06/03/2025 at 01:31 p.m. R49 was observed sitting up in her recliner at bedside. R49 was asked if anyone invited her to facility activity? R49 explained that no one has ever invited her to any activities. R49 denied again that she had ever been provided an activity calendar. No activity calendar was observed in her room. R49 again expressed concern that she was bored at the facility. Review of R49's activity participation, in the medical record, for the last 30 days revealed an activity entitled conversation/reminiscing and documented participation 21 times. R49's activity participation for the last 30 days also revealed that seven times out of those 21 times were only conducted with R49 participating, not staff. The activity record did not demonstrate any group activity being offered to R49. In an interview on 06/03/2025 at 01:53 p.m. Nursing Home Administrator (NHA) A explained that it was her expectation that the Life Enrichment (Activity) Department provide a monthly activity Calander, of list activity programs, to all residents. NHA A also explained that it was her expectation that all residents plan of care included activity preferences. NHA A confirmed that R49 did not have a plan of care demonstrating her activity preferences. NHA A could not explain why no care plan was present for R49's activity preferences. In an interview on 06/04/2025 at 12:54 p.m. Activity Assistant (AA) L explained that activities are documented in the resident's records for each activity that residents are invited to attend or that the resident participates in. AA L explained that all residents are provided an activity calendar that is usually placed on the bathroom door of the residents' room. During observation and interview on 06/04/2025 at 01:08 p.m. R49 was observed sitting up in recliner chair. She was observed coloring with colored pencils. It was also observed that an activity calendar was hanging on the exterior of her bathroom door. R49 explained that someone from the activity program at the facility had come into her room and discussed June's activity calendar and hung it on her bathroom door. R49 also explained that the same person had given her colored pencils and coloring books at that time. R49 explained that she was happy and excited that she was able to color and had been given the option to attend other activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #2 (R2): Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R2 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease and depression. The MDS reflected R2 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact. During an observation and interview on 06/02/25 a 11:58 AM R2 was laying in bed with two medications sitting on the bedside table, dulera inhaler 100mcg/5mcg and fluticasone nasal spray 50mcg. R2 reported the nurse had brought them in earlier and did not administer to R2 and left the room. R2 reported does not take medication on own. During an interview on 6/04/25 at 8:58 AM, Director of Nursing (DON) B reported had been in position at facility for about three months. DON B reported residents should not have medications at the bedside unless they have been assessed to self administer medications. DON B reported R2 had not been assessed to self administer medication, no physician order to self administer and was not care planned for self administration of medications. DON B reported resident medication should be locked in medication carts. Based on observation, interview, and record review the facility failed to ensure proper medication storage of medications for two residents (#2, #3) out of 54 current residents residing at the facility and failed to label mediation in accordance with accepted professional standards, dating of open multi-dose medication, observed in one medication room out of three medication rooms reviewed. Findings included: Resident #3 (R3): Review of the medical record demonstrated R3 was admitted to the facility 04/04/2025 with diagnoses that included cellulitis (bacterial infection) of left lower limb, psoriasis (condition in which skin cells build up and form scales and itchy, dry patches) , type 2 diabetes, atrial fibrillation, atherosclerotic heart disease (build-up of fats in artery walls), hypertension, sleep apnea, asthma, hypothyroidism (low thyroid hormone), glaucoma (group of eye conditions that damage the optic nerve), fibromyalgia (wide spread musculoskeletal pain) , irritable bowel syndrome, sepsis (condition resulting in extreme response to infection), pneumonia, depression, and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2025, revealed R3 had a Brief Interview for Mental Status (BIMS) of 15 (intact cognition) out of 15. During observation and interview on 06/02/2025 at 11:38 a.m. R3 was observed sitting up in her recliner at the bedside. Trelegy 100mcg(micrograms)/62.5mcg/25mcg inhaler and Azelastine 0.1% nasal solution was observed to be sitting on her over bed table. R3 explained that she is allowed to take those medications without the nurse present. Review of R3's medical record had not revealed a physician order for self-administration of medication. R'3s medical record had not revealed a self-administration of medication assessment. R'3s plan of care had not revealed a self-administration of medication plan of care. In an interview on 06/04/2024 at 08:57 a.m. Director of Nursing (DON) B explained that it was facility policy and practice that residents could keep medication in their room and perform self-administration. DON B explained that residents must be assessed for self-administration prior to medication being left in the room and prior to self-administrated. DON B explained if the resident is assessed as safe a physician order would be obtained, resident plan of care would be updated, and lock box would be provide to the resents for storage of the medication in the resident's room. DON B reviewed R3's medical record and could not demonstrate that R3 had a self-administration assessment completed, a self-administration plan of care, or a physician order for self-administration of medication. DON B could not explain why R3 had been observed with medication at R3's bedside. During review of medication storage room on 06/04/2025 at 01:18p.m., it was observed in Rehabilitation Medication Room refrigerator an opened multi-dose 1 ml (milter) vial of Tuberculin 5 tu (tuberculin unit)/0.1ml that was not dated when the tuberculin had been opened. During an interview on 06/04/2025 at 01:20 p.m. Licensed Practical Nurse (LPN) T explained that the multi-dose vial of tuberculin should have been dated when opened. LPN T explained that multi-dose vial of tuberculin will be disposed of appropriately and would not be used for residents. In an interview on 06/04/2025 at 02:04 p.m. Regional Clinical Director of Clinical Services I explained that it was professional practice to date all multi-use medical at the time that the medication container was opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00150737. Based on observation, interview and record review, the facility failed to ensure call lights were responded to in a timely manner for five (R24, R26, R37, R42 and R43), from a census of 54 residents. Findings include: Resident #37 (R37): Review of the medical record reflected R37 admitted to the facility 12/20/23 and readmitted [DATE], with diagnoses that included type 2 diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/10/25, reflected R37 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 06/02/25 at 3:41 PM, R37 was observed seated in a recliner, in their room. Approximately three times per week, on third shift, they waited about 30 minutes for staff to answer their call light to use the urinal. On first and second shift, they waited 15 to 30 minutes to get out of bed. R37 reported the facility was understaffed and did they best they could. Reports for call light response times for R37's room, dated 5/5/25 to 6/4/25 at 10:48 AM, reflected their call light was on for greater than 20 minutes a total of 47 times. The same report reflected a call light response time up to 39 minutes and 16 seconds on 5/18/25. Resident #24 (R24): Review of the medical record reflected R24 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included type 2 diabetes, muscle weakness and need for assistance with personal care. The Quarterly MDS, with an ARD of 5/9/25, reflected R24 scored 12 out of 15 (moderate cognitive impairment) on the BIMS. On 06/02/25 at 3:53 PM, R24 was observed seated in a wheelchair, in their room. R24 reported generally, call light response times were 15 to 30 minutes, on day shift, to get assistance to the bathroom. Once in a while, R24 had episodes of incontinence as a result, per their report. Reports for call light response times for R24, dated 5/5/25 to 6/4/25 at 10:30 AM, reflected R24's call light was on for greater than 20 minutes a total of 14 times. The same report reflected a call light response time up to 35 minutes and 20 seconds on 6/1/25. Resident #42 (R42): Review of the medical record reflected R42 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included heart failure. The Quarterly MDS, with an ARD of 5/20/25, reflected R42 scored nine out of 15 (moderate cognitive impairment) on the BIMS. On 06/02/25 at 12:45 PM, R42 was observed seated in a wheelchair, in their room. According to R42, they experienced extended call light wait times from 40 minutes to two hours for staff assistance. Reports for call light response times for R42, dated 5/5/25 to 6/4/25 at 9:44 AM, reflected R42's call light was on for greater than 20 minutes a total of 15 times. The same report reflected a call light response time up to 35 minutes and 20 seconds on 5/7/25. Resident #43 (R43): Review of the medical record reflected R43 admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease and adult failure to thrive. The Quarterly MDS, with an ARD of 3/15/25, reflected R43 scored 13 out of 15 (cognitively intact) on the BIMS. On 06/02/25 at 12:45 PM, R43 was observed in their room, seated in their wheelchair. According to R43, they experienced extended call light wait times from 40 minutes to two hours for staff assistance. Reports for call light response times for R43, dated 5/5/25 to 6/4/25 at 9:44 AM, reflected R43's call light was on for greater than 20 minutes a total of six times. The same report reflected a call light response time up to 37 minutes and 41 seconds on 6/1/25. Resident #26 (R26): Review of the medical record reflected R26 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included end stage renal disease and dependence on renal dialysis. The admission MDS, with an ARD of 4/2/25, reflected R26 scored 10 out of 15 (moderate cognitive impairment) on the BIMS. On 06/02/25 at 11:54 AM, R26 was observed in their room, seated in a recliner. R26 expressed that at times, their call light was answered in five to ten minutes, and at other times, it took an hour for staff to respond. R26 stated sometimes staff would have to leave their room to get something and would not return. R26 reported issues seemed more problematic at shift change times. Reports for call light response times, dated 5/5/25 to 6/4/25 at 10:34 AM, reflected R26's call light was on for greater than 20 minutes a total of 17 times. The same report reflected a call light response time up to 33 minutes and 6 seconds on 5/29/25. In an interview on 06/04/25 at 1:42 PM, Nursing Home Administrator (NHA) A reported being aware of concerns/complaints pertaining to extended call light response times, and the facility was actively attempting to improve response times. NHA A reported the goal was to answer a call light within 10 minutes, and staff were educated not to turn the call light off until the resident's need had been met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00150266. Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one (R1) of three reviewed. Findings include: Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included dementia, contracture of muscle, and presence of other specified devices. Review of the comments entered for the diagnoses of presence of other specified devices revealed R1 had a baclofen pump that was placed on [DATE]. R1 died in the facility on [DATE]. Review of the records obtained from the physician's office that managed R1's baclofen pump revealed R1's last appointment was on [DATE]. At that time, R1's baclofen dose was decreased from 175.7 mg/hr to 96.1 mcg/hr. The note revealed the next low reservoir alarm date was scheduled for [DATE], but the alarm was turned off as R1 was receiving hospice care. The note indicated refill pump before: [DATE], which indicated the pump would be empty at that time. The note revealed a plan to start baclofen 10 milligrams (mg) three times a day as needed for baclofen withdrawal. This record was not included in R1's medical record. R1 did not have any orders or a care plan indicating he still had a baclofen pump with medication being administered until [DATE]. Review of the Nurses Note dated [DATE] and authored by Director of Nursing (DON) B revealed This writer called [physician who managed baclofen pump] regarding expiration of Baclofen Pump. Per resident's wife, the pump is due to expire January of 2025. At that point we are to start oral Baclofen. Message was left with [physician who managed baclofen pump] to call back with exact expiration date, and oral dosage. In a telephone interview on [DATE] at 10:47 AM, Licensed Practical Nurse (LPN) L reported they cared for R1 and were not aware R1 had a baclofen pump until a few days before he passed away. In a telephone interview on [DATE] at 12:10 PM, LPN J reported they cared for R1 and were not aware R1 had a baclofen pump. LPN J reported if a resident had a baclofen pump, there should be a physician's order and a care plan. In an interview on [DATE] at 12:33 PM, Clinical Care Coordinator (CCC) D reported they were not aware R1 had a baclofen pump until approximately one to two weeks before R1 passed away. CCC D reported they became aware because R1's wife mentioned that the baclofen pump was due to run out. CCC D reported if a resident had a baclofen pump, it should be care planned. In an interview on [DATE] at 1:02 PM, Director of Nursing (DON) B reported they were not aware R1 had a baclofen pump until his wife mentioned it in January. DON B reported the information would typically be in the care plan. In an interview on [DATE] at 2:02 PM with Nursing Home Administrator (NHA) A, DON B, and Regional Consultant (RC) R reported the facility's documentation showed R1's baclofen pump was last filled on [DATE]. It was reported that R1 had the baclofen pump care planned, but that care plan intervention was discontinued on [DATE] leading them to believe the pump off/empty at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00150266. Based on interview and record review, the facility failed to ensure coordination of care and monitoring of a baclofen pump (implanted device that delivers the baclofen, a muscle relaxant medication, directly into the spinal fluid) for one (R1) of three reviewed. Findings include: Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included dementia, contracture of muscle, and presence of other specified devices. Review of the comments entered for the diagnoses of presence of other specified devices revealed R1 had a baclofen pump that was placed on [DATE]. R1 died in the facility on [DATE]. In a telephone interview on [DATE] at 9:16 AM, Family Member P reported R1 last had an appointment related to their baclofen pump on [DATE] at which time the physician decreased the baclofen dose and turned off all pump alarms. Family Member P reported the medication was scheduled to be completely used and the reservoir empty by [DATE]. Family Member P reported R1's family reminded the facility on [DATE] that the pump was due to run out of baclofen and they were notified on [DATE] that there was nothing on file related to the baclofen pump. Family Member P reported the physician's office that managed the pump was contacted by R1's family on [DATE] at which time they were informed R1 should have started oral baclofen tablets on [DATE] to manage spasticity/muscle spasms and prevent withdrawals. Review of R1's medical record revealed the last documentation of any baclofen pump appointment was on [DATE] at which time R1's baclofen pump was refilled and R1 received 175.7 micrograms (mcg) per hour (hr). Review of the records obtained from the physician's office that managed R1's baclofen pump revealed R1's last appointment was on [DATE]. At that time, R1's baclofen dose was decreased from 175.7 mg/hr to 96.1 mcg/hr. The note revealed the next low reservoir alarm date was scheduled for [DATE], but the alarm was turned off as R1 was receiving hospice care. The note indicated refill pump before: [DATE], which indicated the pump would be empty at that time. The note revealed a plan to start baclofen 10 milligrams (mg) three times a day as needed for baclofen withdrawal. This record was not included in R1's medical record. Review of the Physician' Order dated [DATE] revealed an order to call the surgeon who placed the pump if there were any questions regarding the baclofen pump. The order was discontinued on [DATE]. Review of the Physician's Order dated [DATE] revealed an order for baclofen 10 mg every 8 hours as needed for increased spasticity/muscle spasms or signs and symptoms of baclofen withdrawal (itching, irritability, twitching). R1 did not have any orders or a care plan indicating he still had a baclofen pump with medication being administered until [DATE]. There was no documentation that R1 was being monitored for signs and symptoms of baclofen withdrawal after the baclofen pump was empty ([DATE]). Review of the MAR revealed did not receive any as needed baclofen (ordered [DATE] and still active) in [DATE]. Review of the Nurses Note dated [DATE] and authored by Director of Nursing (DON) B revealed This writer called [physician who managed baclofen pump] regarding expiration of Baclofen Pump. Per resident's wife, the pump is due to expire January of 2025. At that point we are to start oral Baclofen. Message was left with [physician who managed baclofen pump] to call back with exact expiration date, and oral dosage. Review of the Physician's Order dated [DATE] revealed an order for baclofen 10 mg orally three times a day for increased spasticity/muscle spasms. According to the Medication Administration Record (MAR), R1 received the first dose on [DATE] at 3:00 PM. In a telephone interview on [DATE] at 10:47 AM, Licensed Practical Nurse (LPN) L reported they cared for R1 and were not aware R1 had a baclofen pump until a few days before he passed away. LPN L reported there was not any monitoring for adverse reactions or baclofen withdrawal since they were unaware R1 had a baclofen pump. In a telephone interview on [DATE] at 12:10 PM, LPN J reported they cared for R1 and were not aware R1 had a baclofen pump. LPN J reported if a resident had a baclofen pump, there should be a physician's order and a care plan. In an interview on [DATE] at 12:33 PM, Clinical Care Coordinator (CCC) D reported they were not aware R1 had a baclofen pump until approximately one to two weeks before R1 passed away. CCC D reported they became aware because R1's wife mentioned that the baclofen pump was due to run out. CCC D reported if a resident had a baclofen pump, it should be care planned. In a telephone interview on [DATE] at 12:43 PM, Registered Nurse (RN) F reported R1 had a baclofen pump when he first arrived at the facility. RN F reported they thought the baclofen pump had been turned off many years ago. RN F reported most staff that worked with R1 were unaware that he had a baclofen pump. In an interview on [DATE] at 12:51 PM, LPN G reported they became aware of R1's baclofen pump when R1's wife mentioned the pump. LPN G reported they were not aware of any monitoring related to R1's baclofen pump or what dose of baclofen was being administered through the pump. In a telephone interview on [DATE] at 1:16 PM, LPN C reported they were not aware R1 had a baclofen pump until his wife mentioned it in January. In an interview on [DATE] at 1:02 PM, Director of Nursing (DON) B reported they were not aware R1 had a baclofen pump until his wife mentioned it in January. DON B reported the information would typically be in the care plan. Any further documentation related to the baclofen pump was requested. In an interview on [DATE] at 2:02 PM with Nursing Home Administrator (NHA) A, DON B, and Regional Consultant (RC) R reported the facility's documentation showed R1's baclofen pump was last filled on [DATE]. It was reported that R1 had the baclofen pump care planned, but that care plan intervention was discontinued on [DATE] leading them to believe the pump off/empty at that time. It was reported the last Physician and/or Nurse Practitioner documentation related to R1's baclofen pump was on [DATE]. No further documentation regarding the baclofen pump was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to 1) ensure two residents (#3 and #37) who had not been deemed incapacitated were acting as their own responsible party; and 2) ensure code status wishes were being honored for one (Resident #37) of two reviewed. Findings include: Resident #37 (#37): Review of the medical record reflected R37 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included diabetes, depression and schizophrenia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R37 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R37's medical record reflected a Physician's Order for full code (cardiopulmonary resuscitation/CPR and life-saving efforts in an emergency). The miscellaneous section of R37's medical record reflected a Do Not Resuscitate (DNR) document with an upload and effective date of [DATE]. In an interview on [DATE] at 2:31 PM, Director of Nursing (DON) B reported R37 was not his own person (own responsible party) and had a Durable Power of Attorney (DPOA). She reported R37 could not sign his own DNR form, and it was not valid since he signed it himself. DON B reported R37 had been deemed incapacitated prior to his admission to the facility. On [DATE] at 3:33 PM, a request was made for documentation reflective of R37 being deemed unable to make his own medical and treatment decisions. R37's OBRA Level II Evaluation for 4/2024 reflected he did not have a legal representative and still acted as his own person with medical and daily choices. He did have a conservator that made financial decisions on his behalf, due to his traumatic brain injury from being hit by a car when he was in his thirties. On [DATE] at approximately 03:38 PM, DON B showed a DPOA document for [DATE], which she said reflected R37 wanted to be a DNR. DON B was queried on whether or not R37 was his own responsible party, as he signed that document in 11/2023. A request was made for the document to be provided to the Survey Team but was not provided prior to the survey exit on [DATE]. In an interview on [DATE] at 9:37 AM, DON B reported the facility did not have anything that reflected R37 had been deemed incompetent. She reported R37 was a DNR when he went to the hospital in February 2024. He returned to the facility with a full code status. DON B reported the Assistant Director of Nursing (ADON) spoke with R37 on [DATE], and he wanted to be a full code. Resident #3 (R3) Review of the medical record revealed R3 admitted to the facility on [DATE] with diagnoses that included dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R3 scored 5 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R3's profile revealed their spouse was their responsible party. In an interview on [DATE] at 1:30 PM, Director of Nursing (DON) B and Assistant Director of Nursing (ADON) C reported as of [DATE], R3's spouse was their decision maker. In an interview on [DATE] at 8:13 AM, Nursing Home Administrator (NHA) A reported R3's spouse made their medical decisions. NHA A provided a patient Patient Advocate form where R3 designated their spouse as their advocate. NHA A reported there was no documentation that R3 had been deemed incompetent to make their own medical decisions. In an interview on [DATE] at 8:47 AM, when asked where it was documented that R3 was not able to make their own decisions as of [DATE], DON B reported the facility was not able to locate the capacity determination documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #37 (R37): Review of the medical record reflected R37 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included diabetes, depression and schizophrenia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/27/24, reflected R37 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The quarterly MDS, with an ARD of 3/27/24, reflected coding for antidepressant use. R37's medical record did not reflect that he had been prescribed an antidepressant since his admission to the facility. In an interview on 06/07/24 at 09:42 AM, MDS Coordinator D acknowledged the coding error and reported she may have miscoded R37's Lurasidone (antipsychotic medication) as an antidepressant. Based on interview and record review, the facility failed to ensure accurate coding of Minimum Data Set (MDS) Assessments for two (Resident #37 and Resident #54) of 13 reviewed. Findings include: Resident #54 (R54) Review of the medical record revealed R54 admitted to the facility on [DATE]. Review of the Discharge Summary revealed R54 discharged home on 3/15/24. Review of the Discharge MDS with an Assessment Reference Date (ARD) of 3/15/24 revealed R54 discharged to the hospital. In an interview on 06/06/24 at 10:28 AM, MDS Coordinator D reported R54 discharged home and agreed the discharge MDS was coded incorrectly.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 55 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 06/07/24 at 09:25 A.M., A common area environmental tour was conducted with Maintenance Technician G and Director of Housekeeping and Laundry Services F. The following items were noted: Nursing Unit Nurses Station: 1 of 2 chairs were observed with (worn, torn, etched) armrests. The hand sink basin backsplash board was also observed (etched, scored, raised). The caulking bead was further observed loose-to-mount and missing periodically. The damaged backsplash board measured approximately 4-inches-wide by 6-feet-long. Beauty Shop: The cosmetology chair was observed soiled with accumulated and encrusted dust and dirt deposits. Director of Housekeeping and Laundry Services F indicated she would have staff thoroughly clean and sanitize the cosmetology chair as soon as possible. Rehabilitation Unit Nurses Station: 2 of 2 chairs were observed (etched, scored, particulate). Maintenance Technician G indicated he would remove the faulty chairs as soon as possible. Meadow Unit (Memory Care) The 200 Unit and 300 Unit corridor flooring surface carpeting was observed heavily stained and soiled with dust, dirt, and food residue deposits. Dining Room: The return-air-exhaust ventilation grill was observed heavily soiled with dust and dirt deposits. Director of Housekeeping and Laundry Services F indicated she would have staff thoroughly clean and sanitize the ventilation grill as soon as possible. Soiled Utility Room: The hopper faucet assembly spout was observed heavily soiled with mineral (calcium and lime) deposits. Nurses Station: The desk countertop Formica laminate edge surface was observed (etched, scored, missing). The damaged Formica laminate surface measured approximately 12-feet-long. One chair was also observed (etched, scored, particulate). Main Dining Room Corridor Janitor Closet: Three 4-inch-wide by 4-inch-long ceramic tiles were observed missing, adjacent to the mop sink basin. Two 6-inch-wide ceramic coving tiles were also observed missing, within the room perimeter. Maintenance Technician G indicated he would make necessary repairs as soon as possible. Activity Room: The flooring surface carpet was observed sporadically stained and soiled with dust, dirt, and grime deposits. Janitor Room: The overhead light assembly was observed non-functional. On 06/07/24 at 11:40 A.M., An environmental tour of sampled resident rooms was conducted with Maintenance Technician G and Director of Housekeeping and Laundry Services F. The following item was noted: 120: The Bed 2 overbed light assembly switch was observed non-functional. On 06/07/24 at 05:00 P.M., Record review of the Policy/Procedure entitled: Routine Cleaning and Disinfection dated 08-11-2022 revealed under Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. On 06/07/24 at 05:15 P.M., Record review of the Policy/Procedure entitled: Environmental Services Inspection dated 08-11-2022 revealed under Policy: It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis.

During an initial kitchen tour on 06/05/24 at 10:08 AM with Dietary Manager (DM) E, the following observations were made: - The reach in refrigerator contained a tray of frozen vegetables that were not covered. DM E reported they were to be cooked later that day. - The reach in refrigerator contained a container of grapes with an expiration date of 6/4/24. DM E removed the container from the refrigerator. - The reach in refrigerator contained an opened half gallon of whole milk that was not dated when opened. DM E removed the milk from the refrigerator. - The walk-in refrigerator contained a container of pasta salad that was not dated. DM E reported they believed it was a staff member's lunch. According to the 2017 FDA Model Food Code, section 3-305.14 Food Preparation, During preparation, unPACKAGED FOOD shall be protected from environmental sources of contamination. According to the 2017 FDA Model Food Code, Section 3-501.17 Date Marking Potentially Hazardous Ready-to-Eat Food, Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, 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 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, (2) date mark all potentially hazardous ready-to-eat food products, and (3) effectively date, label, and store food products effecting 55 residents, resulting in the increased potential for cross-contamination, bacterial harborage, resident foodborne illness, and inadequate mechanical dish machine sanitization final rinse dispersion. Findings include: On 06/06/24 at 08:28 A.M., A comprehensive tour of the food service was conducted with Dietary Manager E. The following items were noted: The Mechanical Dish Machine wash and final rinse temperature gauges were observed loose-to-mount and fogged with excessive moisture accumulation. The final rinse Pounds-Per-Square-Inch (PSI) gauge was also observed 90% full of water and reading off-scale beyond 30 (PSI) during the final rinse cycle. Dietary Manager E indicated he would contact maintenance for necessary repairs. The 2017 FDA Model Food Code section 4-501.11 states: (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. The 2017 FDA Model Food Code section 4-501.113 states: The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). The Dietary Manager's office flooring surface was observed extremely soiled with accumulated and encrusted dirt and grime residue. The Dietary Manager's office was also observed in complete disarray (boxes, cook pans, etc.). Dietary Manager E indicated he would have staff thoroughly clean and sanitize the flooring surface as soon as possible. Walk-In Cooler: The flooring surface was observed with accumulated and encrusted milk residue, directly beneath the milk storage rack. Dietary Manager E indicated he would have staff thoroughly clean and sanitize the flooring surface as soon as possible. The 2017 FDA Model Food Code section 6-501.13 states: (A) Except as specified in (B) of this section, only dustless methods of cleaning shall be used, such as wet cleaning, vacuum cleaning, mopping with treated dust mops, or sweeping using a broom and dust-arresting compounds. (B) Spills or drippage on floors that occur between normal floor cleaning times may be cleaned: (1) Without the use of dust-arresting compounds; and (2) In the case of liquid spills or drippage, with the use of a small amount of absorbent compound such as sawdust or diatomaceous earth applied immediately before spot cleaning. The garbage disposal overhead spray arm valve assembly was observed invading the flood plane level of the sink basin. Dietary Manager E indicated he would have maintenance make necessary repairs as soon as possible. The 2017 FDA Model Food Code section 5-205.12 states: Nondrinking water may be of unknown or questionable origin. Wastewater is either known or suspected to be contaminated. Neither of these sources can be allowed to contact and contaminate the drinking water system. The 2017 FDA Model Food Code section 5-205.15 states: Improper repair or maintenance of any portion of the plumbing system may result in potential health hazards such as cross connections, backflow, or leakage. These conditions may result in the contamination of food, equipment, utensils, linens, or single-service or single-use articles. Improper repair or maintenance may result in the creation of obnoxious odors or nuisances and may also adversely affect the operation of warewashing equipment or other equipment which depends on sufficient volume and pressure to perform its intended functions. The can opener mounting bracket perimeter was observed soiled with accumulated and encrusted food residue, between the bracket assembly and table surface. The True 2-door reach-in cooler door gaskets were observed soiled with accumulated and encrusted dust and dirt deposits. Dietary Manager E indicated he would have staff thoroughly clean and sanitize the door gaskets as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (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. The True 2-door reach-in cooler interior light bulb was observed non-functional. Dietary Manager E indicated he would have maintenance replace the faulty light bulb as soon as possible. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. Rehabilitation Refreshment Room: The Hamilton Beach stainless steel toaster was observed with accumulated and encrusted food residue. Dietary Manager E indicated he would have staff thoroughly clean and sanitize the toaster as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (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. On 06/07/24 at 04:30 P.M., Record review of the Policy/Procedure entitled: Sanitation Inspection dated 08-11-2022 revealed under Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. Record review of the Policy/Procedure entitled: Sanitation Inspection dated 08-11-2022 further revealed under Policy Explanation and Compliance Guidelines: (1) All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00140368. Based on interview and record review, the facility failed to monitor weights according to Physician Orders and prevent significant weight loss for one (Resident #4) of three reviewed for weight loss. Findings include: Review of the medical record reflected Resident #4 (R4) admitted to the facility on [DATE], with diagnoses that included unspecified fracture of right pubis, nondisplaced fracture (broken bone that maintains proper alignment) of 5th metatarsal bone (bone on outer edge of foot) of left foot, nondisplaced fracture of anterior (front) wall of the right acetabulum (socket part of hip joint), dementia and dysphagia (difficulty swallowing). R4 discharged from the facility on 9/28/23 and did not reside in the facility at the time of the survey. R4's August 2023 Treatment Administration Record (TAR) reflected a Physician's Order, with a start date of 8/26/23 and a discontinue date of 10/2/23, for R4 to be weighed daily for three days through 8/27/23. The same order reflected R4 was then to be weighed every Tuesday, starting 8/29/23. R4's August 2023 TAR reflected a Physician's Order, with a start date of 8/29/23 and an discontinue date of 10/2/23, for R4 to be weighed daily for three days through 8/27/23. The same order reflected R4 was then to be weighed every Tuesday morning for monitoring, starting 8/29/23. R4's August 2023 and September 2023 TARs did not reflect documentation of weights being performed as ordered. R4's medical record reflected documentation of weights on 8/25/23, 8/30/23, 9/20/23 and 9/25/23. On 8/25/23, R4 weighed 127.0 pounds (Lbs). On 8/30/23, R4 weighed 126.4 Lbs. On 9/20/23, R4 weighed 119.6 Lbs. The 9/20/23 weight reflected notation of a 5.8 percent (%) loss and 7.4 Lbs weight loss from the comparison weight of 127.0 Lbs on 8/25/2023. On 9/25/23, R4 weighed 120.0 Lbs. The 9/25/23 weight reflected notation of a 5.1% loss and 6.4 Lbs weight loss from the comparison weight of 126.4 Lbs on 8/30/23. A Nutrition/Dietary Progress Note for 8/29/23 reflected the Physician was notified of R4's poor appetite. A Nutrition/Dietary Progress Note for 8/29/23 reflected R4 was to be offered Breeze juice three times daily with medication pass for extra nutrition due to less than 50% intake at meals. A Nurse Practitioner Note for 8/30/23 reflected, .Poor appetite Dietary to follow, Breeze Juice TID [three times daily] with med [medication] passes, health shakes, speech to follow, monitor weights . A Nurse Practitioner Note for 9/20/23 reflected, .The patient has lost weight and reports poor appetite .Anorexia Weight loss, monitor weights, increased Remeron to 15mg [milligrams] at bedtime .nursing to put in dining area to encourage assistance with eating . A Nutrition/Dietary Progress Note for 9/25/23 reflected R4 had a poor appetite and weight loss, and the Physician ordered Remeron on 9/20/23. According to the note, extra nutrition of health shakes with meals and Boost juice three times daily with medication pass was offered. The note reflected, .WEIGHTS AS ORDERED. During an interview on 2/7/24 at 3:33 PM, Registered Dietitian (RD) D reported rehab patients were weighed weekly, and all weights should have been in the electronic medical record. After review of R4's weights, RD D acknowledged R4 had not been weighed weekly. She reported R4 was getting health shakes with all meals. RD D stated the last nutritional intervention she added for R4 was Boost juice on 8/29/23. When asked if she re-evaluated R4 after her documented weight loss on 9/20/23, RD D referenced the Nutrition/Dietary Progress Note for 9/25/23. RD D reported significant weight loss was considered a loss of 5% in 30 days or a 10% loss in 180 days. RD D acknowledged that R4's weight loss was significant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a call light was in place for one (Resident #153) of 13 reviewed, resulting in a missed meal when Resident #153 was not able to call and notify staff that she had not been served breakfast. Findings include: Review of the medical record revealed Resident #153 (R153) was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease, acute kidney failure, and pneumonia. R153's Minimum Data Set (MDS) was in progress. Review of the Dietary Care Plan revealed R153 ate all of her meals in her room and that she requested very soft foods. On 03/13/23 at 3 09:18 AM, R153 was observed sitting in a recliner in her room. R153 yelled help. R153 stated, I would like to have my call button, but it's way over there. R153 pointed to her bed which was across the room. The call light was observed clipped to R153's bed and out of reach. R153 stated, I just want my call button. R153 reported she had not yet been served breakfast. At 9:40 AM, R140 reported she had still not received breakfast and stated, It's going to be lunch time soon. In an interview on 03/13/23 at 09:41 AM, Certified Nursing Assistant (CNA) G was sitting at the nurse's station and reported breakfast was usually served around 8:00 AM and all residents had been served breakfast. When asked about R153, CNA P reported R153 was served two over easy eggs, coffee, and orange juice. When notified that R153 reported otherwise, CNA P then asked if R153 had a Styrofoam container in her room. CNA P then went to R153's room and asked R153 about breakfast. R153 stated, I haven't gotten any breakfast .fortunately I had applesauce, so I ate that. The other aide on the unit then reported she would get breakfast from the kitchen for R153. At 9:47 AM, the other aide came back from the kitchen with breakfast for R153.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete at Minimum Data Set (MDS) assessment for one (Resident #31) of 13 reviewed, resulting in an inaccurate MDS assessment and the potential for unmet care needs. Findings include: Review of the medical record revealed Resident #31 (R31) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of the Resident Profile revealed R31 received dialysis on Mondays, Wednesdays, and Fridays. Review of the Significant Change MDS with and Assessment Reference Date (ARD) of 2/10/23 revealed R153 was not coded as receiving dialysis services. In an interview on 03/14/23 at 12:28 PM, Director of Nursing (DON) B reported the MDS nurse who coded R31's MDS was no longer employed by the facility. DON B reported R31 had received dialysis services since before admission and therefore the MDS should have been coded as receiving dialysis services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observation, interview, and record review the facility failed to assess pressure ulcers on admission and regularly for one resident (#23) of one resident's reviewed for the assessment and monitoring of pressure ulcers resulting in the potential for resident's pressure ulcers to worsen or be provided proper treatments to promote healing. Finding Included: Resident #23 (R23) Review of the medical record revealed R23 was originally admitted to the facility 09/01/2018 and re-admitted [DATE] (following a recent hospital stay) with diagnoses that included metabolic encephalopathy (brain disfunction), cellulitis left lower limb, chronic obstructive pulmonary disease (COPD), congestive heart disease (CHF), chronic kidney disease, type 2 diabetes, obstructive sleep apnea, vascular dementia, insomnia, atherosclerotic heart disease, hypertension, aortic valve stenosis, anemia (low blood volume), vitamin D deficiency, gastro-esophageal reflux, major depression, hyperlipidemia (high fat in blood) , gout (high uric acid deposits in bone joints) , Parkinson disease, and hypothyroidism (low thyroid levels). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/31/2023, revealed R23 had a Brief Interview for Mental Status (BIMS) of 10 (moderately impaired cognition) out of 15. The most recent MDS, with the ARD of 1/31/2023, demonstrated that R23 was readmitted to the facility with one unstageable pressure ulcer. During observation and interview on 03/13/2023 at 12:22 p.m. R23 was observed sitting up in a recliner at his bedside. R23's wife was present at his bedside holding his hand. R23 explained that he had recently returned to the facility following a recent stay at the hospital. R23 explained that he had a wound to his left foot but could not describe what type of wound was present. R23's wife explained that he obtained the wound while in the hospital and not at the facility. R23's feet were covered with a blanket and not visible at that time. During review of R23's medical record revealed a skin observation tool was completed on 01/25/2023 that demonstrated R23 had a pressure wound but did not list the location, length, width, depth, and stage of the wound. R23's medical record revealed a skin observation tool completed 02/03/2023 that did not list any wound. In the section 2. Describe general appearance of feet including skin, nails, and color demonstrated treatment continue on foot. R23's medical record revealed a skin observation tool completed 02/15/2023 that did not list any wound. In section 2. Describe general appearance of feet including skin, nail, and color demonstrated clean and dry. TX(treatment) continued as ordered on foot. During review R23's medical record revealed a Weekly wound Assessment completed on 02/24/2023 that demonstrated an unstageable pressure wound to R23's left lateral foot measuring 2.0 centimeters (cm) in length by 2.0 (cm) in width. This assessment was completed by staff member J. R23's medical record demonstrated that was the first Weekly Wound Assessment that had been completed. R23's medical record demonstrated Weekly Wound Assessment had also been completed 02/28/2023, 03/07/2023, and 03/08/2023. All the Weekly Wound Assessment that were completed demonstrated no change of size or staging of the left lateral foot pressure ulcer. All Weekly Wound Assessment were completed by staff member J. In an interview on 03/14/2023 at 01:52 p.m. with staff member J, she explained that she was an RN and was the Wound Nurse at the facility. She further explained that she had been in the role of the Wound Nurse for a period of 6 months. Staff member J explained that wound assessments are to be completed every week and that it was her responsibility to complete the measurements and staging of the wounds. Staff member J explained that R23's pressure ulcer to his left lateral foot had improved. She explained that the pressure ulcer to his left lateral foot was larger when R23 was admitted . When asked to provide documentation demonstrating the measurements of R23's pressure ulcer to his left lateral foot, she was unable to provide documentation. Staff member J explained that she must have not charted the observation of the pressure ulcer on R23's admission. Staff member J could not explain why Weekly Wound Assessment had not been completed until 02/24/2023 even though R23 had been re-admitted to the facility 01/25/2023. In an interview on 03/15/2023 at 10:12 a.m. Director of Nursing (DON) B explained that it is her expectation and facility policy that resident's pressure ulcers are to be assessed weekly by the facility Wound Nurse. DON B explained that staff member J was the facility RN Wound Nurse. DON B confirmed that pressure ulcer assessments had not been completed weekly, since admission, for R23. DON B could not explain why weekly wound assessments had not been completed weekly. During observation on 03/15/2023 at 11:17 a.m. R23 was sitting up in a reclining chair. Licensed Practical Nurse (LPN) M removed the wound dressing from R23's left foot lateral aspect. LPN M was observed to measure R23's pressure ulcer to left lateral to left foot. It was observed that the pressure ulcer measured 1.5 centimeters (cm) in length and 1.5 cm in width. The pressure ulcer could not be staged as yellow colored slough was observed to be present and obscured the wound bed. LPN M classified the pressure ulcer as unstageable. Review of the facility policy entitled Pressure Injury Prevention and Management, with an implementation date of 06/23/2022, demonstrated section Policy Explanation and Compliance Guidelines number 3c stated licensed nurses will conduct a full body assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. The same policy demonstrated number 3d stated assessments of pressure injuries will be performed by a licensed nurse and documented on the TAR (Treatment administration record) and under assessments .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pain medications were given as ordered for one (resident #157) of one reviewed, resulting in increased pain and the potential for unmanaged pain. Findings include: Review of the medical record revealed Resident #157 (R157) was admitted to the facility on [DATE] with diagnoses that included polyneuropathy, peritonitis, acute cholecystitis, and major depressive disorder. R157's admission Minimum Data Set (MDS) was in progress. Review of R157's hospital discharge medication list revealed oxycodone (narcotic pain medication) 5 milligrams (mg), take one tablet every four hours for pain. Review of the Physician's Order dated 3/7/23 and discontinued 3/8/23 revealed an order for oxycodone HCl 5 mg every four hours as needed for pain for 7 days. Review of the Physician's Order dated 3/8/23 revealed an order for oxycodone HCl 5m every four hours as needed for pain. On 03/13/23 at 08:11 AM, R157 was observed lying in bed. R157 reported at 2:00 AM, he asked for oxycodone for pain, but the facility ran out of oxycodone and therefore he did not receive any. R157 reported he was still waiting for his pain medication and reported his pain level as 7 on a scale of 0 to 10. R157 reported when he was admitted on [DATE] the facility did not have his pain medication until the next day; he waited 36 hours for oxycodone. R157 reported he did not want anything else for pain because the other medications were not effective. Review of the Medication Administration Record (MAR) revealed R157 did not receive oxycodone on 3/7/23 and that the first dose given was on 3/8/23 at 3:59 PM. The MAR revealed R157 last received oxycodone on 3/12/23 at 3:08 PM for a pain level of 4 on a scale of 0 to 10. Review of R157's pain scale revealed on 3/13/23 at 9:45 AM, R157's pain level was 4. There was no documentation of R157's pain level being assessed on 3/13/23 at 2:00 AM. Review of the Proof of Use Sheet revealed the last dose of oxycodone was signed out on 3/12/23 at 3:00 PM. There were no doses remaining. In an interview on 03/14/23 at 09:25 AM, Licensed Practical Nurse (LPN) M reported on 3/13/23, she received in report that R157 ran out of oxycodone the night before and it had not yet been reordered. LPN M reported she then called pharmacy to obtain an authorization to pull oxycodone out of the backup medication supply. LPN M reported the morning of 3/13/23, R157 was painful. LPN M reported the night nurse could have called pharmacy and obtained an authorization to obtain the oxycodone from the back up medication supply. In an interview on 03/14/23 at 09:50 AM, LPN N reported she worked with R157 on 3/12/23 from 10:00 PM until 3/13/23 at 2:00 AM. LPN N reported around 2:00 AM, R157 requested oxycodone for pain, but there was not any left in the medication cart. LPN N stated, They had run out unbeknownst to me. LPN N reported she offered R157 Tylenol, but he declined. LPN N reported she then called the Nurse Practitioner who was going to attempt to get a script for a refill of oxycodone. LPN N reported she was not aware of what happened after that. In an interview on 03/14/23 at 10:40 AM, LPN E reported she worked with R157 on 3/13/23 at 2:00 AM until 6:00 AM. LPN E reported R157 ran out of oxycodone before she arrived. LPN E reported it was her understanding that the oxycodone was never reordered like it should have been. LPN E reported the on-call provider was not familiar with R157 and was not comfortable ordering a refill over the phone. LPN E reported the pharmacy was also closed and the medication was not available for delivery until 10:00 AM. LPN E reported R157 again requested oxycodone at 3:30 PM, but she gave R157 Tylenol which made him upset. In an interview on 03/14/23 at 12:20 PM, Director of Nursing (DON) B reported the nurses should order medication refills when there are approximately five pills remaining. DON B reported the facility also had an afterhours pharmacy that could be used for refills. DON B reported controlled substances could be pulled from the backup medication supply. DON B reported she believed the facility had oxycodone 5 mg in their backup supply. DON B reported she was not aware of any issues with obtaining R157's oxycodone.

Based on observation and interview, the facility failed to ensure that the sole facility medication room and that one facility supply room were free of expired medications resulting in the potential for decreased medication efficacy and adverse side effects in a current facility census of 50 residents. Findings include: On 3/14/23 at 10:51 AM, the facility supply room located on Meadow Hall was reviewed in the presence of Licensed Practical Nurse (LPN) E. During the review, five 1000ml (milliliter) bags of 0.45% (percent) Sodium Chloride Injection with an EXP (expiration) 02/23 date indicated were noted within a cardboard box on the floor of the supply room. LPN E confirmed that the intravenous solution was expired and would be removed from the supply room for disposal. On 3/14/23 at 11:39 AM, the medication room located on the facilities rehabilitation unit was reviewed in the presence of LPN M. During the review, nine 5ml Heparin Lock Flush Solution syringes with an expiration date of 2023-02-28 were noted in a plastic zip lock bag within a cupboard. Within the same cupboard, two 8 FL (fluid) OZ (ounce) bottles of Regular Strength Stomach Relief Bismuth Subsalicylate 525mg (milligram) were noted with an EXP 02/23 date indicated. On the countertop, within the medication room, one 1000ml bag of 0.45% Sodium Chloride Injection was noted with an EXP 02/23 date indicated. LPN M confirmed that the Heparin Lock Flush Solution syringes, the Regular Strength Stomach Relief Bismuth Subsalicylate bottles, and the 0.45% Sodium Chloride Injection were expired, and would disposed of. In an interview on 3/15/23 at 9:53 AM, Director of Nursing (DON) B stated that the expectation would be for the assigned nurse to date any multi dose medication container when opened, to review the expiration dates of all bottles within the medication cart and medication/supply rooms when a new bottle was obtained, and to discard any medications as they reached the expiration date. DON B further stated that the medication carts, medication room, and supply room were audited monthly by the nurse unit manager with the expectation that any expired medication would be disposed of in the cardboard disposal boxes provided by pharmacy and confirmed that the expired facility supplied over the counter medications, intravenous solutions, and heparin flushes should have been disposed of in that manner. The facility policy titled MEDICATION STORAGE IN THE FACILITY with a 11/2019 revision dated stated, .PROCEDURES .N. Stock medication and resident specified medications that are manufacturer's bottles, we will follow manufacturer expiration dates.

In an interview on 03/16/2023 at 09:11 a.m. Director of Nursing (DON) B was explaining the process of Antibiotic Stewardship that was conducted at the facility. She explained that she tracks when residents are identified with an antibiotic and then makes sure that they have appropriate signs and symptoms in accordance with Mcgrees Criteria. She also explained that she makes sure the resident is receiving the appropriate antibiotic based on the results of cultures. When asked to review the tracking of the facility she provided December 2022 line listing. The line listing listed resident that were on antibiotics but did not list what symptoms the resident exhibited or what type of infection. When asked were that information was located on the line listing, she explained that she had a map showing the type of infections by location. When questioned further she agreed that she did not have a completed line listing with all the necessary information for tracking of infections acquired in the facility or the antibiotics that were in use. DON B was asked for a copy of the documents reviewed during this interview at that time. In an interview on 03/21/2023 DON B explained that she could not locate the line listing for December 2022 that she had reviewed with this surveyor on 03/16/2023 at 09:11 a.m. and therefore was unable to provide a copy of the document. DON B explained that during our meeting on 03/16/2022 she was not completing a line listing accurately for the facility that included the symptoms and the diagnoses of the residents. She explained that she had spoken to an Infection Control Consultant on 03/17/2023 and been taught how to properly include necessary information for a proper line listing of resident's antibiotic usage. DON B provided copies of January 2023 and February 2023 which included diagnoses, signs, and symptoms. She explained that she had completed these line listings over the weekend of 03/18/2023 and 03/19/2023. Based on interview and record review, the facility failed initiate antibiotic use protocols and monitor antibiotic use, in one of one reviewed for antibiotic use (Resident #6), resulting in the increased risk for adverse events associated with antibiotic use, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. Findings include: Resident #6 (R6) In review of R6's Minimum Data Set (MDS) assessment, with an assessment reference date of 1/19/23, she had a Brief Interview for Mental Status (BIMS, a brief performance-based cognitive screener for nursing home residents) score of 03 (00-07 Severely Impaired). In review of R6's February 2023's Medication Administration Record (MAR), Amoxicillin 500 milligrams (mg) was ordered on 2/20/23 and to be administered every 12 hours, at 9:00 AM and 9:00 PM. The physician order did not specify a stop date or indication for use. Amoxicillin was started on 2/21/23 at 9:00 PM. The February 2023 MAR revealed 3 doses without any documentation: 2/23/23 at 9:00 PM, 2/24/23 at 9:00 AM, and 2/24/22 at 9:00 PM. R6's March 2023 MAR revealed 5 Amoxicillin doses were not given, and to see nurse's notes, on 3/03/23 at 9:00 PM, 3/04/23 at 9:00 AM, 3/04/23 at 9:00 PM, 3/05/23 at 9:00 AM, and 3/06/23 at 9:00 AM. R6's same MAR revealed 1 dose was refused on 3/01/23 at 9:00 AM. In review of R6's nurses notes, there were no notes regarding why Amoxicillin wasn't given or if the physician was notified R6 did not receive all the ordered doses. Amoxicillin was discontinued on 3/06/23. R6's Care Plan dated 2/20/23 indicated she had an infection related to an ingrown labia hair. There were no symptoms noted on the care plan. R6's February 2023 MAR also revealed a physician order for Tobramycin (antibiotic) eye drops starting on 2/21/23. The same MAR indicated R6 received 16 doses. There was no stop date specified in the Tobramycin order, the order was discontinued on 2/28/23. R6's Care Plans were reviewed, there was no care plan regarding an eye infection. In review of the Antibiotic Stewardship Program Policy, reviewed/revised 9/20/21, indicated Loeb minimum criteria was used to determine treatment of infection with antibiotics. The same policy indicated all prescriptions for antibiotic's would specify dose, duration, and indications for use. Director of Nursing (DON) B was interviewed on 3/14/23 at 10:38 AM and stated she was the infection control practitioner (ICP) for the past 3 months. DON B stated she was not always notified if resident had an antibiotic ordered, the unit manager would be notified. DON B stated they currently did not have any unit managers. DON B stated criteria used to determine appropriateness for antibiotic use was McGreer's criteria (guidance for infection surveillance). After review of February 2023's infection surveillance report, DON B was unable to state whether antibiotic met criteria for appropriateness. DON B stated antibiotic orders should include a diagnosis for use and a stop date. DON B stated the Tobramycin eye drops were not included in her February 2023 surveillance data or report.

Based on interview and record review, the facility failed to notify resident families and representatives of COVID-19 infections in the facility in one of one reviewed for notification (Resident #6), resulting in not fully prepared for status prior to visit and lack of involvement in the resident care plan. Findings include: Resident #6 (R6) In review of R6's Minimum Data Set (MDS) assessment, with an assessment reference date of 1/19/23, she had a Brief Interview for Mental Status (BIMS, a brief performance-based cognitive screener for nursing home residents) score of 03 (00-07 Severely Impaired). In review of facility list provided on 3/13/23, R6 was positive for COVID-19 on 3/03/23. Resident Representative (RR) F was interviewed on 3/13/23 at 11:41 AM and stated she had concern regarding infection control practices in the facility and that she was not contacted after last COVID-19 outbreak. RR F stated she would have preferred to have known there was an outbreak in the facility before planning a visit. RR F stated she typically visited twice a week but would choose not to visit based on the COVID-19 numbers. RR F stated when the facility reached 10 to 20 positive COVID-19 tests, she would like to be notified. Director of Nursing (DON) B was interviewed on 3/14/23 at 11:01 AM and was not able to locate R6's resident representative was contacted regarding R6 positive COVID-19 test COVID-19 on 3/03/23. DON B stated resident representative notification would be in the resident's progress notes.

Based on observation, interview and record review, the facility failed to ensure a Registered Nurse (RN) provided services for at least eight consecutive hours per day, seven days per week resulting in the potential for inadequate coordination of emergent or routine care with negative clinical outcomes affecting all 50 residents in the facility. Findings include: On 3/14/23 at 3:30 PM, the daily staff sheet was observed posted on the desk at the front entrance. Review of the daily staffing sheets revealed the facility did not have a RN that provided services on 2/17/23, 2/23/23, 2/26/23, 2/28/23, 3/7/23, 3/9/23, 3/10/23, 3/11/23, and 3/12/23. In an interview on 03/15/23 at 1:39 PM, Director of Nursing (DON) B reported Scheduler J and Human Resources Director (HRD) K worked on the nursing department schedules together. DON B reported it had been a couple months since she had to cover a nursing shift. On 03/15/23 at 2:33 PM, DON B reported she did not work at all last week and was off starting 3/3/23 and returned to work on 3/13/23. In an interview on 03/15/23 at 1:43 PM, Scheduler J reported she was not aware of the requirement that the facility provide services of a RN at least eight consecutive hours per day, seven days per week. Scheduler J reported the facility did not have a RN in the building on 2/17/23, 2/23/23, 2/26/23, 2/28/23, 3/7/23, 3/9/23, 3/10/23, 3/11/23, and 3/12/23. On 03/16/23 at 8:51 AM, DON B reported she was not aware the facility did not have a RN in the facility for at least eight hours per day, seven days per week.

Based on interview and record review the facility failed to conduct routine Covid-19 testing on all facility employees in accordance with the Center for Disease Control (CDC) and local Public Health Department guidelines during the facilities current Covid-19 outbreak resulting in the potential and likely hood for Covid-19 to spread in the facility and placing the residents at risk for acquiring Covid-19 in a current facility census of 50 residents. Findings Included: In an interview on 03/16/2023 at 09:11 a.m. Director of Nursing (DON) B explained that the facilities most recent outbreak of Covid-19 occurred on February 27, 2023. She explained that on that date four residents and two employees were positive for Covid-19. She further explained that after reviewing the correlating data regarding the outbreak they had made the determination that the outbreak originated with the staff. DON B explained that routine rapid Covid -19 testing was initiated for residents at that time. DON B explained that rapid Covid-19 testing is completed weekly on all residents. When asked if employees have been tested routinely during the current Covid-19 outbreak at the facility, DON B explained that routine testing is not completed for employees in accordance with new CDC guidelines. DON B was asked to provide those CDC guidelines. DON B was asked if the facility contacted the County Health Department regarding the current Covid-19 outbreak. DON B explained that the facility had contacted the County Health Department on February 17th or 18th and had been providing them with a line listing of residents that had tested positive for Covid-19. She explained that the local Health Department had not requested a line listing for employees of the facility. In a telephone interview on 03/20/2023 at 02:59 p.m. with local Health Department Nurse Q explained that she was the person that coordinated Covid-19 for the healthcare facilities in the county. She explained that she had spoken to the facility following the current Covid-19 outbreak at the facility. She explained that she had provided them information that included resident and employee routine testing. She explained that the information directed that both residents and employees needed to have routine Covid-19 testing conducted. She explained that the Director of Nursing (DON) B had called and spoken to her on 03/17/2023. At this time, she again explained the requirements for routine testing of employees for Covid-19. Review of Center for Disease Control and Prevention COVID-19 Infection Control Guidance demonstrated If healthcare-associated transmission is suspected or identified, facilities might consider expanded testing of HCP and patients as determined by the distribution and number of cases throughout the facility and ability to identify close contacts. For example, in an outpatient dialysis facility with an open treatment area, testing should ideally include all patients and HCP. Depending on testing resources available or the likelihood of healthcare-associated transmission, facilities may elect to initially expand testing only to HCP and patients on the affected units or departments, or a particular treatment schedule or shift, as opposed to the entire facility. If an expanded testing approach is taken and testing identifies additional infections, testing should be expanded more broadly. If possible, testing should be repeated every 3-7 days until no new cases are identified for at least 14 days. Review of the same source demonstrated Guidance for outbreak response in nursing homes is described in setting-specific considerations below. Healthcare facilities responding to SARS-CoV-2 transmission within the facility should always notify and follow the recommendations of public health authorities. In an interview on 03/21/2023 at 08:41 a.m. Director of Nursing (DON) B explained that she had talked with the local County Health Department and had spoken with local Health Department Nurse Q on 03/17/2023. She explained that she understood from that conversation that the facility should have been testing the employees twice per week since the start of the current Covid-19 outbreak and would continue employee testing for two weeks after the last positive case of Covid-19. DON B also explained that local Health Department Nurse Q had provided her with a document that demonstrated the guidance for a Covid-19 outbreak.

Based on interview and record review, the facility failed to implement a compliance and ethics program resulting in the potential for criminal, civil, and administrative violations with the potential to affect all 50 residents. Findings include: Review of the facility's Compliance and Ethics Program policy revealed, Policy Explanation and Compliance Guidelines: 1. As part of the facility's culture of compliance, established standards of conduct apply to everyone involved in the company. 2. The facility maintains a designated compliance and ethics program contact to which individuals may report suspected violations, as well as an alternate method of reporting suspected violations anonymously without fear of retribution. 3. All staff, including individuals providing services under a contract and as a volunteer, committing violations of the compliance and ethics program will be subject to disciplinary actions, up to and including termination. 4. Components of the facility's compliance and ethics program include: a. Written compliance and ethics standards, policies, and procedures. b. Assigned individuals within the high-level personnel of the facility with the overall responsibility to oversee compliance with the facility's compliance and ethics program standards, policies and procedures. c. Sufficient resources and authority to reasonably assure compliance. d. Due care not to delegate substantial discretionary authority to individuals who have a propensity to engage in criminal, civil and administrative violations. e. Ongoing communication, through education and other means, of the standards, policies and procedures to the entire staff, individuals contracted by the facility and volunteers, consistent with roles. f. Compliance achievement activities, such as monitoring, auditing, and reporting systems, and data integrity processes. g. Consistent enforcement of the organization's standards, policies, and procedures through appropriate disciplinary mechanisms for noncompliance and/or failures to detect or report a violation of the compliance and ethics program. h. Established procedures to follow when a violation is detected for ensuring appropriate response and preventing further similar violations. 5. The facility reviews the compliance and ethics program annually, revising as needed to: a. Reflect changes in applicable laws or regulations within the organization. b. Improve performance in deterring, reducing and detecting violations. c. Promoting quality care. The policy did not have a date implemented, reviewed, or revised. In an interview on 03/21/23 at 10:02 AM, AIT C and Nursing Home Administrator (NHA) A reported the compliance and ethics program was not yet implemented and they were unsure why it had not been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00134570 and MI00134606 Based on observation, interviews and record review the facility failed to implement their abuse policy for one Resident (R101) of 3 Residents reviewed for abuse, resulting in R101's left hand fracture during staff assisted care and staff observed R101 catastrophic reaction with delay in reporting allegation of abuse, investigation and having the potential for abuse to be ongoing or unnoticed. Findings include: Complaints and Facility Reported Incident(FRI) were filed with the State Agency and alleged that R101 sustained an injury of unknown origin (fracture to the left hand) and alleged the resident was abused by employee/certified nursing assistant (CNA) N. The FRI 24 hour report was submitted by the facility on 1/26/23 at 11:53 a.m. Review of the Facility Abuse Policy, dated 6/27/22 and revised 3/1/23, reflected, Protocol: [Named facility] (CSCC) protects the health, welfare, and rights of residents by developing and implementing written protocols, policies and procedures prohibiting, and with the intention of preventing, abuse, neglect, mistreatment, exploitation and misappropriation of resident property . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment (physical punishment meant to be painful) . Employee Training .New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation .Training topics will be in accordance with federal and/or state requirements and include .1. Prohibition and prevention of abuse, neglect, misappropriation of resident property, and exploitation in accordance with regulatory standards and the Elder Justice Act; 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; 3. Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources; 5. Understanding behavioral symptoms that may increase risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions by residents; b. Wandering or elopement-type behaviors; c. Resistance to care; d. Outbursts or yelling out . Identification of Abuse, Neglect and Exploitation . Possible indicators of abuse include, but are not limited to .Resident, staff or family report of abuse .Physical injury of a resident, of unknown source . Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame . Investigation of Alleged Abuse, Neglect and Exploitation . Identifying and interviewing identified involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Protection of Resident CSCC takes action to protect residents from physical and/or psychosocial harm during and after an investigation . Reporting/Response .Reporting alleged violations to the Administrator/Abuse Coordinator/designee, state agency, adult protective services and to all other required agencies, if needed, (e.g., law enforcement when applicable) within specified timeframes .Immediately (the Abuse Coordinator has 2 hours to report to the State Agency), after forming suspicion of abuse OR if the allegation involves abuse OR results in serious body injury . Resident #101(R101) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that hypertension (high blood pressure), heart failures, diabetes, psychotic disorder, and depression. The MDS reflected R101 had a BIM (assessment tool) score of 9 which indicated his ability to make daily decisions was moderately impaired, and he required two person physical assist with bed mobility, transfers, toileting, dressing and one person physical assist with hygiene and bathing. The MDS reflected R101 did not have behaviors including being physically or verbally aggressive with staff or refusal of care. Review of an Incident/Accident Alleged Abuse document, dated 1/26/23 at 11:14 a.m., reflected, Nursing Description: CNA informed writer that resident had new onset swelling and bruising to left hand. Resident's posterior left hand and digit four and five has dark bruising, swelling present. Resident able to perform ROM in left hand, intermittent pain .Resident Description: Resident states to writer that he was woke up yesterday morning by CNA. Resident states things were fuzzy, but CNA proceeded to grab his hand and bend it. Resident describes CNA as a short, black women. The document indicated R101 was alert to person, place and situation. The document reflected Nursing Home Administrator in training (NHAIT) C, Social Worker (SW) I and the Physician were notified. Review of the FRI investigation, dated 1/26/23, included a five-day summary that reflected, C.N.A [named CNA N] was assigned to [named R101] 1/25/23 2:00PM - 10:30PM. Based off [named R101] description, Administrator in Training and scheduler interviewed [named CNA N] and told her based on the allegations of abuse that she was not allowed in the facility until the investigation was completed. [named CNA N] reported that they were wrestling. When asked to explain wrestling she stated Resident was pushing hands away when she tried to give care. She was rolling him from side to side to do a complete bed change because it was wet. Nurse [named LPN H] entered the room to give meds she could tell [named R101] was agitated and told [named CNA N] not to return to his room for the remainder of the night. Continued review of the investigation included a written statement, dated 1/26/23, signed by CNA G. The statement reflected, Res wanted to sleep in till 10ish went in to do care his left hand was bruised. Res stated that a cena grabed him, stated it was broke. I went and informed unit manager. Continued review of the investigation reflected two interviews with other residents who had reported concerns with CNA N with requests to not receive care from CNA N. Review of the resident interview for room [ROOM NUMBER](same hall as R101), dated 1/26/23 and signed by SW I, reflected, I do think that CNA [named CNA N] is rude and mean! I don't want her pack in my room b/c last night around 6:30 p.m. I heard a gasp coming from room [ROOM NUMBER] then I heard [named resident in room [ROOM NUMBER]] crying with [named CNA N] saying You tried to hit me [named resident in room [ROOM NUMBER]] then said no, I didn't and continued to cry! I pushed my call button and after a ½ hour I told the nurse [named resident in room [ROOM NUMBER]] was crying .I just don't want [named CNA N] helping me b/c she is not nice. Review of the resident interview for room [ROOM NUMBER](CNA N assignment 1/25/23 3rd shift), dated 1/26/23 and signed by SW I. The statement reflected, The other day (Tues. evening 1/24/23) the [named CNA N] came into the room grumpy she seemed to be rushed. When transferring me to my chair she pushed my bedside table forcefully breaking the picture frame, she then said, you people have to much stuff here! Last night the same CNA came into my with the same grumpy attitude and she was with another CNA in which she was training! She told the trainee to get a brief ready b/c we have too much to do. She put me on the toilet continuing to grumble about having so much to do and having to train someone. When she put me on the sit to stand I told her not to high, she said, get used to it. She said the sling twisted causing my skin to get sore .I would prefer if that CNA does not work with me. The investigation reflected no evidence of skin assessments for residents who were unable to report concerns(non-interviewable) with care or evidence that all residents had been interviewed. Review of R101 Nursing Progress Notes, dated 1/26/2023 at 11:24 a.m., indicated, .New order for STAT 2 view XR of left hand, order placed into PCC. Review of the Progress Note, dated 1/26/2023 at 11:44 a.m., reflected,It was brought to this writer's attention by the Unit Nurse Manager that resident made allegations towards a staff member when a bruise on his left hands was noticed this morning. This writer met with resident, and he was alert sitting in his bed . Resident showed this writer his left hand that showed significant bruising on the pinky and on the front of his left hand below his ring and pinky finger. This writer asked if he could tell her what happened. He said he was sleeping yesterday and a CNA (describe as a short, not heavy Mexican or Black female) brought him his breakfast tray and said wake up your food is here .This writer told him that was ok and ask if he could explain what she did to hurt his hand. He said she squeezed it as she was rocking him side to side. He said she was rocking him to get him up he thought. He then said she seemed upset that he was foggy .SW: when she the left the room did you call for help? Resident: No! I did not have to because the other person came in the room (could not describe her) and he told that other person I want her out of my room and I do not want her to come back .SW: Are you sure it was breakfast? Because you take naps during the day and I want to make sure this person does not come back to your room! Resident: He responded let me think!! He then said it was dinner! I am sure it was dinner .This writer asked if he felt safe in this facility and he said I don't have a problem with anyone but I do not want her back in my room because I do not feel safe with her . Review of R101 Interdisciplinary Team Note, dated 1/26/2023 at 4:30 p.m., Left hand XR results received. Reports states the following; There is a fracture involving the proximal 5th phalanx with mild displacement. There is associated soft tissue swelling . Review of the Radiology Report, dated 1/26/23 at 1:11 p.m. reflected R101 had an acute fracture of the proximal 5th phalanx with mild displacement and soft tissue swelling. Review of R101 Progress Note, dated 1/26/2023 at 9:17 p.m., reflected, Resident returned from [named hospital] approximately @2020p via EMT on stretcher. Resident arrived with splint on left hand with pinky finger wrapped. Resident is calm and cooperative with care. No c/o pain or discomfort voiced at this time . Review of the Hospital Records, dated 1/26/23, reflected R101 had reported CNA staff had hurt left hand and caused pain. During an interview on 3/15/23 at 11:28 a.m., NHAIT C reported agency staff do not punch in, but they do have hours staff worked and would provide documentation. NHAIT C reported agency staff are provided folder of items to complete upon starting employment at facility that included skills checklist and abuse training and reported some staff do not turn in documentation to Human Recourses. NHAIT C reported facility did not have evidence of skills checklist or abuse training for CNA N. Review of the Agency Staffing Company Invoice, dated 1/24/23 to 1/31/23, reflected CNA N worked at the facility from 1/25/23 at 2:00 p.m. to 6:00 a.m. on 1/26/23 as evidenced by hours worked. During an observation and interview on 3/15/23 at 11:48 a.m., R101 was observed in bed and appeared calm able to answer questions. R101 was asked if he had concerns of anyone ever being physically rough with him at the facility. R101 reported had one time when staff grabbed left hand and turned and squeezed it very hard and hurt him around the time they were taking tray out of room. R101 reported was unable to recall staff name but reported had dark complexion skin. Reported felt safe and had not had any other incidents with anyone being physically rough or verbally inappropriate with him since. R101 reported incident happened and another staff member came in and he reported he did not want that CNA to come in room again and verified had not seen CNA staff since. R101 left pinky finger was noted with no splint in place and appeared to be abnormally bent compared to right hand. During an interview on 3/15/23 at 12:41 p.m., CNA G reported was working with R101 on 1/26/23 and reported R101 was not a morning person and liked to sleep in. CNA G reported entered R101 room between 10:00 a.m. and 10:30 a.m. to provided morning care and pulled back blankets and noticed R101 left hand was severely bruised and black in color. CNA G reported she asked what had happened to R101 hand and he reported a black women grabbed him aggressively. CNA G reported she exited the room immediately and reported to Unit Manager Licensed Practical Nurse (LPN) F. CNA G reported she completed a written statement and reported everyone working should have competed statement because that was the protocol. CNA G reported R101 did not tell her when incident happened and reported she had arrived that day at 6:00 a.m. CNA G reported R101 required total care and was alert and oriented with slight forgetfulness and able to express needs. CNA G reported R101 breakfast tray was not delivered to him prior to her entering room that day. During a telephone interview on 3/15/23 at 4:20 p.m., Licensed Practical Nurse (LPN) H reported had worked at the facility as an agency staff for the past seven months. LPN H reported was R101's nurse on 1/25/23 second shift and recalled R101 being agitated that day and had told CNA N to be aware with care. LPN H reported R101 was upset because he could not say what he wanted to say that day. LPN H reported she entered R101 room, and he was yelling and swing at CNA N and reported that was very unlike R101 and LPN H reported asked CNA N to leave R101 room and not come back. LPN H reported documented incident in Progress Notes and reported R101 was upset and would not speak with staff and did not report pain. LPN H reported there was not an on-call manager on that night so reported to next shift nurse about incident. LPN H reported received call form NHAIT C on 1/26/23 and was questioned and received education about reporting because R101 was not at all at his baseline, and she had never observed him acting like that and was informed should have reported immediately. LPN H reported CNA N worked a double that night (2nd and 3rd shift) and was moved to another hall for 3rd shift. LPN H reported recalled two other residents who had reported did not want CNA N to care for them again that evening located in room [ROOM NUMBER](same hall as R101) and 127(CNA N 3rd shift assignment). Review of R101 Nurse Progress Note, dated 1/25/2023 at 7:36 p.m., reflected, Resident refused to get accu check, refused all medications and insulin's. Resident was yelling and combative with staff. Safety and comfort measures were maintained. Note was written by LPN H. During an interview and record review on 3/16/23 at 9:00 a.m. Human Resource Manager (HRM) K provided Employee File for LPN H that reflected no evidence of abuse training or discipline. HRM K verified had received complete employee files for requested staff. Scheduler L joined the interview and reported she was responsible for scheduling agency and did not have any records of agency training or disciplines. During an interview on 3/16/23 at 9:24 p.m., LPN F reported was working on 1/26/23 as Unit Manager when CNA G reported to her that R101 had a bruise to his left hand. LPN F reported CNA G had reported R101 told her a CNA staff had hurt his hand and CNA G immediately reported to her (LPN F). LPN F reported she immediately interviewed R101, who reported CNA staff bend his hand and hurt him and was unable to recall name but described CNA as short black female. LPN F reported R101 reported incident happened around meal service. LPN F reported no one fitting that description was working at that time. LPN F reported incident was reported to NHAIT C, Social Worker (SW) I and Physician who was in the facility at the time. LPN F described R101 left hand as black darkish purple colored bruising and swelling. LPN F reported Physician ordered STAT Xray and received results in about two hours R101 had positive fracture of left pinky. LPN F reported R101 was alert and oriented with occasional forgetfulness. LPN F reported R101 was a nice guy with no history of combative behaviors and would describe R101 behavior on 1/25/23 an example of catastrophic reaction because R101's reaction was very unlike him. LPN F reported R101 was sent to the emergency room and returned with a large splint from fingers to above left elbow and was compliant with splint. LPN F reported R101 did follow up with orthopedic consult after incident. Review of R101 Orthopedic Consult, dated 2/8/23, reflected, Chief Complaint patient presents with Left Hand-Injury DOI 1/26/23 x 1w, 6d. Pt got his left hand grabbed by a CNA and his lift little finger bent. He was seen in the ER and splinted. History of Present Illness .He states that the injury occurred when he was grabbed by a CNA and his left hand was struck into a bed rail and he had immediate pain .He reports this his finger is doing better and is less painful than when the injury occurred .Imaging: 02/08/23 Xray: My independent interpretation of radiographs of the left small finger demonstrates a displaced fracture of the small finger proximal phalanx with angulation toward the ulnar side .Plan .Given his physical exam and other health issues I do not recommend surgical interventions; he will still have functional use of his finger. At this point he will be placed in a left ulnar gutter splint .Advised to keep the hand elevated for edema control. No major use of the left upper extremity. This fracture can take 3-5 weeks to heal . Review of R101 Orthopedic Consult, date 2/24/23, reflected, Imaging: 02/24/23 .stable appearance of proximal phalanx base fracture .fracture is not yet healed .he was transitioned from a splint to buddy straps. He will wear the buddy straps for the next 2 weeks. We will see him in clinic in 2 weeks with interval radiographs . Review of the Electronic Medical Record reflected same residents lived in rooms 109, 111 and 127 currently as when interviewed on 1/26/23. During an interview on 3/16/23 at 9:50 a.m., entered room [ROOM NUMBER] (same hall as R101). Resident alert and oriented and able to answer questions and verified was questioned by SW I about concerns with CNA N. Resident reported informed SW I CNA N was, impatient, abrupt, and condescending. Resident reported informed SW I had heard resident in 111 crying when CNA N was providing care the night before SW I interviewed resident (1/25/23). Resident reported heard CNA N yell at resident in room [ROOM NUMBER] not to hit her. Resident reported did not believe resident in 111 would ever hit staff and had never heard resident cry out in distress like that. Resident verified statement taken on 1/26/23 by SW I that reflected Resident had a BIM score of 12(cognitively intact). During an interview on 3/16/23 at 10:10 a.m., entered room [ROOM NUMBER](shared bathroom with room [ROOM NUMBER]). Resident reported unable to recall speaking with SW I about care concerns and reported had no memory of CNA N. During an interview on 3/16/23 at 10:17 a.m., entered room [ROOM NUMBER](CNA N 3rd shift assignment 1/25/23). Resident verified statement and reported residents should not feel like they are a burden to staff and reported CNA N made her feel that way and reported if she did not need assistance she would not ask. During an interview on 3/16/23 at 10:42 a.m., SW I reported had interviewed R101 about the abuse allegation on 1/26/23. SW I reported R101 told her CNA staff was being rough with him and bent hand back. SW I reported observed dark bruising on R101's left hand and looked like someone squeezed hand. SW I reported investigation done and CNA N was removed from schedule related to R101 description, staff interviews and other resident interviews. SW I reported R101's biggest concern was he did not want that CNA N back. SW I reported R101 was a little foggy on incident time of day initially but clarified was dinner time the day prior (1/25/23). SW I reported did interview few residents on R101 hall post incident with some reported concerns with CNA N as well as complaints reported by resident in room [ROOM NUMBER] on other nursing hall. SW I reported put it together and determined was same CNA N that had new assignment on 1/25/23 3rd shift after R101 incident. SW I reported did not interview all interviewable residents just a few and unable to answer why. During a telephone interview on 3/16/23 at 4:44 p.m., LPN M reported was R101 nurse on 1/25/23 third shift starting about 10:00 p.m. LPN M reported heard agency CNA N hurt R101 hand or bent back finger on 1/25/23 second shift couple days later. LPN M reported could not recall if she went into R101 room during 1/25/23 shift between 10pm and 7am on 1/26/23 and reported if she had noticed anything abnormal, she would have documented in progress note. LPN M reported did not complete witness statements and was not involved in investigation. LPN M reported did recall resident in room [ROOM NUMBER] reported had overheard resident in room [ROOM NUMBER] verbal altercation with CNA N and reported had told LPN M she did not want that CNA N caring for her on 1/25/23 3rd shift. LPN M reported same night resident in room [ROOM NUMBER] reported to LPN M did not want CNA N to care for her. LPN M reported did not recall why and did not report to management. During a telephone interview on 3/20/23 at 8:22 a.m., NHAIT C reported completed the investigation for R101 FRI on 1/26/23. NHAIT C reported was notified of R101's left hand bruising the morning of 1/26/23 by LPN F. NHAIT C reported was told CNA G identified R101's new bruising to left hand who immediately reported to Unit Manager LPN F. NHAIT C reported LPN F ordered Xray after contacting Physician, and reported NHAIT C contacted local police, Adult Protective Services, state agency, CNA registry, and spoke with SW I who assisted with investigation. NHAIT C reported she contacted CNA N because she was only staff that met description and informed not to return to the facility and obtained statement. NHAIT C reported had interviewed LPN H (R101 nurse 1/25/23 2nd shift) who had reported had walked in R101 room on 1/25/23 and observed R101 very agitated during care with CNA N. NHAIT C reported LPN F asked CNA N not to come back to R101 room. NHAIT C reported the investigation was inconclusive because she could not say for sure R101 was abused and reported R101 was, adamant about how incident happened and verified R101 was own responsible person. NHAIT C reported during investigation other residents who received care from CNA N between 1/24/23 and 1/26/23 reported CNA N was rough and rude. NHAIT C was queried, would you expect staff to report rough and rude staff as potential allegation of abuse? NHAIT C stated, No, because other residents did not report abuse and stated they felt safe and reported would expect staff to ask why was meant by rough and rude. During a telephone interview on 3/20/23 at 10:18 a.m., NHAIT C reported skin assessments were not competed for non-interviewable residents during R101 investigation for residents who were cared for by CNA N on 1/25/23 2nd and 3rd shift. NHAIT C reported only a few residents were questioned about CNA N care because of BIM scores. NHAIT C reported did speak with LPN H during R101 investigation, who reported had asked CNA N not to enter R101 again because of his witness agitation with CNA N. NHAIT C reported would not expect LPN H to report R101 unusual behavior. NHAIT C was unable to say what a resident catastrophic reaction was. NHAIT C was queried if LPN H was provided abuse education during R101 investigation of after? NHAIT C reported everyone received abuse education after most recent abuse Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00134570 and MI00134606 Based on observation, interview and record review the facility failed to ensure one of three residents (Resident #101) reviewed for abuse, was reported immediately to the facility's Abuse Coordinator, and the state agency, resulting in the potential for further actual or alleged abuse to not be reported immediately to the facility's Abuse Coordinator and state agency. Findings Included: Complaints and Facility Reported Incident(FRI) were filed with the State Agency and alleged that R101 sustained an injury of unknown origin (fracture to the left hand) and alleged the resident was abused by employee/certified nursing assistant (CNA) N. The FRI 24 hour report was submitted by the facility on 1/26/23 at 11:53 a.m. Review of the Facility Abuse Policy, dated 6/27/22 and revised 3/1/23, reflected, Protocol: [Named facility] (CSCC) protects the health, welfare, and rights of residents by developing and implementing written protocols, policies and procedures prohibiting, and with the intention of preventing, abuse, neglect, mistreatment, exploitation and misappropriation of resident property . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment (physical punishment meant to be painful) . Employee Training .New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation .Training topics will be in accordance with federal and/or state requirements and include .1. Prohibition and prevention of abuse, neglect, misappropriation of resident property, and exploitation in accordance with regulatory standards and the Elder Justice Act; 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; 3. Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources; 5. Understanding behavioral symptoms that may increase risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions by residents; b. Wandering or elopement-type behaviors; c. Resistance to care; d. Outbursts or yelling out . Identification of Abuse, Neglect and Exploitation . Possible indicators of abuse include, but are not limited to .Resident, staff or family report of abuse .Physical injury of a resident, of unknown source . Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame . Investigation of Alleged Abuse, Neglect and Exploitation . Identifying and interviewing identified involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Protection of Resident CSCC takes action to protect residents from physical and/or psychosocial harm during and after an investigation . Reporting/Response .Reporting alleged violations to the Administrator/Abuse Coordinator/designee, state agency, adult protective services and to all other required agencies, if needed, (e.g., law enforcement when applicable) within specified timeframes .Immediately (the Abuse Coordinator has 2 hours to report to the State Agency), after forming suspicion of abuse OR if the allegation involves abuse OR results in serious body injury . Resident #101(R101) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that hypertension (high blood pressure), heart failures, diabetes, psychotic disorder, and depression. The MDS reflected R101 had a BIM (assessment tool) score of 9 which indicated his ability to make daily decisions was moderately impaired, and he required two person physical assist with bed mobility, transfers, toileting, dressing and one person physical assist with hygiene and bathing. The MDS reflected R101 did not have behaviors including being physically or verbally aggressive with staff or refusal of care. Review of an Incident/Accident Alleged Abuse document, dated 1/26/23 at 11:14 a.m., reflected, Nursing Description: CNA informed writer that resident had new onset swelling and bruising to left hand. Resident's posterior left hand and digit four and five has dark bruising, swelling present. Resident able to perform ROM in left hand, intermittent pain .Resident Description: Resident states to writer that he was woke up yesterday morning by CNA. Resident states things were fuzzy, but CNA proceeded to grab his hand and bend it. Resident describes CNA as a short, black women. The document indicated R101 was alert to person, place and situation. The document reflected Nursing Home Administrator in training (NHAIT) C, Social Worker (SW) I and the Physician were notified. Review of the FRI investigation, dated 1/26/23, included a five-day summary that reflected, C.N.A [named CNA N] was assigned to [named R101] 1/25/23 2:00PM - 10:30PM. Based off [named R101] description, Administrator in Training and scheduler interviewed [named CNA N] and told her based on the allegations of abuse that she was not allowed in the facility until the investigation was completed. [named CNA N] reported that they were wrestling. When asked to explain wrestling she stated Resident was pushing hands away when she tried to give care. She was rolling him from side to side to do a complete bed change because it was wet. Nurse [named LPN H] entered the room to give meds she could tell [named R101] was agitated and told [named CNA N] not to return to his room for the remainder of the night. Continued review of the investigation included a written statement, dated 1/26/23, signed by CNA G. The statement reflected, Res wanted to sleep in till 10ish went in to do care his left hand was bruised. Res stated that a cena grabed him, stated it was broke. I went and informed unit manager. Continued review of the investigation reflected two interviews with other residents who had reported concerns with CNA N with requests to not receive care from CNA N. Review of the resident interview for room [ROOM NUMBER](same hall as R101), dated 1/26/23 and signed by SW I, reflected, I do think that CNA [named CNA N] is rude and mean! I don't want her pack in my room b/c last night around 6:30 p.m. I heard a gasp coming from room [ROOM NUMBER] then I heard [named resident in room [ROOM NUMBER]] crying with [named CNA N] saying You tried to hit me [named resident in room [ROOM NUMBER]] then said no, I didn't and continued to cry! I pushed my call button and after a ½ hour I told the nurse [named resident in room [ROOM NUMBER]] was crying .I just don't want [named CNA N] helping me b/c she is not nice. Review of the resident interview for room [ROOM NUMBER](CNA N assignment 1/25/23 3rd shift), dated 1/26/23 and signed by SW I. The statement reflected, The other day (Tues. evening 1/24/23) the [named CNA N] came into the room grumpy she seemed to be rushed. When transferring me to my chair she pushed my bedside table forcefully breaking the picture frame, she then said, you people have to much stuff here! Last night the same CNA came into my with the same grumpy attitude and she was with another CNA in which she was training! She told the trainee to get a brief ready b/c we have too much to do. She put me on the toilet continuing to grumble about having so much to do and having to train someone. When she put me on the sit to stand I told her not to high, she said, get used to it. She said the sling twisted causing my skin to get sore .I would prefer if that CNA does not work with me. The investigation reflected no evidence of skin assessments for residents who were unable to report concerns(non-interviewable) with care or evidence that all residents had been interviewed. Review of R101 Nursing Progress Notes, dated 1/26/2023 at 11:24 a.m., indicated, .New order for STAT 2 view XR of left hand, order placed into PCC. Review of the Progress Note, dated 1/26/2023 at 11:44 a.m., reflected,It was brought to this writer's attention by the Unit Nurse Manager that resident made allegations towards a staff member when a bruise on his left hands was noticed this morning. This writer met with resident, and he was alert sitting in his bed . Resident showed this writer his left hand that showed significant bruising on the pinky and on the front of his left hand below his ring and pinky finger. This writer asked if he could tell her what happened. He said he was sleeping yesterday and a CNA (describe as a short, not heavy Mexican or Black female) brought him his breakfast tray and said wake up your food is here .This writer told him that was ok and ask if he could explain what she did to hurt his hand. He said she squeezed it as she was rocking him side to side. He said she was rocking him to get him up he thought. He then said she seemed upset that he was foggy .SW: when she the left the room did you call for help? Resident: No! I did not have to because the other person came in the room (could not describe her) and he told that other person I want her out of my room and I do not want her to come back .SW: Are you sure it was breakfast? Because you take naps during the day and I want to make sure this person does not come back to your room! Resident: He responded let me think!! He then said it was dinner! I am sure it was dinner .This writer asked if he felt safe in this facility and he said I don't have a problem with anyone but I do not want her back in my room because I do not feel safe with her . Review of R101 Interdisciplinary Team Note, dated 1/26/2023 at 4:30 p.m., Left hand XR results received. Reports states the following; There is a fracture involving the proximal 5th phalanx with mild displacement. There is associated soft tissue swelling . Review of the Radiology Report, dated 1/26/23 at 1:11 p.m. reflected R101 had an acute fracture of the proximal 5th phalanx with mild displacement and soft tissue swelling. Review of R101 Progress Note, dated 1/26/2023 at 9:17 p.m., reflected, Resident returned from [named hospital] approximately @2020p via EMT on stretcher. Resident arrived with splint on left hand with pinky finger wrapped. Resident is calm and cooperative with care. No c/o pain or discomfort voiced at this time . Review of the Hospital Records, dated 1/26/23, reflected R101 had reported CNA staff had hurt left hand and caused pain. During an interview on 3/15/23 at 11:28 a.m., NHAIT C reported agency staff do not punch in, but they do have hours staff worked and would provide documentation. NHAIT C reported agency staff are provided folder of items to complete upon starting employment at facility that included skills checklist and abuse training and reported some staff do not turn in documentation to Human Recourses. NHAIT C reported facility did not have evidence of skills checklist or abuse training for CNA N. Review of the Agency Staffing Company Invoice, dated 1/24/23 to 1/31/23, reflected CNA N worked at the facility from 1/25/23 at 2:00 p.m. to 6:00 a.m. on 1/26/23 as evidenced by hours worked. During an observation and interview on 3/15/23 at 11:48 a.m., R101 was observed in bed and appeared calm able to answer questions. R101 was asked if he had concerns of anyone ever being physically rough with him at the facility. R101 reported had one time when staff grabbed left hand and turned and squeezed it very hard and hurt him around the time they were taking tray out of room. R101 reported was unable to recall staff name but reported had dark complexion skin. Reported felt safe and had not had any other incidents with anyone being physically rough or verbally inappropriate with him since. R101 reported incident happened and another staff member came in and he reported he did not want that CNA to come in room again and verified had not seen CNA staff since. R101 left pinky finger was noted with no splint in place and appeared to be abnormally bent compared to right hand. During an interview on 3/15/23 at 12:41 p.m., CNA G reported was working with R101 on 1/26/23 and reported R101 was not a morning person and liked to sleep in. CNA G reported entered R101 room between 10:00 a.m. and 10:30 a.m. to provided morning care and pulled back blankets and noticed R101 left hand was severely bruised and black in color. CNA G reported she asked what had happened to R101 hand and he reported a black women grabbed him aggressively. CNA G reported she exited the room immediately and reported to Unit Manager Licensed Practical Nurse (LPN) F. CNA G reported she completed a written statement and reported everyone working should have competed statement because that was the protocol. CNA G reported R101 did not tell her when incident happened and reported she had arrived that day at 6:00 a.m. CNA G reported R101 required total care and was alert and oriented with slight forgetfulness and able to express needs. CNA G reported R101 breakfast tray was not delivered to him prior to her entering room that day. During a telephone interview on 3/15/23 at 4:20 p.m., Licensed Practical Nurse (LPN) H reported had worked at the facility as an agency staff for the past seven months. LPN H reported was R101's nurse on 1/25/23 second shift and recalled R101 being agitated that day and had told CNA N to be aware with care. LPN H reported R101 was upset because he could not say what he wanted to say that day. LPN H reported she entered R101 room, and he was yelling and swing at CNA N and reported that was very unlike R101 and LPN H reported asked CNA N to leave R101 room and not come back. LPN H reported documented incident in Progress Notes and reported R101 was upset and would not speak with staff and did not report pain. LPN H reported there was not an on-call manager on that night so reported to next shift nurse about incident. LPN H reported received call form NHAIT C on 1/26/23 and was questioned and received education about reporting because R101 was not at all at his baseline, and she had never observed him acting like that and was informed should have reported immediately. LPN H reported CNA N worked a double that night (2nd and 3rd shift) and was moved to another hall for 3rd shift. LPN H reported recalled two other residents who had reported did not want CNA N to care for them again that evening located in room [ROOM NUMBER] (same hall as R101) and 127 (CNA N 3rd shift assignment). Review of R101 Nurse Progress Note, dated 1/25/2023 at 7:36 p.m., reflected, Resident refused to get accu check, refused all medications and insulin's. Resident was yelling and combative with staff. Safety and comfort measures were maintained. Note was written by LPN H. During an interview and record review on 3/16/23 at 9:00 a.m. Human Resource Manager (HRM) K provided Employee File for LPN H that reflected no evidence of abuse training or discipline. HRM K verified had received complete employee files for requested staff. Scheduler L joined the interview and reported she was responsible for scheduling agency and did not have any records of agency training or disciplines. During an interview on 3/16/23 at 9:24 p.m., LPN F reported was working on 1/26/23 as Unit Manager when CNA G reported to her that R101 had a bruise to his left hand. LPN F reported CNA G had reported R101 told her a CNA staff had hurt his hand and CNA G immediately reported to her (LPN F). LPN F reported she immediately interviewed R101, who reported CNA staff bend his hand and hurt him and was unable to recall name but described CNA as short black female. LPN F reported R101 reported incident happened around meal service. LPN F reported no one fitting that description was working at that time. LPN F reported incident was reported to NHAIT C, Social Worker (SW) I and Physician who was in the facility at the time. LPN F described R101 left hand as black darkish purple colored bruising and swelling. LPN F reported Physician ordered STAT Xray and received results in about two hours R101 had positive fracture of left pinky. LPN F reported R101 was alert and oriented with occasional forgetfulness. LPN F reported R101 was a nice guy with no history of combative behaviors and would describe R101 behavior on 1/25/23 an example of catastrophic reaction because R101's reaction was very unlike him. LPN F reported R101 was sent to the emergency room and returned with a large splint from fingers to above left elbow and was compliant with splint. LPN F reported R101 did follow up with orthopedic consult after incident. Review of R101 Orthopedic Consult, dated 2/8/23, reflected, Chief Complaint patient presents with Left Hand-Injury DOI 1/26/23 x 1w, 6d. Pt got his left hand grabbed by a CNA and his lift little finger bent. He was seen in the ER and splinted. History of Present Illness .He states that the injury occurred when he was grabbed by a CNA and his left hand was struck into a bed rail and he had immediate pain .He reports this his finger is doing better and is less painful than when the injury occurred .Imaging: 02/08/23 Xray: My independent interpretation of radiographs of the left small finger demonstrates a displaced fracture of the small finger proximal phalanx with angulation toward the ulnar side .Plan .Given his physical exam and other health issues I do not recommend surgical interventions; he will still have functional use of his finger. At this point he will be placed in a left ulnar gutter splint .Advised to keep the hand elevated for edema control. No major use of the left upper extremity. This fracture can take 3-5 weeks to heal . Review of R101 Orthopedic Consult, date 2/24/23, reflected, Imaging: 02/24/23 .stable appearance of proximal phalanx base fracture .fracture is not yet healed .he was transitioned from a splint to buddy straps. He will wear the buddy straps for the next 2 weeks. We will see him in clinic in 2 weeks with interval radiographs . Review of the Electronic Medical Record reflected same residents lived in rooms 109, 111 and 127 currently as when interviewed on 1/26/23. During an interview on 3/16/23 at 9:50 a.m., entered room [ROOM NUMBER](same hall as R101). Resident alert and oriented and able to answer questions and verified was questioned by SW I about concerns with CNA N. Resident reported informed SW I CNA N was, impatient, abrupt, and condescending. Resident reported informed SW I had heard resident in 111 crying when CNA N was providing care the night before SW I interviewed resident (1/25/23). Resident reported heard CNA N yell at resident in room [ROOM NUMBER] not to hit her. Resident reported did not believe resident in 111 would ever hit staff and had never heard resident cry out in distress like that. Resident verified statement taken on 1/26/23 by SW I that reflected Resident had a BIM score of 12(cognitively intact). During an interview on 3/16/23 at 10:10 a.m., entered room [ROOM NUMBER](shared bathroom with room [ROOM NUMBER]). Resident reported unable to recall speaking with SW I about care concerns and reported had no memory of CNA N. During an interview on 3/16/23 at 10:17 a.m., entered room [ROOM NUMBER](CNA N 3rd shift assignment 1/25/23). Resident verified statement and reported residents should not feel like they are a burden to staff and reported CNA N made her feel that way and reported if she did not need assistance she would not ask. During an interview on 3/16/23 at 10:42 a.m., SW I reported had interviewed R101 about the abuse allegation on 1/26/23. SW I reported R101 told her CNA staff was being rough with him and bent hand back. SW I reported observed dark bruising on R101's left hand and looked like someone squeezed hand. SW I reported investigation done and CNA N was removed from schedule related to R101 description, staff interviews and other resident interviews. SW I reported R101's biggest concern was he did not want that CNA N back. SW I reported R101 was a little foggy on incident time of day initially but clarified was dinner time the day prior (1/25/23). SW I reported did interview few residents on R101 hall post incident with some reported concerns with CNA N as well as complaints reported by resident in room [ROOM NUMBER] on other nursing hall. SW I reported put it together and determined was same CNA N that had new assignment on 1/25/23 3rd shift after R101 incident. SW I reported did not interview all interviewable residents just a few and unable to answer why. During a telephone interview on 3/16/23 at 4:44 p.m., LPN M reported was R101 nurse on 1/25/23 third shift starting about 10:00 p.m. LPN M reported heard agency CNA N hurt R101 hand or bent back finger on 1/25/23 second shift couple days later. LPN M reported could not recall if she went into R101 room during 1/25/23 shift between 10pm and 7am on 1/26/23 and reported if she had noticed anything abnormal, she would have documented in progress note. LPN M reported did not complete witness statements and was not involved in investigation. LPN M reported did recall resident in room [ROOM NUMBER] reported had overheard resident in room [ROOM NUMBER] verbal altercation with CNA N and reported had told LPN M she did not want that CNA N caring for her on 1/25/23 3rd shift. LPN M reported same night resident in room [ROOM NUMBER] reported to LPN M did not want CNA N to care for her. LPN M reported did not recall why and did not report to management. During a telephone interview on 3/20/23 at 8:22 a.m., NHAIT C reported completed the investigation for R101 FRI on 1/26/23. NHAIT C reported was notified of R101's left hand bruising the morning of 1/26/23 by LPN F. NHAIT C reported was told CNA G identified R101's new bruising to left hand who immediately reported to Unit Manager LPN F. NHAIT C reported LPN F ordered Xray after contacting Physician, and reported NHAIT C contacted local police, Adult Protective Services, state agency, CNA registry, and spoke with SW I who assisted with investigation. NHAIT C reported she contacted CNA N because she was only staff that met description and informed not to return to the facility and obtained statement. NHAIT C reported had interviewed LPN H(R101 nurse 1/25/23 2nd shift) who had reported had walked in R101 room on 1/25/23 and observed R101 very agitated during care with CNA N. NHAIT C reported LPN F asked CNA N not to come back to R101 room. NHAIT C reported the investigation was inconclusive because she could not say for sure R101 was abused and reported R101 was, admit, about how incident happened and verified R101 was own responsible person. NHAIT C reported during investigation other residents who received care from CNA N between 1/24/23 and 1/26/23 reported CNA N was rough and rude. NHAIT C was queried, would you expect staff to report rough and rude staff as potential allegation of abuse? NHAIT C stated, No, because other residents did not report abuse and stated they felt safe and reported would expect staff to ask why was meant by rough and rude. During a telephone interview on 3/20/23 at 10:18 a.m., NHAIT C reported skin assessments were not competed for non-interviewable residents during R101 investigation for residents who were cared for by CNA N on 1/25/23 2nd and 3rd shift. NHAIT C reported only a few residents were questioned about CNA N care because of BIM scores. NHAIT C reported did speak with LPN H during R101 investigation, who reported had asked CNA N not to enter R101 again because of his witness agitation with CNA N. NHAIT C reported would not expect LPN H to report R101 unusual behavior. NHAIT C was unable to say what a resident catastrophic reaction was. NHAIT C was queried if LPN H was provided abuse education during R101 investigation of after? NHAIT C reported everyone received abuse education after most recent abuse Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00133567 Based on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin for one (Resident #2) of four reviewed, resulting in the potential for unidentified injuries and abuse. Findings include: Review of the medical record revealed Resident #2 (R2) was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, dysphagia, and dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/22 revealed R2 was severely cognitively impaired. R2 was discharged from the facility on 12/23/22. Review of the Incident Note dated 12/9/22 revealed Staff reported bruising noted on right inner thigh. Description; blue, purple and yellow/green bruising. Measurements 10cm [centimeters] x 4cm. No redness or swelling noted. Does not verbalize pain. Baseline ROM [range of motion] active without difficulty. Review of the facility reported incident revealed It was reported by family/staff that resident has a large dark bruise on the upper right inner thigh. After talking to the family they indicated that they suspected abuse. A head to toe assessment of the resident was done on admission and again today. Bruising was congruent with hoyer lift sling marking but full investigation will be completed. Resident did not show any signs of harm or anguish. Review of the facility's investigation revealed the facility did not obtain statements from staff who cared for R2 prior to the identification of the bruise or statements and/or assessments of other residents. In an interview on 2/13/23 at 10:35 AM, Administrator In Training (AIT) C reported she did not obtain staff statements or statements or assessments from other residents as part of the investigation. AIT C did not know why statements and assessments were not obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00134129 Based on interview and record review, the facility failed to ensure post fall assessments were completed per policy for one (Resident #6) of one reviewed, resulting in the potential for further injury. Findings include: Review of the medical record revealed Resident #6 (R6) admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, epilepsy, vascular dementia with psychotic disturbance, visual loss, and a fall with femur fracture. The significant change Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed R6 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance of one to two staff for Activities of Daily Living (ADLs), had one fall with injury except major, and one fall with major injury since prior assessment. The significant change MDS with an ARD of [DATE] revealed R6 scored 3 out of 15 (severe cognitive impairment) on the BIMS and required extensive assistance of two people for transfers and toilet use. R6 died in the facility on [DATE]. Review of R6's Incident Report dated [DATE] revealed Writer was called to the room by the cna. Resident was observed sitting in recliner chair in room. When asked what happened cna [Certified Nursing Assistant] stated when wheeling resident out of bathroom she leaned forward in chair and fell to the ground. Pt [patient] was observed with a [sic] injury to her scalp . The incident report revealed R6 was transferred to the hospital. Review of a facility statement/interview with CNA D revealed she [CNA D] stated they had the resident in the bathroom getting her ready for bed. They transferred her into the chair & scooted her back. Resident lunged forward & fell out of the chair. CNA did range of motion & then had other agency CNA help get the resident off the floor & into the recliner so they could see where she was bleeding from. Then they called nurse down to assess. In a telephone interview on [DATE] 2:30 pm, CNA D reported her and another aide were getting R6 ready for bed, but the other aide was needed to sit in the dining room with the other residents, so she stepped out of R6's room while CNA D waited for her to return. CNA D stated I waited, but by that time [R6] dove over the side of her wheelchair and hit her head. I went and got the nurse. CNA D reported she witnessed R6 fall out of her wheelchair and described the fall as R6 bending over to try to pick up something off the floor and just fell out headfirst. CNA D reported her and CNA N transferred R6 into the recliner before notifying the nurse. In a telephone interview on [DATE] at 11:49 AM, CNA N reported on [DATE], R6 was leaning in her chair a lot. CNA N reported that evening, she was taking another resident to their room when she heard a noise. CNA N reported she left the other resident outside the room and entered R6's room where she saw R6 on the floor and CNA D in the room. CNA N reported she assisted CNA D with getting R6 off the floor and into the recliner before notifying the nurse. CNA D was unable to report what fall interventions were in place at the time but reported she did not hear a fall alarm sounding at the time. In a telephone interview on [DATE] at 12:07 PM, Licensed Practical Nurse (LPN) R reported on [DATE], she was called into the room after R6 was placed back into her recliner by the CNAs. LPN R reported R6 had a laceration towards the front of her scalp and R6 was transferred to the hospital. In an interview on [DATE] at 9:23 AM, Director of Nursing (DON) B reported it was not standard practice for CNAs to perform range of motion or assess residents after a fall. Review of the facility's Fall Prevention Policy last reviewed on 8/2018 revealed When any resident experiences a fall, the facility will: a. Assess the resident b. A facility staff member stays with the resident until the nurse is able to assess the resident c. The resident will not be moved from the the position they are in due to the fall until the licensed nurse has completed an assessment and none or minimal injury identified or the resident gets up on their own.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00132430 Based on interview and record review, the facility failed to administer pain medication as ordered for one (Resident #1) of two reviewed, resulting in the potential for increased pain. Findings include: Review of the medical record revealed Resident #1 (R1) was admitted to the facility on [DATE] and with diagnoses that included dementia without behavioral disturbance, adult failure to thrive, and chronic pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/22 revealed R1 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). R1 transferred to the hospital on [DATE] and did not return to the facility. Review of the Physician's Order dated 10/10/22 revealed Lidoderm patch apply to low back pain topically in the evening for 12 hours on and 12 hours off. Review of the Medication Administration Record (MAR) revealed the Lidoderm patch was not applied on 10/10/22 (documented as not available), 10/11/22 (documented as not in medication cart), and 10/18/22 without any documentation as to why the patch was not applied. The documentation also reflected R1 did not receive the Lidoderm patch on 10/13/22 and 10/17/22, but biofreeze was applied instead. Review of the Physician's Order dated 9/23/22 and with a start date of 9/25/22, revealed and order for Fentanyl Patch 12 mcg/hr (micrograms per hour), apply one patch transdermally every 72 hours for pain. Review of the MAR revealed the Fentanyl patch was not applied on 10/10/22 because it was not available. Review of the Controlled Medication Records revealed the first Fentanyl prescription of five patches was depleted on 10/7/22. The next order was dated 10/13/22. A Fentanyl patch was not signed out nor administered on 10/10/22. In an interview on 2/9/23 at 9:32 AM, Director of Nursing (DON) B reported the facility did not have Fentanyl patches in the back up medication supply. DON B agreed the documentation showed that R1 did not receive the Fentanyl patch on 10/10/22 and the Lidoderm patch on 10/10/22, 10/11/22, and 10/18/22. The documentation also reflected R1 did not receive the Lidoderm patch on 10/13/22 and 10/17/22, but biofreeze was applied instead. In a telephone interview on 2/9/23 at 12:27 PM, Pharmacy Manager (PM) S reported the pharmacy received an order for Lidoderm patches on 10/10/22, however R1's insurance would not cover the patches. PM S reported the pharmacy notified the facility to change the order to biofreeze gel. PM S reported the pharmacy received a script for Fentanyl patches on 9/23/22 and delivered five patches on 9/23/22. PM S reported the pharmacy did not receive another order for Fentanyl patches until 10/13/22 at which time five more patches were delivered to the facility.