**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that only trained staff paused and restarted enteral feeding (feeding directly into the gastrointestinal tract through a tube) for 1 resident (R102) of 4 residents reviewed for nursing services. Findings include: Review of an admission Record revealed R102 admitted to the facility on [DATE] with pertinent diagnoses which included esophageal cancer and esophageal obstruction. Review of R102's Physician's Orders active 2/4/2025 revealed he received enteral feeding. In a telephone interview on 5/27/2025 at 12:05 PM, former Certified Nursing Assistant (CNA) H reported late the evening of 2/3/2025 or early the morning of 2/4/2025 she provided care to R102. CNA H reported she paused his tube feeding prior to providing care and then restarted the tube feeding after care was completed. In an interview on 12/27/2025 at 12:30 PM, the Director of Nursing (DON) reported CNAs were not trained to pause and restart tube feeding. In a telephone interview on 12/27/2025 at 12:57 PM, Licensed Practical Nurse (LPN) E reported CNAs were not supposed to pause or restart tube feeding. LPN E stated, they are supposed to get the nurse for that. In an interview on 5/27/2025 at 1:24 PM, CNA F reported CNAs were able to pause and restart tube feeding during care and this occurred regularly. CNA F stated, why, are you not able to do that? In an interview on 5/29/2025 at 1:30 PM, the DON reported only trained staff such as licensed nurses and med techs were able to pause and restart tube feeding to prevent complications such as aspiration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00148807 Based on interview and record review, the facility failed to adhere to professional standards for one of three residents (Resident #307) reviewed for medication administration of narcotics. Findings: Resident #307 (R307) Review of an admission Record revealed R307 was a [AGE] year-old male, last admitted to the facility on [DATE], with pertinent diagnoses of seizure disorder, frequent falls, weakness, and unsteadiness on his feet. R307 requires assistance from at least one staff person to get dressed, go to the bathroom, transfer, and bed mobility. Review of a Order Summary for R307 reflected an order for the controlled substance Vimpat (Lacosamide) 50 milligrams (mg) twice daily for seizure disorder. Review of a Control Substance Record for R307 revealed documentation for dates and times the medication Vimpat was given to the resident. The last date and time the medication was given, per this record, was 01/12/25 at 7:00 AM. At that time, the medication had run out and no other Vimpat pills were available to be dispensed. Review of an additional Control Substance Record for R307 showed that the facility received 30 tablets of Vimpat on 01/16/25 and the medication was administered to R307 at 7:00 AM on 01/16/25. Review of an Electronic Medication Administration Record (Emar) for R307 and dated January 2025 reflected that R307 was given one tablet of Vimpat 50 mg the evening of 01/14/25. This dose of Vimpat was not accounted for on either of the above mentioned Control Substance Record for R307. During an interview on 01/16/25 at 10:30 AM, Unit Manager (UM) K reviewed the January 2025 Emar for R307 and checked to see if the medication Vimpat had been available to administer via a back up system. It was determined that the Vimpat was not available in the building to administer to R307 the evening of 01/14/25 and UM K could not explain why the Vimpat was signed out as administered to R307 on the evening of 01/14/25. The Professional Standard of Quality for documentation of the residents health care in a medical record is the information must be true and complete. (Fundamentals of Nursing, Concepts, and Practice. Mosby. [NAME], P.A., [NAME], A.G., 2023)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00148807 Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for one of five residents (Resident #305 and the resident residing in bed 104-A) reviewed for accommodation of needs. Findings: Resident #305 (R305) Review of an admission Record revealed R305 was a [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of dementia, unsteadiness on her feet, cognitive communication deficit, and lack of coordination. R305 required assistance from at least one staff person for transfers, bed mobility, going to the bathroom, and getting cleaned up each day. During an observation on 01/14/25 at 9:46 AM, R305 sat in bed with eyes open and the call light laid on the floor under the bed, out of sight and out of reach of the resident. When asked how she would alert staff if she had any needs, R305 stated that she does everything for herself and would just do it. During an observation on 01/14/25 at 3:40 PM, R305's call light laid on the floor under the bed. During an observation on 01/15/24 at 8:35 AM, R305 laid in bed and the call light remained on the floor under the bed, out of sight and out of reach of of the resident. During an observation on 01/15/25 at 10:01 AM, R305 sat up in a wheelchair in her room, her bed had been made and the call light remained on the floor under the bed out of sight and out of reach of the resident. During an observation on 01/15/25 at 3:05 PM, the resident in bed 104-A laid awake watching television and the call light cord was hooked through the bed frame at the head of the bed and the call light laid on the floor at the head of the bed, out of sight and out of reach of the resident. When asked if she could reach the call light, the resident looked around her bed and stated that she did not know where it was. During an interview on 01/15/25 at 3:10 PM, Certified Nurse Aide (CNA) R stated that all staff are expected to check call light placement each time they enter a room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform a resident assessment, obtain a physician order for the self-administration of a breathing treatment for 1 (R225) of 4 residents reviewed for medication administration, resulting in a resident self-administering a nebulizer treatment without appropriate supervision and assessments. Findings include: Review of a Face Sheet revealed R225 admitted to the facility on [DATE] with pertinent diagnoses of pneumonitis, heart disease, lack of coordination, and blindness in one eye. During an observation on 10/28/24 at 7:49 AM, R225 was in his room starting a breathing treatment when Registered Nurse (RN) Q walked out of his room. RN Q did not assess R225 before his treatment and when she went back to his room when he finished the treatment, she did not do a post assessment. RN Q reported he received Arformoteral (Brovana) which is a nebulizer treatment. Review of the Medication Administration Record (MAR) for R225 revealed an order started on 10/9/24 for Arformoterol Tartrate Inhalation Nebulization Solution 15 MCG/2ML (micrograms/milliliters), inhale orally via nebulizer every 12 hours for COPD (chronic obstructive pulmonary disease), inhale the contents of 1 vial (2mL) via Nebulization BID (twice daily). (sic) In an interview on 10/30/24 at 1:14 PM, Licensed Practical Nurse (LPN) N reported when a resident receives a nebulizer treatment, they are to stay with the residents when they get a breathing treatment. When asked about R225 receiving a breathing treatment with no nurse present, LPN N reported To be honest, we just don't have time. Review of the Electronic Medical Record for R225 revealed there are no orders, assessments, or care plan for self-administration of medications. Review of a policy titled Self-Administration of Medications adopted 7/11/2018 revealed It is the policy of this facility to respect the wishes of alert, competent residents to self-administer prescribed medication choosing to and capable of self-administration. Purpose: To determine the ability of alert residents to participate in self-administration of medications. To maintain the safety and accuracy of medication administration. 2. If a resident, desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change n the resident's status. if the resident is a candidate for self-administration of medications, this will be indicated in the chart. 6. Nursing will be responsible for recording self-administered doses in the resident's medication administration record (MAR). 9. Appropriate notation of these determinations will be placed in the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor and assess the use of psychotropic medications for 1 (R19) of 5 residents reviewed for psychotropic medications. Findings include: Review of a policy titled Psychoactive Drug Use adopted 7/11/2018 revealed Purpose: . To ensure that no drug is used in excessive dose, for an excessive duration, or without adequate monitoring, or without adequate indications for its use. Review of a Face Sheet revealed R19 admitted to the facility on [DATE] with pertinent diagnoses of schizoaffective disorder, bipolar disorder, and post-traumatic stress disorder (PTSD). During an observation and an interview on 10/27/24 at 2:36 PM, R19 was in her room sitting at the edge of her bed alone. When asked general questions about her stay at the facility, she was very tearful and intermittently crying then laughed when asked about the food at the facility. Review of the Care Plan for R19 revealed the resident has a behavior concern r/t (related to) PTSD. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Refer to current physician orders and medication administration records (MAR). Review of a Behavioral Health document dated 10/8/24 for R19 revealed: Plan: 1. D/C (discontinue) Hydrozine (sic) routine and PRN (as needed) orders. 2. Monitor for changes in mood or behaviors for 14 days. Disposition: Behavioral Management Planning; Review of the October 2024 MAR for R19 revealed she is taking the following psychotropic medications: Ambien for insomnia, bupropion for depression, Clozapine for schizophrenia, and hydroxyzine for anxiety. The hydroxyzine was discontinued on 10/8/24. No monitoring for signs and symptoms, side effects, or effectiveness of psychotropic medications is documented. Review of the electronic medical records (EMR) for R19 revealed no monitoring of the psychotropic medications. In an interview on 10/30/24 at 1:26 PM, Licensed Practical Nurse (LPN) N reported R19 does not have documentation in the MAR for monitoring her behaviors or side effects of psychotropic medications and should. LPN N was able to view another resident who is on psychotropic medications and has appropriate monitoring documented to show how R19 should be monitored.

Based on observation, interview, and record review, the facility failed to label and date mark opened medications, dispose of expired medications, and secure a medication cart in 2 of 3 medication carts reviewed, in a total of 5 medication carts and stored personal belongings in 1 of 2 medication rooms reviewed. Findings include: Review of a medication cart on the 100 hall on 10/30/24 at 11:00 AM revealed the following: -Flex Touch 1000 insulin pen, not opened in the cart but is supposed to refrigerated until ready for use. -A vial of Lantus long-acting insulin did not have a label on the bottle with the resident's name or the date it was opened. - 2 bottles of Systane eye drops not labeled on the bottle with the names and dates it was opened. -Polymyxin antibiotic eye drops not labeled with the name and dates it was opened. -Dorzolamide/Timol eye drops had no open date. In an interview on 10/30/24 at 11:00 AM, Registered Nurse (RN) S reported the Flex Touch 1000 insulin pen should not be in the cart and should have been refrigerated because it was not opened. She reported the eye drops, and the insulin vial should have been labeled with the resident's name and the date opened. Review of the medication room on the 100 hall had a large black purse in the room inside a cabinet. When queried, Unit Manager (UM) J reported the purse belonged to a nurse and it should not be stored in the room. Review of a policy titled Medication Access and Storage adopted on 7/11/2018 did not address labeling of medications. The facility provided a copy of the Medication Access and Storage Policy with an Adopted date of 7/11/18 for review. The policy reflected, It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. During an observation and interview on 10/27/24 at approximately 8:50 AM, a medication cart was observed unlocked and there were no nurses in the hall near the cart. A few moments later Licensed Practical Nurse (LPN) N walked out of a resident room (not in view of the medication cart) and returned to the cart. When asked if LPN N forgot to lock the cart while away, LPN N stated, Yes, I should have locked it. During an observation and interview on 10/27/24 at approximately 8:55 AM, a medication treatment cart was observed in the hall unlocked. This surveyor pulled the top drawer open and observed several topical prescription medications in the drawer. There were no nurses noted within view of the cart. Staff were asked who was assigned to the medication treatment cart and they stated LPN O who was seated at the nurses' desk (not in view of the cart). When asked if the medication treatment cart should be locked when unattended, LPN O stated, Yes. LPN O walked over to the cart and locked it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide collaborative hospice care for 2 Residents (R16 and R41) of 2 Residents reviewed for hospice care, resulting in a lack of coordinated care and the potential for care needs to be unmet. Findings included: R16 Review of R16's face sheet dated 10/29/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: multiple sclerosis, encounter for palliative care, and neuromuscular disfunction. R16 was observed in bed on 10/27/24 at 10:10 AM. R16 said she was in hospice care. R16 did not have any schedule in her room that indicated when the hospice staff visited her. R16 was aware the hospice aide came on Wednesdays but said she did not have a set time. R16 did not know when any other hospice staff visited or planned to visit. R16 said the only pain she had was in her left leg. During an interview with facility Social Worker (SW) R on10/29/24 at 9:00 AM, SW R said he does the initial hospice start up and invites hospice to the care conferences. SW R could not locate any documentation that confirmed R16's hospice had participated in her care conferences. R16 did not know when hospice staff visited with R16 or what services they had been providing. Documentation of weekly visits was not located in R16's electronic medical records. An email request for R16's hospice records for the last month was made to the Nursing Home Administrator (NHA) on 10/29/24 at 12:19 PM. Records showing the hospice aide was providing weekly showers was located, however it was not known if the hospice aide was providing other services. Hospice had last provided a copy of their records to the facility on October 16, 2024. R41 Review of R41's face sheet dated 10/29/24 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had diagnoses that included: hemiplegia and hemiparesis (weakness one side of the body), dysphagia (difficulty swallowing) and chronic kidney disease. R41 was observed in bed on 10/27/24 at 10:19 AM, R41 said her pain in her stomach was a 10 out of 10. R41 said she had a pill for pain but wanted more. R41 put on her call light and Registered Nurse (RN) M said R41 was getting Tylenol for pain and R41 was on hospice. RN M said she would check to see what else could be done for R41's pain. RN M did not know when R41's nurse or hospice providers were scheduled to visit. A request of R41's hospice records was made on 10/29/24 at 12:52 PM. The last hospice records in R41's medical record had been faxed to the facility on 9/30/24. During an interview with facility Social Worker (SW) R on10/29/24 at 9:00 AM, SW R said he does the initial hospice start up and invites hospice to the care conferences. SW R could not locate any documentation that confirmed R41's hospice had participated in her care conferences. SW R did not know when hospice staff visited with R41 or what services they had been providing. Documentation of weekly visits was not located in R41's electronic medical records. On 10/29/24 at 2:41 PM the Nursing Home Administrator (NHA) provided the last hospice RN note she could locate on 10/15/24. All other notes were done weekly in the electronic medical record. There was no explanation provided for a hospice nurse not showing or documenting in R41's medical record for over a week. NHA located documentation that R41 was refusing hospice nurse aide services. Review of R41's progress notes revealed a hospice note dated 10/15/24 at 16:00 (4:00 PM), Patient sleeping and does not awaken for visit today. This nurse checks vitals: BP (blood pressure) 122/72, pulse 62, patient does not awaken. Breathing deep and regular rate at 16, lung sound CTA (clear to auscultation). No nausea or vomiting noted today. Coordinated with nurse proper name. Review of progress note dated 10/27/24 at 10:30 AM revealed, Resident complains of stomach pain with a score of 10/10 and nausea, Zofran 4 mg (nausea medication) and Tylenol 325 mg, 2 tablets given by mouth and resident has an emesis o 100 ml stomach content and mucus, however medications not visualized in emesis. Will follow up on effectiveness of medications. No indication of hospice notification of condition change noted. Review of progress noted dated 10/29/24 at 10:28 AM revealed, PA (physician assistant) into see resident, and reviewed KUB (kidney, ureter and bladder) Xray which she stated was negative, resident not very responsive, did shake her head yes when asked if she was nauseated, took am BP (blood pressure) med (medication) and given prn (as needed) Zofran (nausea medication) at 9 am, 10:30 am resident sleeping at this time, call placed to name of hospice service, message left with nurse regarding recent c/o (complaint] of and test that was order and results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer the pneumococcal vaccine to one resident (Resident #29) of 5 residents reviewed for immunizations. Findings include: Review of an admission Record revealed Resident #29 (R29) admitted to the facility on [DATE] with pertinent diagnoses which included heart disease and hypertension. Review of R29's Michigan Care Improvement Registry (a database that consolidates immunization information for individuals in Michigan), dated as reviewed upon admission to the facility on 4/25/2024, revealed R29 was due for the pneumococcal vaccine PCV20 since his admission to the facility. Review of R29's Consent to Administer Pneumococcal Vaccine PCV20 revealed R29 consented to receive PCV20 upon his admission to the facility on 4/24/2024. Review of R29's Electronic Health Record immunization history, active 10/30/2024, revealed R29's pneumococcal status as pending. In an interview on 10/30/2024 at 10:27 AM, the Director of Nursing (DON) reported R29 was due for the pneumococcal vaccine PCV20 when he admitted to the facility on [DATE]. The DON reported the unit manager should have scheduled this to be completed but for some reason this did not occur. The DON was not sure whether the Infection Preventionist had a process to ensure residents were offered pneumococcal vaccines in a timely manner. Review of facility policy/procedure Immunizations-Pneumococcal, reviewed 11/11/2019, revealed .It is the policy of this facility that all residents will be offered the pneumococcal vaccines to aid in preventing pneumonia . Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccines and when indicated, will be offered the vaccinations, unless medically contraindicated or the resident has already been vaccinated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2 Based on interview and record review, the facility failed to implement their water management plan for reducing the risk of legionella and opportunistic pathogens, potentially affecting the entire resident population. Findings include: Review of results from a facility water analysis collected 7/17/2024 and reported on 8/5/2024 revealed the following abnormal results: 1- Hot Post Mixing Valve, 1.0 colony forming units per milliliter (CFU/ml), Legionella species (not pneumophila) 2- room [ROOM NUMBER], Hot sink, 23.5 CFU/ml, Legionella species (not pneumophila) 3- room [ROOM NUMBER], Hot sink, 7.0 CFU/ml, Legionella species (not pneumophila) Review of the facility water management program revealed 10 to 99 CFU/ml in a sample to require remedial action #4, Implement action 3. Cleaning and/or biocide treatment of the equipment is indicated. This level of Legionella represents a moderately high level of concern, since it is approaching levels that may cause outbreaks. It is uncommon for samples to contain number of Legionella that fall in this category. A Control Measures & Corrective Action grid revealed the facility should enhance monitoring when water analysis results are not within normal limits. In an interview on 10/30/2024 at 9:10 AM, Director of Maintenance D reported he discussed the results of the abnormal water analysis with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and Environmental Services Director C but he did not notify Regional Director of Maintenance E of the abnormal results. Director of Maintenance D reported he had not read the entire water management plan and needed to familiarize himself with this. Director of Maintenance D reported resident room sinks were not being flushed prior to the abnormal test results and the facility began having housekeeping staff run water in the sinks every day during routine cleaning as a response to the abnormal testing. Director of Maintenance D reported the facility did not send a repeat analysis or otherwise enhance monitoring as the water management plan indicated. Director of Maintenance D reported the water is analyzed quarterly and is due to be tested again soon. Regional Director of Maintenance E reported he had not been notified that the facility had an abnormal water analysis. In an interview on 10/30/2024 at 10:09 AM, Environment Services Director C reported housekeeping staff began flushing sinks in resident rooms during daily room cleaning when Director of Maintenance D discussed the abnormal water analysis with her, but staff did not document this action. In an interview on 10/30/2024 at 11:35 AM, Housekeeper G reported she had worked at the facility for 2.5 months and had not been taught to flush sinks in resident rooms. Housekeeper G reported she cleaned the sinks with a disinfectant but did not run the water for any amount of time. Review of a policy titled Changing IV Administration Set last revised 2/2019 revealed: Purpose: To provide guidance regarding specific intervals administration sets and tubing will be changed in order to prevent infections associated with IV therapy equipment. 6. Label all tubing with start and change date and time. Change and then label accordingly any tubing that is observed not to have a label. 7. Apply a sterile end cap to the end of primary tubing when it is disconnected from the catheter. Discard the sterile end cap when tubing is reconnected to catheter. 8. IV fluid bags shall be changed every 24 hours. 9. Label IV tubing indicating the date and time started and nurse's initials. Review of a policy titled Intermittent Infusion last revised 12/2014 revealed: Administration sets used for intermittent therapy will be changed every 24 hours or per facility policy. 4. Administration sets used for more than one dose in a 24-hour period will have a new sterile end cap placed on the end of the administration set upon completion of each dose. 5. The practice of attaching the exposed end of the administration set to an injection port on the same set (looping) should be avoided. R225 Review of a Face Sheet revealed R225 admitted to the facility on [DATE] with pertinent diagnoses of pneumonitis, heart disease, lack of coordination, and blindness in one eye. During an observation and an interview on 10/28/24 at 7:49 AM, Registered Nurse (RN) Q was observed starting an intravenous antibiotic (IV) for R225 by removing an undated tubing from the previous antibiotic bag that was hanging on the IV pole and spiking the antibiotic (50 milliliters (ml) of 2 grams Cefepime). When queried about the tubing not being dated, RN Q and was told in report the tubing was new from last night. During an observation and an interview on 10/28/24 at 8:24 AM, RN Q disconnected the IV antibiotic tubing from R225 when it was finished infusing from his PICC (peripherally inserted central catheter) and attached the end of the tubing to a port on the IV line that was hanging on the pole without any disinfecting of the port. When queried why the nurse attached the end of the tubing like that to the port and not disinfect it, RN Q reported they did not have much tubing and didn't have an answer as to why she didn't clean the port. This citation has 2 separate Deficient Practice Statements (DPS) #1 and #2. DPS #1 Based on observation, interview and record review the facility failed to ensure Enhanced Barrier Precautions (EBP) and Contact-Based Precautions were implemented for three residents (R23, R68 and R69) of 80 residents reviewed for infection control and follow policies and procedures for IV (intravenous) administration for 1 (R225) of 1 resident reviewed for IV antibiotics. Findings include: R23 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R23 admitted to the facility on [DATE] with diagnosis of (but not limited to) wound infection, pressure ulcer, diabetes and peripheral vascular disease. Brief Interview for Mental Status (BIMS) reflected a score of 12 out of 15 which represented R23 was cognitively intact. R23 required extensive staff assistance of 1-2 with all activities of daily living. The sign on R23's door reflected Enhanced Barrier Precautions and instructed staff and providers to wear gloves and a gown when caring for devices such as central line, urinary catheter, feeding tube, tracheostomy. On 10/27/24 at approximately 3:30 PM, LPN N and RN M were about to enter R23's room when asked about the care R23 would be provided. RN M stated she was going to discontinue the PICC (peripherally inserted central catheter). When asked if this Surveyor could observe the care, RN M stated, Yes. Both nurses entered the room with only gloves on (no gowns as the sign indicated) and walked up next to R23 who was seated in a wheelchair in his room. This Surveyor asked R23 if it would be okay if this Surveyor observed the staff with his care and he stated, No. This Surveyor exited the room and waited just outside the door until the two nurses exited the room. While reviewing the sign on R23's door with RN M the Surveyor asked if she had donned a gown before discontinuing the PICC and RN M stated, No but after re-reading this sign, I should have. The facility provided a copy of the MDS Resident Matrix with a print date of 10/28/24 at 7:56 AM for review. The Matrix reflected that R68 and R69 were in transmission-based precautions. On 10/27/24 at approximately 3:00 PM, this Surveyor observed all rooms and infection control signs on the residents' doors. R68 and R69 both had signs on the door indicating the need for Enhanced Barrier Precautions. In a subsequent observation on 10/30/24 at 9:08 AM, the sign was changed to Contact Precautions. The change in precautions reflected that all providers and staff that enter the room must always wear gloves and gowns upon entry to the room. Additionally, the sign reflected, Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another. R68 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R68 admitted to the facility on [DATE] with diagnosis of (but not limited to) wound infection to stage 4 pressure ulcer, (vancomycin-resistant enterococcus) and paraplegia (unable to move lower half of body). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represented R68 was cognitively intact. R68 required extensive staff assistance of 1-2 with all activities of daily living. According to the physician order dated 10/29/24 reflected, Contact Precautions for osteomyelitis left hip . Despite R68 being admitted on [DATE] and placed on Enhanced Barrier Precautions, transmission-based precautions of Contact Precautions were not implemented until the physician ordered it on 10/29/24 (over 6 weeks after admission). R69 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R69 admitted to the facility on [DATE] with diagnosis of (but not limited to) sepsis (infection), diabetes, and gangrene. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represented R69 was cognitively intact. R69 required extensive staff assistance of 1-2 with all activities of daily living. According to a progress note dated 10/7/24 reflected, HOSPITAL COURSE: (Name of R69) is a [AGE] year-old female presented to the acute hospital with septic shock and was found to have MSSA (Methicillin-Sensitive Staphylococcus Aureus) bacteremia involving multiple sites . According to the physician order dated 10/29/24 reflected, Contact Precautions for sepsis. Despite the R69 being admitted on [DATE] and placed on Enhanced Barrier Precautions, transmission-based precautions of Contact Precautions were not implemented until the physician ordered it on 10/29/24 (25 days after admission).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure care planned interventions were in place to prevent the worsening of contractures for 1 resident (Resident #11), out of 2 residents reviewed for limited mobility, resulting in the potential for avoidable worsening of contractures. Findings: Resident #11 Review of an admission Record reflected R11 admitted to the facility with diagnosis that included hemiplegia and hemiparesis following cerebral infarct (paralysis and weakness on one side of the body following a stroke), dystonia (abnormal muscle tone and abnormal posture), aphagia (difficulty speaking or understanding other people speaking), contracture (shortening and hardening of the muscles, tendons or other tissues often leading to the deformity and rigidity of joints) of the left elbow, left hip and left ankle. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected that from the time R11 admitted to the facility, R11 was dependent on staff for upper and lower body dressing. Review of a Care Plan initiated 12/15/2011 reflected R11 needs assistance with Activities of Daily Living (ADLs) related to weakness and decreased mobility secondary to history of CVA (Cerebral Vascular Accident) with resulting left sided hemiparesis. An intervention to meet the goal of receiving ADL assistance was added to the care plan on 5/15/2018 and revised on 7/7/2023 that specified Restorative Splint/Brace: Apply left arm and left-hand splint with AM (morning) care, remove after lunch or upon (R11's) request. As tolerated. During an interview on 10/22/23 at 2:30 PM, R11's Durable Power of Attorney (DPOA) F reported that staff do not apply R11's splints regularly. DPOA F said that R11 had a splint for her left hand and another for the left elbow and tolerated the splints when applied. During the interview, R11 was not wearing the splints which were observed on a shelf next to R11's bed. During an observation on 10/23/23 at 10:58 AM, R11 did not have splints in place, they were on the shelf next to the bed. During an observation on 10/23/23 at 12:50 PM, Resident #11 did not have splints in place, they were on the shelf next to the bed. During an observation and follow-up interview on 10/23/23 at 3:50 PM, R11 did not have splints in place. DPOA F was at R11's bedside and reported that he does not think this is his job to apply them. During an observation on 10/24/23 at 7:50 AM, R11 did not have her splints in place. During an observation on 10/24/23 at 9:29 AM, R11 did not have her splints in place. Review of the October 2023 Treatment Administration Record (TAR) reflected an order Restorative Splint/Brace: Apply left arm and hand splint with AM care, remove after lunch or upon (R11's) request as tolerated every shift for DX:169.134. A check mark in the boxes for the days R11 was observed in the morning hours (10/23/23 and 10/24/23), indicated that the splints were in place, when in fact the splints were not. The evening documentation reflected blanks and some evidence R11 had refused the splints as evidenced by the number 10 noted in the date fields, which meant refused.

Based on observation and interview, the facility failed to keep essential kitchen equipment in a state of repair that would allow for the machine's operational requirements to be met. This deficient practice has the potential to increase the risk of contamination to items sanitized by the dish machine. During a tour of the kitchen, at 9:25 AM on 10/22/23, observation of the dish machine found that it would only achieve five pounds per square inch (psi) for the final rinse pressure. An interview with Dietary Aide E found that a vendor comes out to check and set up the chemicals but doesn't think anyone regularly services the dish machine. Over the course of running the dish machine another three loads, all observed rinse pressures would show five psi when engaged. A review of the dish machines data plate found that it requires 20 psi +/- 5 psi. During a revisit to the kitchen, at 10:15 AM on 10/22/23, an interview with Maintenance Director D, found that the rinse gauge was not working properly, but the gauge on the underside of the dish machine showed proper temperature and rinse pressure. Observation of the gauge on the underside found that the rinse pressure would also drop to 5-10 psi when the sanitizing rinse was engaged. During a revisit to the kitchen, at 11:25 AM 10/22/23, an interview with Maintenance Director D found that the top spray wand in the dish machine was found with a bearing that needed repair. The bearing was allowing water to leak out of the sides of the spray arm, decreasing the psi during the final sanitizing rinse. Maintenance Director D stated he would get the needed parts and get it fixed tomorrow. According to the 2017 FDA Food Code section 4-501.113 Mechanical Warewashing Equipment, Sanitization Pressure. 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 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure updated and accurate advance directive information was in place for 2 residents (R49 and R63) reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings Include: R49 Review of face sheet for R49 revealed they initially admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnosis that included: acquired absence of left leg, Diabetes Mellitus Type 2, cognitive communication deficit, and chronic kidney disease. Further review of R 44's electronic medical record revealed he was not his own responsible party and was listed as DNR (Do not resuscitate). Review of R49's electronic medical records (EMR) revealed a form Resident Incapacity To Give Informed Consent and To Exercise Resident Rights and it was signed by one physician, on [DATE] stating that R49 lacked the ability to make medical decisions. There was not a second physician signature. Further review of documents revealed R49 had signed his own Advanced Directives document and Do-Not-Resuscitate Order on [DATE]. A request for electronic copies of these documents was requested and the DON (director of nursing) responded on [DATE] at 8:28 AM with the same documents. On [DATE] at 12:16 PM during an interview with R49's DPOA they stated they visit R49 almost every day. On [DATE] at 02:42 PM an interview was completed with social worker (SW) S. SW S confirmed the DPOA is activated for R49. SW S looked in R49's EMR and also could not find s second physician signature for incapacity. SW S left the room briefly and came back and stated that he requested medical records look for the completed form. SW S was asked why the DPOA had not reviewed and signed the DNR and advanced directive forms. SW S stated they were new to long term and did not know when there is change in resident mental status that the DNR should be re-signed. SW S stated the DPOA of R49 comes in regularly, and they could easily complete the new forms. On [DATE] at 8:28 AM an email was sent to the DON and NHA stating, I spoke with your social worker yesterday afternoon regarding these documents, they are trying to locate a copy of the incompetency determination with two signatures, because there is only a form with one signature on the EMR and in what you sent me. He also stated he would also work on getting the resident's advanced directive signed by the DPOA. All these documents don't coordinate with one another. Per face sheet the resident does have the DPOA activated. On [DATE] at 9:10 AM an interview was completed with the DON regarding R49's incapacity paperwork. The DON stated they had two physicians complete the incapacity but they were not signed on the same form, they will be completing the incapacity form so two physicians are on together. On [DATE] at 12:59 PM an email was sent to the DON reiterating a continued concern that the DPOA had not signed the advanced directive paperwork. R63 A review of R63's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated [DATE], revealed R63 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included a stroke and traumatic brain injury (TBI). In addition, R63's MDS revealed he had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 6 which revealed R63 was severely cognitively impaired. A review of R63's hospital Palliative Medicine Physician Progress Notes, dated [DATE], revealed Physician (MD) KK examined R63 and documented Patient (R63) currently is not informed or aware of their condition(s), proposed treatments and the nature of the decisions before them. The patient does not understand the natural course of the current medical condition. The patient does not understand their options and the risk/benefits of all their choices, including the option to forgo treatment. The patient cannot weigh these options out, exhibit logical decision process and arrive at a cogent decision. The patient does not maintain consistency/durability in this decision or decision process. I have assessed this patient in addition to the patient's attending physician and after my evaluation/examination I agree w/ the primary attending's assessment that the patient is no longer capable of participating in the medical treatment decision-making process. In my opinion, this patient is cognitively impaired and it is in their best interest to activate a DURABLE POWER OF ATTORNEY for health care decisions at this time or pursue guardianship immediately. A review of R63's hospital Internal Medicine Physician Progress Notes, dated [DATE], revealed MD JJ examined and assessed R63 3 days in a row. Patient (R63) is not able to indicate that he understands or is aware of his current medical conditions, does not understand the prognosis and is not able to engage in making any decisions regarding his care. He has significant cognitive impairment and I see nothing to indicate that this will improve enough to render him appropriate for making his own decisions. I recommend activation of DURABLE POWER OF ATTORNEY for health care decisions at this time and pursue guardianship. A review of R63's Advanced Directive form, dated [DATE], revealed R63 appointed Patient Advocate (PA) LL as his patient advocate and authorized her to make medical decisions on his behalf if he should become incapacitated/unable to make medical decisions. However, R63 signed this form during the time that MD JJ was examining and assessing R63 for his ability to make medical decisions ([DATE] to [DATE]) and had found R63 unable to make medical decisions (which would include appointing a patient advocate and/or a durable power of attorney (DPOA) on [DATE]). A review of R63's Advanced Directives, signed [DATE] (one day before admission to the facility) by PA LL and witnessed by two witnesses on [DATE] (the day of admission), revealed PA LL decided that R63's code status was Full Code (cardiopulmonary resuscitation (CPR)) in the event that R63's heart and/or breathing stopped. During an interview on [DATE] at 10:48 AM with Social Worker (SW) S and Unit Manager (UM) T, SW S deferred to UM T for answers to the surveyor's questions regarding R63. UM T stated the advanced directive paperwork is included in the admission packet that the nurses complete when a resident is admitted to the facility. She stated if a resident comes in unable to make medical decisions, they review the DPOA paperwork to see who was appointed. UM T further stated that because R63's inability to make medical decisions was signed by two physicians at the hospital (MD JJ and MD KK in their progress notes), it was acceptable to use that instead of having their physician evaluate R63 for ability to make medical decisions. UM T also stated they did not question R63's Advanced Directive form, dated [DATE], that indicated R63 appointed PA LL as his patient advocate even though it was signed while MD JJ was actively evaluating and assessing R63 for his ability to make medical decisions. UM T stated they did not question R63's Advanced Directive form appointing PA LL as his patient advocate because it was signed the day before MD KK and two days before MD JJ officially declared R63 unable to make medical decisions. UM T also stated that since two hospital physicians had declared R63 unable to make medical decisions before R63's admission to the facility, there was not any need for the facility physician(s) to re-evaluate R63's ability to make medical decisions during his stay at the facility. SW S stated he had nothing to add to UM T's statement and verbally agreed with everything UM T stated. A review of R63's Quarterly MDS, dated [DATE], revealed R63 had a BIMS score of 14 which revealed R63 was cognitively intact. However since R63 was currently cognitively intact, and was severely cognitively impaired on admission, the facility had made no effort to re-assess R63's ability to make medical decisions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI000129873 Based on interview and record review, the facility failed to prevent the mistreatment of 1 resident (Resident #70) when a staff member failed to meet the resident need prior to turning off a call light and leaving the room. This deficient practice resulted in neglect and the feeling of frustration. Findings: Review of a facility policy Abuse and Neglect last revised 6/17/2019 reflected It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. The policy specified Neglect is the failure to provide necessary and adequate (medical, personal or psychological) care. Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional. Examples of neglect included Lack of toileting or changing disposable briefs which causes incontinence and results in resident sitting or lying in urine or feces. The policy went on to highlight Resident perceptions of abuse and/or neglect including Being ignored or minimized Staff not following through on commitments or promises .Staff not responding quickly when assistance is necessary, including poor response to call lights. Resident #70 (R70) Review of a facility admission Record reflected R70 admitted to the facility with diagnoses that included myoneural disorder (lower motor neuron disease-lead to weakness, muscle atrophy, spasms, nerve pain etc.), alcohol dependence, peripheral vascular disease, chronic pain, constipation, inguinal hernia, high blood pressure and radiculopathy. A Minimum Data Set (MDS) assessment dated [DATE] reflected R70 was cognitively intact and needed extensive assistance from two people for bed mobility, transfers, dressing, personal hygiene and toilet use. During an interview and observation on 8/8/22 at 1:00 PM, R70 was seated in his chair in his room and was finishing up lunch. R70 recalled an incident where a Certified Nurse Aide (CNA A) was nasty and rude to him and did not assist him with getting cleaned up after being incontinent of bowels. According to R70 the incident made him feel angry and disrespected. Review of a Facility Reported Incident (FRI) reflected On 7/13/2022 (R70) reported that at approximately 12pm he had a BM (bowel movement). He pressed his call light, and (CNA A) answered it. R70 told CNA A he needed to be cleaned up. CNA A responded, They better get it together because I'm not going to do it. She turned off the call light without answering his needs and left the room. Another staff member assisted (R70) upon request. (R70) reported the incident to his nurse who immediately notified the Director of Nursing (DON). Further review of the FRI reflected the following conclusion After thorough investigation the facility had determined that the allegation of mistreatment can be substantiated .(CNA A) was interviewed and admitted to answering the call light and having a conversation with (R70) about his bowel medications but denied being told that he needed to be changed. (CNA A) stated that she thought (R70) needed to speak with a nurse and admits to turning off the call light and never reporting to the nurse because she was too busy providing care to her other residents however; when this incident was reported facility Administrator was initially unable to locate (CNA A) on her clinical floor and found her to be socializing in a manager office on the opposite end of the building .Statements from the coworker who assisted (R70) in getting cleaned up supports (R70's) allegation . Review of a staff statement dated 7/14/22 reflected that Licensed Practical Nurse (LPN) CC was rounding on her residents on 7/13/22 and was notified by (R70) that he needed to speak to a manager because his aide (CNA A) wheeled him in his room and left him soiled after he asked for assistance. (R70) stated that his aide told him They better figure it out and left the room. While talking to me I observed his pants saturated and he was visibly upset demanding to speak to the DON if the manager was unavailable. I asked him if he would like me to provide brief change at that time, but he refused, cussing and demanding that I notify my DON immediately. I then left the room and notified (DON). When I returned to the room to let him know she would be down to talk to him, he was calmer and allowed another CNA to provide brief change. Review of a staff statement dated 7/15/22 (two days after the incident) reflected CNA A was interviewed by the DON and the Nursing Home Administrator (NHA) via telephone. According to CNA A, she responded to R70's call light and R70 stated his bowel meds are making him go. (CNA A) suggested he speak with the nurse about adjusting the meds. (R70) agreed. (CNA A) turned off call light. (CNA A) states she was unaware (R70) was incontinent and admits to not asking him. (R70) did not asked to be changed and (CNA A) did not ask him if he needed to be changed. (CNA A) did not see the nurse as she was busy caring for other residents so was unable to notify nurse. Review of a statement documented by the NHA dated 7/15/22 reflected On 7/13/22 DON and facility administrator were notified of a care concern involving (R70) and his assigned (CNA A). I (the NHA) could not initially locate (CNA A) on the clinical floor or anywhere on her assigned unit. I remembered that our BOM (business office manager) and (CNA A) talked outside of work so I went to the BOM office and found (CNA A) visiting with the BOM with the door closed. Review of a statement obtained by the DON from the BOM was signed 8/10/22 and reflected On 7/13/22 (CNA A) was in my office sitting down and talking with me and (NHA) came in and told her she needed to speak with her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake M100124418. Based on interview and record review, the facility failed to prevent misappropriation of property for 1 (Resident #40), resulting in a missing ring that had an irreplaceable sentimental value that caused psychosocial distress. Findings include: Resident #40 (R40) Review of the Face Sheet revealed R40 admitted to the facility on [DATE] with pertinent diagnosis of dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) revealed R40 had a Brief Interview for Mental Status (BIMS) indicating she is moderately cognitively impaired. Review of a Facility Reported Incident (FRI) revealed on 10/31/21 at 4:38 PM, the facility Administrator was notified of an incident for a potential misappropriation of property when R40 reported her ring was missing. The police were contacted on 11/2/21 at 8:30 AM. The State Agency was notified on 11/1/21 and the final report was submitted on 11/8/21. The Nursing Home Administrator (NHA) who conducted the investigation is no longer at the facility. The report revealed the resident saw her ring the night before when she placed it on top of the lock box in her nightstand. When questioned by the NHA if she was sure the ring was missing that night, the resident replied no. R40 reported a staff member whom she described but did not know her name admired her ring and commented how pretty the ring was when R40 was cleaning her top drawer that had the ring inside of it. R40 reported that staff member worked the night shift but did not see anyone take her ring out of the drawer. The facility did a room sweep which turned up no findings. Staff interviews were done, and some staff reported the resident did have a ring but also had a few room changes. The facility concluded that misappropriation could not be substantiated at that time and did not result in harm, pain, or mental anguish. There is no documentation indicating that a sweep or audits of other residents potentially missing items were done, and staff education was not completed. In an interview on 8/10/22 at 12:07, R40 was sitting in a chair in her room and recalled many memories associated with the gold band that came up missing in her room on 10/31/21. R40 reported this ring had special and personal memories and would always put the ring on top of her lock box in her top drawer at bedtime. R40 reported she thinks she knows which Certified Nursing Assistant (CNA) took the ring but could not remember her name and did not want to implicate her. R40 reported this CNA still works there at the facility and comes in her room. R40 did not want to single this CNA out because she did not personally see her take the ring but recalled that night when she was placing the ring on top of her lock box, the CNA commented on how beautiful the ring was and the next day it came up missing. R40 did not recall the police coming to the facility or talking to them. R40 was tearful while reminiscing the memories this ring represented that were dear to her. R40 reported she cried for days after the ring came up missing because of the sentimental value and said she had the ring since she was [AGE] years old. R40 repeated how beautiful the ring was and that God will hold that person accountable. R40 reported she did not get reimbursed for the ring and felt that a new ring could not replace the sentimental attachment to the ring that was missing. The resident was able to reiterate the same incident as reported in 10/31/21. Review of the Electronic Medical Record (EMR) for R40 revealed no form accounting for the residents' belongings at the facility. Review of the Police Report revealed they were notified on 11/2/21 at 9:26 AM via phone. The facility told the police that it is unclear if the event is factual or not and the NHA requested only a report number for their records. The NHA told the police that they could not confirm a ring had been in R40's possession during her stay at the facility. The police did not go to the facility or interview the resident or staff. Review of a Social Services Progress Noted dated 10/26/21 for R40 revealed she had no behaviors. Review of the Social Services Progress Note dated 11/3/21 revealed she expressed sad feelings about her missing ring and was reminded of the ongoing investigation. On 11/4/21 Spoke about her missing ring, however when asked is she felt safe at the facility the resident stated, I like this place very much. (sic) In an interview on 8/11/22 at 8:42 AM, the Director of Nursing (DON) and the current NHA confirmed the police were notified on 11/2/21 of the missing ring. The DON reported the resident will misplace things frequently and will usually find things when they search the room. The NHA reported when an incident of misappropriation occurs, the facility is to report it to the State Agency, then do a reeducation to staff on abuse policies, and interview like residents for missing items. The NHA confirmed an audit of like residents was not done and staff education was not done to potentially aid in the future prevention of misappropriation. Review of a policy titled Abuse and Neglect last revised 6/17/19 revealed: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegations of injuries of unknown origin, potential abuse, neglect and exploitation to the state survey agency for 2 residents (R72 and R275) reviewed for abuse, resulting in allegations of abuse and neglect not being reported to the state survey agency and the potential for residents to not be protected from abusive individuals. Findings include: R72 Review of face sheet for R72 revealed they initially admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnosis that included: hemiplegia and hemiparesis (one sided weakness and paralysis), aphasia following cerebral infarction (inability to understand or express speech caused by brain damage), contracture of left elbow, left hip, and ankle, anxiety, depression, convulsions, epilepsy and chronic pain. She is not her own responsible party. Her last quarterly MDS (minimum data set) assessment on [DATE] revealed a BIMS (brief interview for mental status) score of 0/15 indicating severe cognitive impairment. She required extensive assistance to total dependence of one person physical assist on a majority of her activities of daily living. On her [DATE] readmission MDS assessment a BIMS was not completed due to the resident was unable to complete Brief Interview for Mental Status and staff assessed her as having okay short and long term memory and with modified independence on daily decision making despite her previous score of 0/15 on the [DATE] assessment. Review of facility provided incident with a date of [DATE] revealed resident husband said her R ankle appears swollen .resident facial expression would change upon touching R ankle and appeared to be in pain. Resident shook head yes when asked if was during a transfer. The incident had one staff witness listed. The interview or interviews were not provided in the document provided by the facility. Review of progress notes revealed that on [DATE] at 4:59 PM, Physician Assistant (PA) DD entered a progress note with a review of the resident for right foot pain and bruising. Will re-xray the right foot, had recent xray when foot appeared swollen, no documented trauma. Xray negative for fracture, but did recommend repeat or CT(diagnostic scan) if sx (symptoms) persist. Now with ecchymosis (discoloration of the skin) as well, will monitor closely, cont (continue) norco (opiod pain reliever) for pain. Stat (immediate) 2 view xray r/o (rule out) fracture. Review of a facility provided Risk Management Report with a date of event [DATE] regarding R72 revealed On [DATE] [R72] was sent to the hospital for uncontrolled abd (abdominal) pain and shortness of breath requiring oxygen. She was presumed + for Covid .Hospital called on 6/23 reporting a fracture of her left femur. Resident complaining of increased abd pain on 6/23 so facility performed stat imaging of chest, abdomen, left hip, pelvis, and left knee which were all neg for fracture or dislocation .[R72]'s husband, reported that while in the hospital they stated that her bones are like glass and even normal re-positioning in the bed could cause a fracture .[R72] did not sustain any injury or have any falls while at the facility. On 6/21 she was unable to maintain truncal support while in the shower chair requiring staff members to quickly transfer her. This was witnessed with a statement obtained by her husband who has no concerns with the transfer or the facility causing injury. In the section reported to the appropriate state agencies, NO is written as the answer. The facility response section revealed: The facility completed an investigation into the event. A risk was completed in PCC (electronic medical record) along with statements from staff who participated in the transfer as well as the spouse who is not concerned with the facility causing this injury .care plan was being followed- This was not due to abuse, neglect or mistreatment. An attached incident report referred to an incident in the shower on [DATE] where R72 was unable to maintain truncal control in the shower chair. Per 3 staff and R72's DPOA interviews, R72 was showing no signs or symptoms of distress or pain after being returned to bed. Review of facility provided progress notes revealed that on [DATE] at 1:00 PM, Physician Assistant (PA) DD entered a progress note regarding R72: Patient is seen for acute hypoxemia and respiratory distress last evening .An x-ray of the left lower extremity was also done today due to severe pain. This showed no fracture or dislocation . Review of hospital discharge paperwork for R72 with admission date [DATE] revealed a history of present illness: presents today with severe left hip pain following slide off chair in the shower 2 days prior at long-term care facility. At baseline patient answers yes or no due to history of hemorrhagic stroke .since the fall, patient has had severe pain with any transfers . A CT scan revealed: There is a new acute or subacute left hip subcapital fracture . On [DATE] at 03:36 PM a face to face visit was completed with R72 in their room. They were viewed to be awake and laying in bed. Several attempts to interview R72 were made and R72 stared blankly forward. R72 tracked movement with her eyes but did not give any verbal noises and did not give any meaningful gestures or movements such as blinking or head nods with interaction. During an interview with R72's DPOA (durable power of attorney) on [DATE] at 4:00 PM he stated that R72 is not very communicative and at times it can be hard for him to get any limited verbal responses or head nods from R72. He stated it has been that way for quite a while. R72's DPOA stated that R72 had recently suffered an injury where the top of their femur was fractured. He stated that R72's bones are quite fragile and the injury happened when the resident started to slide out of a shower chair. R72's DPOA stated they were there when the shower incident occurred and that R72 did not fall out of the chair, they just could not maintain balance and had to be transferred back to their room, the resident had some pain after the incident and transferred to the hospital where they found the femur was fractured. R72's DPOA stated the resident is pretty much bed bound because of weakness. R72's DPOA stated there was a previous ankle injury that the resident sustained but he was not sure how that happened. An email was received from the DON (Director or Nursing) on [DATE] at 8:25 AM in reference to R72: This resident has extremely fragile bones with a Dx (diagnoses) of osteopenia and osteoporosis along with history of fractures. The incident in February [R72] had a bruise to her foot with swelling. She could confirm that this occurred during a transfer and that she was not mistreated. The CNA felt that she likely bumped her foot on the mechanically lift during a transfer as her legs are difficult to maneuver with her contractures. She was evaluated right away. Her pain was assessed and we ordered stat x-rays. X-rays were normal and her comfort was monitored closely. Notifications were made and there were no concerns of mistreatment from her husband who is here daily. I reprinted the information with more details on the most recent incident with witness statements. During an interview on [DATE] at 09:10 AM with the DON (Director of Nursing), R72's ankle injury and femur fracture were discussed. The DON stated they did not report either injury to the state. The DON stated R72 had some swelling and bruising on their ankle and they think that the ankle injury was due to hoyer lift. The DON stated they were sure this is how it happed since they got witness statements, and the resident denied abuse. The DON stated R72 could confirm that this occurred during a transfer and that she was not mistreated. The CNA staff who recently cared for her felt that she likely bumped her foot on the mechanically lift during a transfer as her legs are difficult to maneuver with her contractures. She was evaluated right away. Her pain was assessed and we ordered stat x-rays. X-rays were normal and her comfort was monitored closely. Notifications were made and there were no concerns of mistreatment from her husband who is here daily. For the leg injury, R72 had an x-ray after slip in the shower incident and the xray was clear, but then after transfer to the hospital, a fracture was found. The DON stated R72 had very brittle bones and the fracture was found to be pathological due to her bone weakness and could have even occurred during the transferred by EMS (emergency medical services) as well. The DON stated interviews done with staff, the resident and her husband (DPOA). They did not report the incidences because the resident shook her head no that she was not harmed by anyone. It was discussed with the DON that R72 was not her own responsible party and had limited communication. It was also discussed that brittle bones prone to fracture does not eliminate the possibility that an abusive or neglectful action caused an injury when the time and mode of injury was not definitive. The DON was asked for all documents regarding the R72's injuries and informed due to not having a definitive cause for the injuries, the incidences should have been reported to the state agency and a full investigation submitted. During a follow-up interview on [DATE] at 10:37 AM, the DON reported that on [DATE] R72's husband reported bruising and swelling to R72's ankle. An x-ray was ordered that did not show a fracture and a brief investigation into the injury identified CNA GG reported she thought she may have bumped R72's foot on the Hoyer lift during a transfer causing the injury. No additional staff statements were obtained and it was not clear if the transfer had been completed with a second person as would be required and additional witness statements to support that the care plan was followed were noted. During the interview Regional Nurse HH confirmed that R72 was diagnosed with osteoporosis and osteopenia on [DATE] and that while R72 was not able to participate in a BIMS assessment, a staff assessment on of R72's cognition reflected her short- and long-term memory were intact according to the MDS dated [DATE]. The DON reported that R72 was sent to the hospital on [DATE] due to respiratory distress and complaints of abdominal pain with a history of ileus (interruption of intestinal movement). A stat (right away) x-ray of R72's left side was obtained and the results were not received by the facility prior to R72 being sent to the hospital. The hospital called the nurse on duty to report R72 had been diagnosed with a hip fracture. The DON and NHA were both informed of R72's hip fracture at around the same time and according to the DON a Risk report was initiated to try an identify if anything could have caused R72's fracture. The DON and NHA reported they did not report the hip fracture to the state agency due to their belief the hip fracture was likely sustained during the shower incident on [DATE] and was therefore not an injury of unknown origin and the hospital records clearly identified that the fracture was as the result of the fall in the shower on [DATE]. The DON confirmed that witness statements were not gathered from staff who worked with R72 after the shower incident on [DATE] and before R72's transfer to the hospital on [DATE]. According to the DON, the x-ray that was taken in the facility prior to R72's transfer to the hospital were obtained via email several days after [DATE] due to a problem with the electronic health system and were all negative for fracture. Review of facility policy with the subject Abuse and Neglect with the most recently revised date of [DATE] revealed: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Signs and symptoms of suspected abuse/neglect include: Suspicious history, description of the injury is inconsistent with physical findings. Unexplained injuries, old injuries never treated properly, incongruent history. if abuse/neglect is suspected the facility will: Notify the appropriate/designated organization/authority (State Agencies) that an investigation is being initiated immediately following intervention for the resident's safety .Conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses . Report the investigation findings to the appropriate State Agencies, as required by law. Under the section Identification the facility should have procedures to Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation . An injury should be classified as an injury of unknown source when both of the following conditions are met: a. The source of injury was not observed by any person or the source of injury could not be explained by the resident; and b. The injury is suspicious because of the extent of the injury or the location of the injury (example: the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at a particular point in time or the incidence over time. Under the section Investigation: Investigate all allegations of abuse, neglect, misappropriation of property and incidents such as injuries of unknown source. All allegations will be investigated by the Administrator or Designee immediately. A review of Resident Rights policy and procedure related to Photographing and Video Recording last revised [DATE]. Policy: It is the policy of this facility to adhere to CMS regulations regarding photographing and video recording of residents to prevent abuse and violation of resident's privacy and confidentiality. Procedure: 1. No photographs or recordings of a resident and/or his/her private space without the resident's, or designated representative's, written consent will be taken. this will include resident's images taken using any type of equipment, including but not limited to camera, smartphones, and other electronic devices. 3. If a photograph or recording of a resident, or the manner that it is used, demeans or humiliates a resident(s), regardless of whether the resident provided consent and regardless of their resident's cognitive status, this will be considered as an allegation of abuse. This would include, but is not limited to: . showing a body part without the resident's face whether it is the chest, limbs, or back . Showing the resident in a compromised position . 5. When abuse is alleged, all abuse procedure will be put into action by the facility as per the abuse policy. Review of a facility Resident Rights policy and procedure related to Abuse and Neglect last revised [DATE] reflected definitions, policies and procedures consistent with CFR 483.12 Freedom from Abuse, Neglect, and Exploitation regulatory groups for Long Term Care Facilities. Resident #275 (R275) Review of R275's Face Sheet reflected that she was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included systemic Lupus, Sarcoidosis of the lung, Sepsis, Hypertensive Heart and Chronic Kidney Disease and Heart Failure, Bipolar Disorder, and Chronic Diastolic Congestive Heart Failure. Review of a Minimum Data Set (MDS) admission assessment reflected R275 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15/15. Two complaints involving an incident with R275 were reviewed. A description of an event/incident that happened on [DATE] coincided with Resident #275's medical record. Pictures of R275 were posted on Facebook, by another Resident, Resident #75's (R75's) Family Members. Including allegations of poor care being provided to the residents in the facility. On [DATE] at 1:40 PM, DON was asked for all incident reports, accident and concern forms regarding R275. DON stated she would get the information. During an Interview on [DATE] at 2:50 PM, DON revealed that they did not have any incidents, accident or concern forms regarding (Name of Resident) R275. However, a Risk Management Report was done after finding out about pictures of (Name of R275), being posted on Facebook on [DATE]. DON reported that the other resident's (R75's) family member had lost guardianship and now had a court appointed guardian, because of posting pictures and video of (Name of R275) without permission. DON stated education was given to all staff and visitors that they cannot take pictures or video residents. DON revealed that the incident was not reported to the State Agency because the Allegation mentioned the Name of the Facility and not (Name of R275). DON explained R275's face could not be seen in the pictures. Surveyors were informed by the DON that the pictures were still posted (on Facebook) and provided R75's family member's name. DON revealed that R275 was telling the nurse she wanted to leave and was leaving when she collapsed in the nurses arms. The nurse then laid the resident on the ground, called for help and dialed 911. Prior to the completing of the interview, DON stated, if you blew the picture up, you could see an aide sitting at the resident's head. Her head was on a pillow. A Blood Pressure cuff and O2 were observed in the picture along with a nurse being at a med cart by resident's feet. DON stated (Name of R275) was hypotensive and passed in the ambulance due to cardiac arrest. On [DATE] at approximately 3:30 PM, a review of a Facebook page belonging to another residents (R75's) family member confirmed that picture of R275 were still on her Facebook page. A reasonable person would probably not want this picture posted. Review of a facility Risk Management Report provided by the Director of Nursing (DON) on [DATE] reflected an Unplanned death on [DATE] then [DATE] it was reported that there was pictures posted on Facebook of this resident. Review of the Summary of Trigger Situation or Event: revealed, On Sunday [DATE]th, 2021, Resident was lowered to the floor from a standing position by licensed nursed due to syncopal episode. Resident was immediately assessed by licensed nurse who noted critically low blood pressure. She had staff paged overhead for assistance, oxygen had been applied, a pillow was placed under the resident's head and 911 was called. Resident went into cardiac arrest in the ambulance on the way to the hospital CPR (Cardiopulmonary Resuscitation) and ACLS (Advanced Cardiac Life Support) was continued without ROSC (Return of Spontaneous Circulation). Time of death 1710 at the hospital. Cause of death was cardiac arrest. On [DATE] Facility staff reported that another resident's (R75's) family member had posted a picture of the resident on the floor making statements about her not being attended to. However, the above actions were all taken and there was also another staff member in the picture who is on the floor assisting the resident. Review of R275's General Progress Note for [DATE] at 17:34, reflected it was a late entry and the following, Resident came out of her room stating that she was leaving this place. She was running towards me and collapse into my arms. I lowered her to the floor and placed a pillow under her head. I called for help and Vitals obtained. The CENA came and sat down and stayed with patient, when I assessed the patient, her pupils were fixed, and her blood pressure was low. I called 911, notified IPC and New orders to send Patient to Name of Hospital. EMS arrived at facility to transport Patient to Name of Hospital Emergency Department EMS and Patient exited facility [DATE] at 1701. Transport documents and Bed hold policy sent with patient. Further review of R275's medical record failed to mention any incident of being photographed, nor did it mention that the pictures were posted on Facebook.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident (Resident #59) maintained bowel continence, resulting in the potential for abnormal bowel function and feelings of diminished self-worth. Findings: Review of an admission Minimum Data Set (MDS) assessment reflected Resident #59 (R59) admitted to the facility on [DATE] with diagnoses that included anemia, arrythmia, coronary artery disease, high blood pressure, benign prostatic hyperplasia, renal insufficiency, a history of a urinary tract infection and hyperlipdemia. The assessment reflected R59 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14/15. The assessment reflected R59 needed extensive assistance from 2 people for toilet use and was never continent of bowel and no bowel or bladder toileting program was in use. Review of a Bowel and Bladder Program Screener assessment dated [DATE] reflected R59 was a candidate for scheduled toileting. The assessment reflected that R59 voided appropriately without incontinence at least daily and was never incontinent of bowel. Review of a Care Plan reflected that R59 had an ADL (activities for daily living) self-care performance deficit related to Parkinson's disease, frequent falls, weakness and debility with the goal of having R59 participate in ADL tasks with therapy services as ordered to attain and maintain prior level of function through the review date. Interventions included Encourage and/or assist (R59) to meet toileting needs either with utilization of bathroom, bedpan, commode or urinal per his request, preference and as needed. During an observation and interview on 8/9/22 at 9:20 AM, R59 reported that his only concern with his stay at the facility is that he has to have a bowel movement in his brief and he feels undignified. R59 reported he can feel when he needs to have a bowel movement and would prefer to use a bedpan, however no staff has ever offered him one. During a follow-up interview on 8/10/22 at 1:34 PM, Licensed Practical Nurse (LPN) Q asked R59 if he could feel when he was about to have a bowel movement. R59 said he could feel when he needed to move his bowels and would like to use a bed pan as it would be easier for everyone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify the physician for 1 (Resident #37) in a total sample of 20, resulting in the physician not being aware of the resident refusing pertinent medications and the potential for adverse consequences. Findings include: Resident #37 (R37) Review of a Face Sheet for R37 revealed a [AGE] year-old female admitted to the facility on [DATE] with pertinent diagnoses of delusional disorder, epilepsy, and stroke with one sided weakness. During an observation and interview on 8/10/22 at 8:39 AM, Registered Nurse (RN) V took scheduled medications to R37 that included antidepressants/psychotropics Sertraline, Seroquel, Buspirone, Divalproex, Neurontin and Keppra for seizures, and metoprolol for blood pressures. R37 refused the medications even after the nurse educated her and encouraged her to take them. The nurse left the room with the medications and disposed of them in the drug buster. When queried what she will do next, she reported she will document what the resident said and put refused on the Medication Administration Record (MAR). In an interview on 8/10/22 at 12:40 PM, RN V reported she did not call the physician regarding R37 refusing her medication because the Physician Assistant will be around soon since she is in the building. In an interview on 8/11/22 at 12:15 PM, the Director of Nursing (DON) reported the physician should be notified if the resident refuses all medication after a good faith attempt and reapproached. In an interview on 8/11/22 at 12:19 PM, the Physician Assistant (PA) W reported residents refuse medications many times and the staff will put the information in the physician communication book instead of calling them because of the frequency of refusals. PA W reported she was not notified or aware that R37 refused her medications the day before. Review of the Medication Administration Records (MAR) for R37 revealed she refused medications on 7/7/22, 7/18/22, 7/29/22, 8/4/22, 8/10/22 with no follow up from the facility or physician notification. Review of the Care Plan for R37 revealed she is Care Planned for refusing medications that was last revised on 11/18/21 with no interventions for medication refusals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to implement physician-approved pharmacy recommendations for 1 of 5 resident (R1), resulting in a delay in changing R1's recommended medication orders and the potential for serious adverse effects of receiving a medication dosage above the manufacturer's recommendations. Findings include: A review of R1's admission Record, dated 8/10/22, revealed Resident #1 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 1's admission Record revealed she had multiple diagnoses that included allergic rhinitis (runny nose from allergies) and chronic kidney disease. A review of R1's Medication Regimen Review (MRR) Note to Attending Physician/Prescriber, dated 1/19/22, revealed the pharmacist recommended a change in R1's loratadine (an allergy medication) administration schedule from daily to every other day based on the manufacturer's recommendation of changing the loratadine (Claritin) dosing for residents with a creatinine clearance (a value that determines how well the kidneys are functioning- a low value means the kidneys are not functioning properly and drug levels that are absorbed by the kidneys can reach toxic levels in the blood) below 30 ml/min due to R1's recent low creatinine clearance value of 13 ml/min. R1's physician approved this change on 2/4/22. A review of R1's MRR Note to Attending Physician/Prescriber, dated 3/18/22, revealed the pharmacist again (second recommendation) recommended a change in R1's loratadine administration schedule from daily to every other day based on the manufacturer's recommendation of changing the the loratadine (Claritin) dosing for residents with a creatinine clearance below 30 ml/min due to R1's recent low creatinine clearance value of 12 ml/min. R1's physician approved this change on 3/24/22. A review of R1's Medication Administration Records (MAR), dated 1/1/22 to 4/30/22, revealed R1 received loratadine 10 mg daily from 1/15/22 to 4/1/22. In addition, R1's March 2022 MAR revealed the loratadine order for 10 milligrams (mg) daily was discontinued on 3/31/22 at 11:12 AM. A review of R1's physician order, dated 3/31/22 (almost 2 months after R1's physician had originally approved the change on the January 2022 MRR and a week after approving the change on the March 2022 MRR), revealed R1's physician had changed the loratadine order to 10 mg every other day at 11:00 AM. However, R1 still received a daily dose of loratadine on 4/1/22 and it was not until then (starting on 4/3/22) that R1's loratadine was changed from daily until every other day (per R1's April 2022 MAR).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to limit an as needed psychotropic medication without the required documentation for 1 (Resident #17), from a total sample of 20, resulting in the potential for unnecessary and unmonitored medications and the potential drug diversion. Findings include: Resident #17 (R17) Review of a Face Sheet for R17 revealed a [AGE] year-old female who originally admitted to the facility on [DATE] with pertinent diagnoses of chronic obstructive pulmonary disease, cirrhosis of the liver and morbid obesity. Review of Physician Orders for R17 revealed an order to admit to hospice on 8/5/22. Lorazepam 0.5 milligrams (mg) every 4 hours as needed for anxiety. Aripiprazole (Abilify) 17 mg once a day for anxiety. Buspirone 20 mg three times a day for anxiety. Fluoxetine 40 mg once a day for depression. Gabapentin 100 mg twice a day for neuropathy (not in list of diagnoses). Haloperidol 1mg every 4 hours as needed. Review of the June 2022 Medication Administration Record (MAR) for R17 revealed 2 orders for Xanax (antianxiety medication) 0.25 mg as needed twice daily. Review of the July 2022 MAR for R17 revealed 4 different orders for Xanax 0.25 mg to 0.50 mg as needed. Review of the August 2022 MAR for R17 revealed Lorazepam 0.5 mg as needed, ordered 8/5/22 had not been utilized as of 8/10/22. Xanax 0.5 mg every 12 hours as needed. Review of the Electronic Medical Records for R17 revealed no monitoring of psychotropic medication side effects. No physician rationale documented for the continuation of as needed medications. Review of a Pharmacy Note to the Attending Physician/Prescriber document for R17 dated 4/19/22 revealed R17 had a PRN (as needed) order for Xanax every 12 hours. The pharmacy was asking for documentation to continue the medication or to discontinue it. The physician wrote on the document Risk vs Benefit in place. Review of the Pharmacy Medication Review for R17 revealed on May 26, 2022, the pharmacy alerted the physician of needing a rationale for the as needed Xanax and the physician responded on the form with Risk vs benefit and no end. Review of a Consultant Pharmacist's Medication Regimen Review document dated 7/1/22 and 7/20/22 for R17 revealed the resident is on Abilify (Aripiprazole) which can cause involuntary movements including tardive dyskinesia (TD), but an AIMS or DISCUS (assessment tools) assessment is not documented in the resident record within the previous 6 months. On 7/21/22 it was signed by a nurse that the AIMS is scheduled to be completed 7/21/22 and then quarterly. In an interview on 8/9/22 at 4:05 PM, Social Worker (SW) S reported R17 just signed on to hospice and started Ativan as needed and has been on Xanax. Requested the rationale documentation for the as needed medications from the physician. At the end of this survey, the documentation was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00128328: Based on interview and record review, the facility failed to maintain complete and accurate medical records for 3 residents (R35, R64, and R63) reviewed, resulting in inaccurate and incomplete medical records and the potential for providers not having an accurate picture of the residents condition. Findings include: R35 Review of face sheet for R35 revealed they initially admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnosis that included: hemiplegia and hemiparesis (weakness and paralysis on one side), diabetes mellitus type 2, depression, chronic pain and adjustment disorder with anxiety. R64 Review of face sheet for R64 revealed they initially admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnosis that included: dementia, acute respiratory failure, diabetes mellitus type 2, bipolar disorder, depression and anxiety. Review of facility reported incident (FRI) dated [DATE] revealed that on [DATE] residents R35 and R64 stated a staff member made inappropriate verbal statements while providing cares on [DATE]. R35 and R64 are roommates. Review of R35 and R64's electronic medical record on [DATE] at approximately 1:45 PM revealed no progress note on [DATE] or [DATE] related to the allegations of verbal abuse. Further review of R64's progress notes on [DATE] reveals a social work wellness visit. There is no reference the visit was occurring regarding an incident. The next note on [DATE] at 11:37 AM reveals a contact with the guardian regarding a reportable. Incident discussed. The next progress note on [DATE] at 1:29 PM is another note by social services and it refers to an incident where a staff member walked into the bathroom without knocking, the verbal abuse incident is not referenced. Further review of R35's progress notes revealed a progress note regarding a contact with their guardian on [DATE] at 11:49 AM, there was no reference to an incident. There was a progress note on [DATE] at 1:29 PM with social services related to a well visit to check on concerns. [R35] only had one concern and that was she would like staff to address her .roommate [R64] in the same way that she is address (sic) .she did bring up the incident that happened with [R64] yesterday and that he was just really embarrassed. On [DATE] at 10:36 AM an interview was completed with the Director of Nursing (DON) regarding FRI information related information in the resident medical record. The DON stated FRI information is documented in risk management reports. It was verified this is not part of the resident medical record. The DON stated it is not part of their procedure to put in a progress note in a resident's electronic medical record related to allegations of abuse or neglect. It was discussed with the DON that facility reported incidents are part of the resident's medical record because if they are unsubstantiated or imagined allegations, it could be indicative of an behavior pattern with a resident and if the allegation is substantiated to have occurred it can be important to be aware if the resident is experiencing effects from the abuse or neglect. The DON stated there would be social work follow up notes documented related to any incident. It was confirmed that there were notes in both residents progress notes a few days later, but there no indication about what type of incident had allegedly occurred and what was being followed up on. R63 A review of R63's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated [DATE], revealed R63 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included a stroke and traumatic brain injury (TBI). In addition, R63's MDS revealed he had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 6 which revealed R63 was severely cognitively impaired. A review of R63's hospital Palliative Medicine Physician Progress Notes, dated [DATE], revealed Physician (MD) KK examined R63 and documented that R63 was unable to make medical decisions and it is in their best interest to activate a DURABLE POWER OF ATTORNEY for health care decisions at this time or pursue guardianship immediately. A review of R63's hospital Internal Medicine Physician Progress Notes, dated [DATE], revealed MD JJ examined and assessed R63 and determined that R63 had significant cognitive impairment and I see nothing to indicate that this will improve enough to render him appropriate for making his own decisions. I recommend activation of DURABLE POWER OF ATTORNEY for health care decisions at this time and pursue guardianship. A review of R63's Advanced Directive form, dated [DATE], revealed R63 appointed Patient Advocate (PA) LL as his patient advocate and authorized her to make medical decisions on his behalf if he should become incapacitated/unable to make medical decisions. A review of R63's Advanced Directives, signed [DATE] (one day before admission to the facility) by PA LL and witnessed by two witnesses on [DATE] (the day of admission), revealed PA LL decided that R63's code status was Full Code (cardiopulmonary resuscitation (CPR)) in the event that R63's heart and/or breathing stopped. During an interview on [DATE] at 10:48 AM, Social Worker (SW S) and Unit Manager (UM) T were asked about the discrepancy on R63's Advanced Directives (which indicated R63 was a Full Code) between PA LL's dated signature of [DATE] (one day before admission) and the two witnesses signatures (on [DATE] which indicated they witnessed PA LL's signature). SW S and UM T stated when they had looked at R63's signed Advanced Directives form they had not noticed the discrepancies between the signature dates. UM T further stated that PA LL had probably written the wrong date on the form because it was written on the facility's form (not the hospital's) and PA LL would have signed it on [DATE] (the date of admission) and not before. UM T then stated that the accuracy of the date of when PA LL signed R63's Advanced Directives form was not their issue and suggested that the surveyor speak directly to PA LL and not to them about it. The surveyor asked SW S and UM T if the facility was responsible for the accuracy of residents' medical records and they both stated it was.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure proper communication/documentation, show hospice services were provided, and designate a coordinator for Hospice services for 2 (Resident #17 and Resident #29) of a total sample of 20, resulting in the likelihood for uncoordinated care and unmet needs. Findings include: Resident #17 (R17) Review of a Face Sheet for R17 revealed a [AGE] year-old female who originally admitted to the facility on [DATE] with pertinent diagnoses of chronic obstructive pulmonary disease, cirrhosis of the liver and morbid obesity. Review of Physician Orders for R17 revealed an order to admit to hospice on 8/5/22. Review of a Facility Notification of Hospice Admission/Change for R17 revealed an agreement for hospice services between the facility and the Hospice Agency. Review of the Electronic Medical Records (EMR) for R17 revealed no hospice elect/consent form signed by the resident or designated representative. In an interview on 8/9/22 at 9:33 AM, Hospice Registered Nurse (RN) X reported R17 is now on hospice as of Friday (8/5/22). RN X reported she is filling in for the regular nurse this day. RN X reported she does not chart in the computer system at this facility unless this surveyor requires it. The hospice nurse reported she gives a verbal report to the nurse before she leaves and does not document anything at the facility. RN X reported she does not review the facilities medical records for the residents because it should be the same as the Hospice Agency charting. RN X reported she could fax the hospice notes to the facility when queried about where the hospice agreement and progress notes for R17 was located. In an interview on 8/9/22 at 2:30 PM, the Medical Records staff (MR) Z reported she was all caught up with the medical records that needed to be scanned into the computer and hospice records are either in the computer or in binders at the nurse's station. In an interview on 8/9/22 at 3:47 PM, the Director of Nursing (DON) could not clarify who the hospice coordinator at the facility is. The DON reported some Hospice providers chart in the facilities computer system, and some write notes on paper that is scanned into the chart. The DON reported that Hospice RN X wrote a progress note on a blank piece of paper for R17 and handed it to the receptionist at the front desk before she left the facility this day. Hospice RN X talked with the DON after talking to this surveyor. In an interview on 8/9/22 at 4:08 PM, Social Worker (SW) S reported he is not the hospice coordinator, but he does send referrals to hospice along with the face sheet, medication list, the history and physical, and the order for hospice. SW S reported R17's guardian initiated and reached out to the hospice provider to sign her up. Resident #29 (R29) Review of a Face Sheet revealed R29 is an [AGE] year-old female originally admitted to the facility on [DATE] with pertinent diagnoses of cerebral palsy, pressure ulcers and epilepsy. Review of a Significant change Minimum Data Set (MDS) dated [DATE] for R29 revealed she is now on hospice. During an observation and an interview on 8/8/22 at 12:53 PM, CNA BB reported R29 did not get a lunch tray because she just throws up the food. CNA BB reported the resident is on hospice and did drink her milk and cranberry juice. The resident was observed n bed in the same position noted earlier. The resident declined the protein drink from the nurse at this time and was not easily aroused. In an interview on 8/9/22 at 9:45 AM, Licensed Practical Nurse (LPN) Y reported she thought the hospice staff do paper charting that is in a binder at the nurse's station. When we walked to the nurses' station there was no binder for R29. The Unit Manager (UM) T was at the nurse's station at this time and could not find the hospice binder either for R29. LPN Y reported it could be in the resident's room. When we went to R29's room, it was not there. They reported the Social Worker, and the DON were the hospice coordinators. During an observation and an interview on 8/9/22 at 9:55 AM, LPN Y provided a hospice binder for R29 and reported she just overlooked it. Inside the binder were forms titled Hospice Care Coordination but there was no documentation written inside the binder. A printed New admission Hospice Care Plan dated 6/3/22 with a meeting date of 6/15/22 was in the sleeve of the binder. In an interview on 8/9/22 at 4:10 PM, Social Worker S reported R29 signed on to hospice in June. Once a resident is signed on to hospice, the Unit Manager meets with them and directs their expectations to the hospice staff for visits. During an observation on 8/10/22 at 8:55 AM, R29 observed in a Broda chair next to her bed, dressed, and her breakfast tray on the bedside table. Her food was not touched, and no staff observed in the room to assist her. In an interview on 8/10/22 at 3:01 PM, the CNA reported she put R29 to bed around 1PM and was in her chair from 7:30 AM to 1:00 PM. Observations of R29's skin revealed a large purple, un-blanchable area on coccyx and the right heel had a large half dollar sized reddened area. The legs were not elevated. Review of the Electronic Medical Record (EMR) for R29 revealed no hospice elect/consent form signed by the resident or designated representative. There are only wound care progress notes from the Physician Assistant and Dietary progress notes. No documentation about R29 not eating or drinking from nursing staff. No documentation indicating hospice staff visited the resident and is communicating care/services provided since 7/13/22. Review of a Hospice IDG Comprehensive Assessment and Plan of Care Update Report for R29 with a last visit date of 6/27/22 revealed: Delete both wound (diagnosis) no wounds present per admitting and RN Case (Manager). Review of a Nursing Skin assessment dated [DATE] for R29 revealed the residents' skin is intact. Review of a Physician Progress Note dated 7/8/22 for R29 revealed she has a pressure injury noted 13 weeks ago on her left medial foot, a pressure injury on the right great toe that was noted 11 weeks ago. She had pressure injuries from her socks on both ankles from her socks and continues with the pressure injury on her left ankle. Review of a Hospice IDG Comprehensive Assessment and Plan of Care Update Report for R29 with a last visit date of 7/12/22 for R29 does not mention R29 having pressure sores. Review of the Meal Intake document for 7/12/22 to 8/9/22 revealed the resident had several days when she refused her meals or 50% or less was eaten. No hydration assessment noted, no hospice notification noted, and no indication a physician is aware of decreased intake Review of a Physician Assistant Progress note dated 7/15/22 for R29 revealed she has an unstageable pressure injury on her foot, stage II pressure ulcer on her left ankle and a new unavoidable pressure ulcer on on her left medial buttock. Review of a Physician Progress note dated 7/29/22 for R29 revealed she was seen for a follow up to the pressure injuries on her bilateral feet. The left medial foot was noted 16 weeks ago, and the right great toe was noted 14 weeks ago. The resident was noted to have a pressure injury on her left buttock on 7/13/22. The pressure injury to the foot is unstageable, pressure injury of the right toe is a stage 3, and pressure injury of the left buttock is a stage 2. Staff to continue to assist resident with frequent turning when in bed. Review of the July Medication Administration and Treatment Administration Records (MAR/TAR) for R29 revealed orders for 1) Apply skin prep to discolored areas on bilateral anterior ankles and the purple area on the left medial foot every night shift for wound care. Treatment missed on 7/11/22. 2) Right first toe and left anterior ankle wounds; cleanse with saline and gauze, apply TAO and cover with Band-Aids every night shift every other day for wound care. Discontinued 7/22/22. Treatment not done on 7/15/22 and 7/19/22. 3) Right first toe and left anterior ankle wounds; cleanse with saline and gauze, apply TAO and cover with Band-Aids every night shift every other day for wound care. Discontinued 7/29/22. Treatment not done 7/24/22. 4) Nurse to verify bed block in place every shift for skin protection, not documented as done on 7/11/22 and 7/19/22. 5) Zinc Oxide Ointment to coccyx and buttocks every shift for skin care not done 7/11/22 and 7/22/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain best infection control practices during medication pass for 1 (Resident #43), of a total sample pf 20, and failed to provide a clean and sanitary environment for 3 resident rooms observed, resulting in the potential for an increased risk for infections. Findings include: Resident #43 (R43) Review of a Minimum Data Set (MDS) dated [DATE] revealed R43 admitted to the facility on [DATE] with pertinent diagnoses of a stroke and aphasia and requires extensive assistance of 2 staff for cares. During an observation on 8/10/22 at 7:43 AM, Registered Nurse (RN) V was preparing medications for R#43 who has a PEG (percutaneous endoscopic gastrostomy) tube where she receives her medications. RN V went to the medication room and pulled out the liquid labetalol medication bottle from the refrigerator and attached to the bottle was a plastic pouch taped to the bottle. Inside the pouch was a syringe to draw up the medication. RN V used the syringe to pull up the medication and put the medication in a plastic cup, then immediately placed the used syringe back into the plastic pouch attached to medication bottle and placed it back into the refrigerator. In an interview on 8/11/22 at 12:15 PM, the Director of Nursing (DON) reported that reusing the syringe to draw up the labetalol is not okay and an infection control problem. Environment During an observation on 8/8/22 at 11:43 AM, room [ROOM NUMBER] had a dirty, dusty build up on the fan. The bathroom walls had a wet and grimy like streaks and the tiled baseboards had a moldy/dirty like appearance on the grout. During an observation on 8/9/22 at 9:31 AM, room [ROOM NUMBER] still had feces like material on the side of the toilet that was observed on 8/8/22 during the initial tour. In an interview on 8/9/22 at 10:00 AM, Housekeeper (HK) L reported she is assigned to rooms 101 to 119. She did not know who worked the last few days because she had been off and last time, she worked she was in laundry. During an observation on 8/9/22 at 2:24 PM, room [ROOM NUMBER] had a dirty/dusty bathroom fan and the toilet had black spots inside of it like a residue or potential mold. The bathroom walls had grimy streaks all over. During an interview on 8/9/22 at 3:00 PM, the Housekeeping Supervisor (HS) M reported HK L had gone home for the day. HS M reported they do a deep cleaning to the rooms once a month. At this time, we went to room [ROOM NUMBER] which has dried grimy soap like streaks all around the bathroom walls. HS M reported they tried cleaning the walls, but they will not come clean. This surveyor took a paper towel, wet it, and wiped an area on the wall, dried it, and the area was clean. The baseboard had a graying grime on the tile and a tannish drip streak coming down from the mirror. room [ROOM NUMBER]. We went to room [ROOM NUMBER] which had a build up of grime on the walls in the bathroom and a dirty bathroom fan. The bedside table for R43 had dark black spots all over the base of the table that rubbed off when HS M rubbed it. The baseboards in the residents' room were soiled and pulled away from the wall. room [ROOM NUMBER]. Had similar findings in the bathroom walls, baseboards, and fan. The toilet still had a black caked on debris inside and the HS M reported it cannot come off. Review of a Deep Clean Procedures document revealed the facility has not been following them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R72 Review of face sheet for R72 revealed they initially admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnosis that included: hemiplegia and hemiparesis (one sided weakness and paralysis), aphasia following cerebral infarction (inability to understand or express speech caused by brain damage), contracture of left elbow, left hip, and ankle, anxiety, depression, convulsions, epilepsy and chronic pain. She is not her own responsible party. Her last quarterly MDS (minimum data set) assessment on 5/5/22 revealed a BIMS (brief interview for mental status) score of 0/15 indicating severe cognitive impairment. She required extensive assistance to total dependence of one person physical assist on a majority of her activities of daily living. On her 7/2/22 readmission MDS assessment a BIMS was not completed due to the resident was unable to complete Brief Interview for Mental Status and staff assessed her as having okay short and long term memory and with modified independence on daily decision making despite her previous score of 0/15 on the 5/5/22 assessment. Review of facility provided incident with a date of 2/1/22 revealed resident husband said her R ankle appears swollen .resident facial expression would change upon touching R ankle and appeared to be in pain. Resident shook head yes when asked if was during a transfer. The incident had one staff witness listed. The interview or interviews were not provided in the document provided by the facility. Review of progress notes revealed that on 2/10/22 at 4:59 PM Physician Assistant (PA) DD entered a progress note with a review of the resident for right foot pain and bruising. Will re-xray the right foot, had recent xray when foot appeared swollen, no documented trauma. Xray negative for fracture, but did recommend repeat or CT(diagnostic scan) if sx (symptoms) persist. Now with ecchymosis (discoloration of the skin) as well, will monitor closely, cont (continue) norco (opiod pain reliever) for pain. Stat (immediate) 2 view xray r/o (rule out) fracture. Review of a facility provided Risk Management Report with a date of event 6/23/22 regarding R72 revealed On 6/23/22 [R72] was sent to the hospital for uncontrolled abd (abdominal) pain and shortness of breath requiring oxygen. She was presumed + for Covid .Hospital called on 6/23 reporting a fracture of her left femur. Resident complaining of increased abd pain on 6/23 so facility performed stat imaging of chest, abdomen, left hip, pelvis, and left knee which were all neg for fracture or dislocation .[R72]'s husband, reported that while in the hospital they stated that her bones are like glass and even normal re-positioning in the bed could cause a fracture .[R72] did not sustain any injury or have any falls while at the facility. On 6/21 she was unable to maintain truncal support while in the shower chair requiring staff members to quickly transfer her. This was witnessed with a statement obtained by her husband who has no concerns with the transfer or the facility causing injury. In the section reported to the appropriate state agencies, NO is written as the answer. The facility response section revealed: The facility completed an investigation into the event. A risk was completed in PCC (electronic medical record) along with statements from staff who participated in the transfer as well as the spouse who is not concerned with the facility causing this injury .care plan was being followed- This was not due to abuse, neglect or mistreatment. An attached incident report referred to an incident in the shower on 6/21/22 where R72 was unable to maintain truncal control in the shower chair. Per 3 staff and R72's DPOA interviews, R72 was showing no signs or symptoms of distress or pain after being returned to bed. Review of facility provided progress notes revealed that on 6/23/22 at 1:00 PM, Physician Assistant (PA) DD entered a progress note regarding R72: Patient is seen for acute hypoxemia and respiratory distress last evening .An x-ray of the left lower extremity was also done today due to severe pain. This showed no fracture or dislocation . Review of hospital discharge paperwork for R72 with admission date 6/23/22 revealed a history of present illness: presents today with severe left hip pain following slide off chair in the shower 2 days prior at long-term care facility. At baseline patient answers yes or no due to history of hemorrhagic stroke .since the fall, patient has had severe pain with any transfers . A CT scan revealed: There is a new acute or subacute left hip subcapital fracture . On 08/08/22 at 03:36 PM a face to face visit was completed with R72 in their room. They were viewed to be awake and laying in bed. Several attempts to interview R72 were made and R72 stared blankly forward. R72 tracked movement with her eyes but did not give any verbal noises and did not give any meaningful gestures or movements such as blinking or head nods with interaction. During an interview with R72's DPOA (durable power of attorney) on 8/9/22 at 4:00 PM he stated that R72 is not very communicative and at times it can be hard for him to get any limited verbal responses or head nods from R72. He stated it has been that way for quite a while. R72's DPOA stated that R72 had recently suffered an injury where the top of their femur was fractured. He stated that R72's bones are quite fragile and the injury happened when the resident started to slide out of a shower chair. R72's DPOA stated they were there when the shower incident occurred and that R72 did not fall out of the chair, they just could not maintain balance and had to be transferred back to their room, the resident had some pain after the incident and transferred to the hospital where they found the femur was fractured. R72's DPOA stated the resident is pretty much bed bound because of weakness. R72's DPOA stated there was a previous ankle injury that the resident sustained but he was not sure how that happened. An email was received from the DON (Director or Nursing) on 8/10/22 at 8:25 AM in reference to R72: This resident has extremely fragile bones with a Dx (diagnoses) of osteopenia and osteoporosis along with history of fractures. The incident in February [R72] had a bruise to her foot with swelling. She could confirm that this occurred during a transfer and that she was not mistreated. The CNA felt that she likely bumped her foot on the mechanically lift during a transfer as her legs are difficult to maneuver with her contractures. She was evaluated right away. Her pain was assessed and we ordered stat x-rays. X-rays were normal and her comfort was monitored closely. Notifications were made and there were no concerns of mistreatment from her husband who is here daily. I reprinted the information with more details on the most recent incident with witness statements. During an interview on 08/10/22 at 09:10 AM with the DON (Director of Nursing), R72's ankle injury and femur fracture were discussed. The DON stated they did not report either injury to the state. The DON stated R72 had some swelling and bruising on their ankle and they think that the ankle injury was due to hoyer lift. The DON stated they were sure this is how it happed since they got witness statements, and the resident denied abuse. The DON stated R72 could confirm that this occurred during a transfer and that she was not mistreated. The CNA staff who recently cared for her felt that she likely bumped her foot on the mechanically lift during a transfer as her legs are difficult to maneuver with her contractures. She was evaluated right away. Her pain was assessed and we ordered stat x-rays. X-rays were normal and her comfort was monitored closely. Notifications were made and there were no concerns of mistreatment from her husband who is here daily. For the leg injury, R72 had an x-ray after slip in the shower incident and the xray was clear, but then after transfer to the hospital, a fracture was found. The DON stated R72 had very brittle bones and the fracture was found to be pathological due to her bone weakness and could have even occurred during the transferred by EMS (emergency medical services) as well. The DON stated interviews done with staff, the resident and her husband (DPOA). They did not report the incidences because the resident shook her head no that she was not harmed by anyone. It was discussed with the DON that R72 was not her own responsible party and had limited communication. It was also discussed that brittle bones prone to fracture does not eliminate the possibility that an abusive or neglectful action caused an injury when the time and mode of injury was not definitive. The DON was asked for all documents regarding the R72's injuries and informed due to not having a definitive cause for the injuries, the incidences should have been reported to the state agency and a full investigation submitted. During a follow-up interview on 8/10/22 at 10:37 AM, the DON reported that on 2/1/22 R72's husband reported bruising and swelling to R72's ankle. An x-ray was ordered that did not show a fracture and a brief investigation into the injury identified CNA GG reported she thought she may have bumped R72's foot on the Hoyer lift during a transfer causing the injury. No additional staff statements were obtained and it was not clear if the transfer had been completed with a second person as would be required and additional witness statements to support that the care plan was followed were noted. During the interview Regional Nurse HH confirmed that R72 was diagnosed with osteoporosis and osteopenia on 1/25/2021 and that while R72 was not able to participate in a BIMS assessment, a staff assessment on of R72's cognition reflected her short- and long-term memory were intact according to the MDS dated [DATE]. The DON reported that R72 was sent to the hospital on 6/23/22 due to respiratory distress and complaints of abdominal pain with a history of ileus (interruption of intestinal movement). A stat (right away) x-ray of R72's left side was obtained and the results were not received by the facility prior to R72 being sent to the hospital. The hospital called the nurse on duty to report R72 had been diagnosed with a hip fracture. The DON and NHA were both informed of R72's hip fracture at around the same time and according to the DON a Risk report was initiated to try an identify if anything could have caused R72's fracture. The DON and NHA reported they did not report the hip fracture to the state agency due to their belief the hip fracture was likely sustained during the shower incident on 6/21/22 and was therefore not an injury of unknown origin and the hospital records clearly identified that the fracture was as the result of the fall in the shower on 6/21/22. The DON confirmed that witness statements were not gathered from staff who worked with R72 after the shower incident on 6/21/22 and before R72's transfer to the hospital on 6/23/22. According to the DON, the x-ray that was taken in the facility prior to R72's transfer to the hospital were obtained via email several days after 6/23/22 due to a problem with the electronic health system and were all negative for fracture. Review of facility policy with the subject Abuse and Neglect with the most recently revised date of 6/17/19 revealed: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Signs and symptoms of suspected abuse/neglect include: Suspicious history, description of the injury is inconsistent with physical findings. Unexplained injuries, old injuries never treated properly, incongruent history. if abuse/neglect is suspected the facility will: Notify the appropriate/designated organization/authority (State Agencies) that an investigation is being initiated immediately following intervention for the resident's safety .Conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses . Report the investigation findings to the appropriate State Agencies, as required by law. Under the section Identification the facility should have procedures to Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation . An injury should be classified as an injury of unknown source when both of the following conditions are met: a. The source of injury was not observed by any person or the source of injury could not be explained by the resident; and b. The injury is suspicious because of the extent of the injury or the location of the injury (example: the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at a particular point in time or the incidence over time. Under the section Investigation: Investigate all allegations of abuse, neglect, misappropriation of property and incidents such as injuries of unknown source. All allegations will be investigated by the Administrator or Designee immediately. Resident #76 (R76) Review of the Face Sheet revealed R76's admitted to the facility on [DATE] with pertinent diagnosis of Cellulitis of the left lower limb, Type 2 diabetes mellitus, Pressure Ulcer of left buttock, and chronic pain. Resident is his own Representative. Review of the admission Minimum Data Set (MDS) revealed R76 had a Brief Interview for Mental Status score of 14/15 (BIMS) indicating he was cognitively intact. Review of a Facility Reported Incident (FRI) revealed on 4/5/22 at 12:53 PM, the facility Administrator was notified by the social worker at (Name of R76's) dialysis center that the patient stated that a tech that worked at the facility he is staying mistreated him. He was unable to identify the tech but reported he was not harmed. Because of (Name of R76's) allegation, this was reported as mistreatment. The State Agency was notified on 4/5/22 at 1:11 PM, and the final report was submitted on 4/12/22. The police were contacted on 4/5/22 at 19:46:37. The report revealed (Name of R76's) statement was on the morning of 4/5/22 2 female aides came in to help him get ready. While the first was near the foot of the bed, the second aide leaned over, put her hands around his neck, and whispered, Remember, I am the boss. Administrator asked (Name of R76) what the first aide did when this occurred. He stated that the aide did not see or hear it because she was doing something with his foot. Since he was unable to provide the name of the aide, he gave a description. Based on the description and the days assignment, Administrator was able to determine the identity, (Name of Certified Nurse's Aide (CNA) EE). CNA EE was suspended pending further investigation. A skin and pain assessment completed with no findings. Staff interviews were done, along with like resident's. The facility concluded abuse was not substantiated and no deficient practices were found. There was no staff education completed. Further review of the facility 5-day report noted, Resident's Daughter was called, per request, to inform of the investigation conclusion. During call, daughter stated that she had questioned if the alleged incident occurred as her dad, (Name of R76), Stated he felt bad about the allegation and her dad was never one to apologize if he was certain he was right. Daughter stated desire to just let this go. Review of FRI folder revealed a Certificate of Completion for (Name of CNA EE) has completed and earned 1.0 Contact hour(s) for the program Abuse, Neglect, and Exploitation Prevention, Saturday, April 2, 2022. Further review of the complete FRI folder failed to provide any like resident interviews. Review of a Skin Observation Tool for R76 described as Other on 4/5/22 at 16:00 reflected no reason or explanation for the skin assessment being completed. Review of R76 Pain Tool assessment was created on 4/5/22 at 10:00. Documentation of the resident having pain in Right lower leg (Front) and Left lower leg (front). The document reflected resident had increased pain (rated at a10) with movement, touch and weight bearing. Review of the comment portion of the document only reflected resident reports BLE is the only location of pain. Review of R76's Electronic Medical Record (EMR) from 3/30/22-4/9/22 failed to reflect/document any incidents, reportable events, or follow-ups with the resident by staff. Review of the Police Report Incident Number 22-009383 revealed they were notified on 4/5/22 at 19:46:37. Review of the report Summary revealed: The complainant, (Name of NHA) speculates that (Name of R76) is making false accusations against (Name of CNA EE) for an incident that occurred last week. There was reportedly another staff member in the room with (Name of CNA EE) at the time of the alleged assault; the other staff member did not see anything. (Name of R76) did not have visible injuries. Review of the officers interview with the NHA reflected an incident, On Saturday (4-2-22) (Name of CNA EE) went into (Name of R76's) room to provide care. When (Name of CNA EE) went to move his leg, she inadvertently caused (Name of R76) extreme pain. (Name of R76) became agitated with (Name of CNA EE) for hurting him. (Name of NHA) went into the room to help calm the situation. (Name of R76) explained that his leg, have to be moved a certain way to avoid pain. (Name of CNA EE) did not know this, so (Name of NHA) thought it was constructive that they were having this conversation. She treated it as a learning moment for both (Name of CNA EE) and (Name of R76) and thought the tension was settled. Review of the officer's interview with (Name of R76) reflected, He told me this all started when (Name of CNA EE) hurt his leg while moving it last Thursday (not Saturday like (Name of NHA) had reported). He told me that his leg is so sensitive it has to be moved a certain way. He claimed that (Name of CNA EE) was moving it incorrectly, so he yelled out in pain and told her that it hurt. (Name of R76) claimed that (Name of CNA EE) pushed his leg up towards his chest causing him more pain. She then said something to the effect I am the boss. This morning, (Name of CNA EE) came back into the room with another nurse (Name of CNA/Nurse FF) When (Name of CNA/Nurse FF) was not paying attention and apparently preoccupied with something else, (Name of CNA EE) put her hands around his neck and said, Remember, I am the boss. When asked how long (Name of CNA EE) had her hands squeezed him, he claimed it was about 10 seconds. He told me that he did not have any visible injuries because (Name of CNA EE) did not squeeze hard enough. (Name of R76) claimed that (Name of CNA EE) knew what she was doing. I asked (Name of R76) if he yelled for help, but he claimed he did not because he did not want (Name of CNA EE) to hurt him more. I asked if he told (Name of CNA/Nurse FF) to step in and help, but he claimed that he did not want to tell her for fear that she was working in cahoots with (Name of CNA EE). When asked why (Name of CNA EE) would want to hurt him, he claimed he did not know, probably because she hurt his leg on Thursday. Further review of the officers report documented, (Name of R76) wants to press charges for the alleged assault. Forward for review. Follow up to the officers report dated 4/6/22 noted it was, Forwarded to the CA's office on 4/6/22 for review. CA's office reviewed this case and criminal history for (Name of CNA EE) and denied charges. During an interview on 8/10/22 at 2:15 PM, NHA was questioned on why all the education for (Name of CNA EE) was provided in (Name of R76's) FRI folder and not her personnel folder. NHA revealed that (Name of CNA EE) only had 1(Teachable Moment) to show and it was from 1/10/20 (and was for a different resident). During the interview NHA stated, she did not know why CNA EE had completed an education on Abuse, Neglect, and Exploitation Prevention on Saturday, April 2, 2022 (Several days before the reported FRI/incident.) NHA was asked about the 4/2/22 incident (between R76 and CNA EE) that was mentioned in the 4/5/22 police report. (Review of R76's medical record failed to document any incident on 4/2/22 or any additional FRI reports.) NHA revealed (Name of CNA EE) did an education because of an incident on 4/2/22. NHA was asked if (Name of CNA EE) was re-educated after the 4/5/22 incident? NHA stated, Why would we re-educate if she already had been educated. This citation pertains to intakes M100129873, M100127871, and M100124418 Based on interview and record review, the facility failed to thoroughly investigate and take actions to prevent abuse and misappropriation of property for 4 (Resident #40, Resident #70, Resident #72, and Resident #76), resulting in the potential for further abuse or misappropriation to occur. Findings include: Resident #40 (R40) Review of the Face Sheet revealed R40 admitted to the facility on [DATE] with pertinent diagnosis of dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) revealed R40 had a Brief Interview for Mental Status (BIMS) indicating she is moderately cognitively impaired. Review of a Facility Reported Incident (FRI) revealed on 10/31/21 at 4:38 PM, the facility Administrator was notified of an incident for a potential misappropriation of property when R40 reported her ring was missing. The police were contacted on 11/2/21 at 8:30 AM. The State Agency was notified on 11/1/21 and the final report was submitted on 11/8/21. The Nursing Home Administrator (NHA) who conducted the investigation is no longer at the facility. The report revealed the resident saw her ring the night before when she placed it on top of the lock box in her nightstand. When questioned by the NHA if she was sure the ring was missing that night, the resident replied no. R40 reported a staff member whom she described but did not know her name admired her ring and commented how pretty the ring was when R40 was cleaning her top drawer that had the ring inside of it. R40 reported that staff member worked the night shift but did not see anyone take her ring out of the drawer. The facility did a room sweep which turned up no findings. Staff interviews were done, and some staff reported the resident did have a ring but also had a few room changes. The facility concluded that misappropriation could not be substantiated at that time and did not result in harm, pain, or mental anguish. There is no documentation indicating that a sweep or audits of other residents potentially missing items were done, and staff education was not done. Review of the Electronic Medical Record (EMR) for R40 revealed no form accounting for the residents' belongings at the facility. Review of the Police Report revealed they were notified on 11/2/21 at 9:26 AM via phone. The facility told the police that it is unclear if the event is factual or not and the NHA requested only a report number for their records. The NHA told the police that they could not confirm a ring had been in R40's possession during her stay at the facility. The police did not go to the facility or interview the resident or staff. In an interview on 8/11/22 at 8:42 AM, the Director of Nursing (DON) and the current NHA confirmed the police were notified on 11/2/21 of the missing ring. The DON reported the resident will misplace things frequently and will usually find things when they search the room. The NHA reported when an incident of misappropriation occurs, the facility is to report it to the State Agency, then do a reeducation to staff on abuse policies, and interview like residents for missing items. The NHA confirmed an audit of like residents was not done and staff education was not done to potentially aid in the future prevention of misappropriation. Review of a policy titled Abuse and Neglect last revised 6/17/19 revealed: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Resident #70 (R70) Review of a facility admission Record reflected R70 admitted to the facility with diagnoses that included myoneural disorder (lower motor neuron disease-lead to weakness, muscle atrophy, spasms, nerve pain etc.), alcohol dependence, peripheral vascular disease, chronic pain, constipation, inguinal hernia, high blood pressure and radiculopathy. A Minimum Data Set (MDS) assessment dated [DATE] reflected R70 was cognitively intact and needed extensive assistance from two people for bed mobility, transfers, dressing, personal hygiene and toilet use. During an interview and observation on 8/8/22 at 1:00 PM, R70 was seated in his chair in his room and was finishing up lunch. R70 recalled an incident where a Certified Nurse Aide (CNA A) was nasty and rude to him and did not assist him with getting cleaned up after being incontinent of bowels. According to R70 the incident made him feel angry and disrespected. Review of a Facility Reported Incident (FRI) reflected On 7/13/2022 (R70) reported that at approximately 12pm he had a BM (bowel movement). He pressed his call light, and (CNA A) answered it. R70 told CNA A he needed to be cleaned up. CNA A responded, They better get it together because I'm not going to do it. She turned off the call light without answering his needs and left the room. Another staff member assisted (R70) upon request. (R70) reported the incident to his nurse who immediately notified the Director of Nursing (DON). Further review of the FRI reflected the following conclusion After thorough investigation the facility had determined that the allegation of mistreatment can be substantiated .(CNA A) was interviewed and admitted to answering the call light and having a conversation with (R70) about his bowel medications but denied being told that he needed to be changed. (CNA A) stated that she thought (R70) needed to speak with a nurse and admits to turning off the call light and never reporting to the nurse because she was too busy providing care to her other residents however; when this incident was reported facility Administrator was initially unable to locate (CNA A) on her clinical floor and found her to be socializing in a manager office on the opposite end of the building .Statements from the coworker who assisted (R70) in getting cleaned up supports (R70's) allegation . Review of a staff statement dated 7/14/22 reflected that Licensed Practical Nurse (LPN) CC was rounding on her residents on 7/13/22 and was notified by (R70) that he needed to speak to a manager because his aide (CNA A) wheeled him in his room and left him soiled after he asked for assistance. (R70) stated that his aide told him They better figure it out and left the room. While talking to me I observed his pants saturated and he was visibly upset demanding to speak to the DON if the manager was unavailable. I asked him if he would like me to provide brief change at that time, but he refused, cussing and demanding that I notify my DON immediately. I then left the room and notified (DON). When I returned to the room to let him know she would be down to talk to him, he was calmer and allowed another CNA to provide brief change. Review of a staff statement dated 7/15/22 (two days after the incident) reflected CNA A was interviewed by the DON and the Nursing Home Administrator (NHA) via telephone. According to CNA A, she responded to R70's call light and R70 stated his bowel meds are making him go. (CNA A) suggested he speak with the nurse about adjusting the meds. (R70) agreed. (CNA A) turned off call light. (CNA A) states she was unaware (R70) was incontinent and admits to not asking him. (R70) did not asked to be changed and (CNA A) did not ask him if he needed to be changed. (CNA A) did not see the nurse as she was busy caring for other residents so was unable to notify nurse. Review of a statement documented by the NHA dated 7/15/22 reflected On 7/13/22 DON and facility administrator were notified of a care concern involving (R70) and his assigned (CNA A). I (the NHA) could not initially locate (CNA A) on the clinical floor or anywhere on her assigned unit. I remembered that our BOM (business office manager) and (CNA A) talked outside of work so I went to the BOM office and found (CNA A) visiting with the BOM with the door closed. Further review of the FRI dated 7/13/22 and submitted to the State Agency for review reflected the staff were re-educated on proper call light response but were not educated about the residents right to be free from abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient and adequate medically- related social services to identify and ensure the needs of one (Resident #6), of a total sample of 20, resulting in a lack of written and verbal communication in a language the resident can understand, advocating for resident rights, lack of legal representation, inaccurate resident assessments, assisting with financial and legal matters, advance care planning, and not seeking resources to meet the residents' needs. Findings include: Resident #6 (R6) Review of a Face Sheet revealed Resident #6 is an [AGE] year-old female who admitted to the facility on [DATE] with a pertinent diagnosis of dementia and a wedge compression fracture. Primary language is other. Review of the admission Minimum Data Set (MDS) revealed R6 had a Brief Interview for Mental Status (BIMS) on 11/23/21 upon admission with a score of 5. On 2/17/22 the resident had a BIMS score of 7, and on 5/5/22 a score of 00. The MDS dated [DATE] revealed a staff assessment based on observations only indicated R6 is moderately cognitively impaired. A BIMS score of 00 to 07 indicates a resident severely cognitively impaired and a score of 08 to 12 is moderately cognitively impaired. During an observation on 8/8/22 at 11:24 AM, R6 was ambulating in her room speaking another language this surveyor could not understand. R6 was trying hard to communicate and had facial grimacing that appeared to be frustration as she could not communicate. There is a handwritten paper on the wall next to her bed with three different phone numbers and at the bottom of the paper is says call this number to help translate. H is family. During an observation on 8/8/22 at 12:32 PM, R6 observed with her meal tray in front of her that had mashed potatoes that were untouched and a plastic covering was placed over it and a small piece of chicken that was at the end of her fork. R6 walked over to her roommate and gave it to her after trying to offer this surveyor her chicken while grabbing her throat with a grimacing facial expression. Her meal ticket revealed R6 was to have rice, soup, and a chicken breast. On 8/8/22 at 4:00 PM, an attempt to contact the family was not successful. A few minutes later the resident was observed eating rice in a bowl in her room and appeared to be happy. During an observation on 8/10/22 at approximately 8:40 AM, R6 was in the hallway trying to communicate with Registered Nurse (RN) V who reported she is not familiar with the residents on this unit because she normally works another unit and had a new assignment this day. R6 was observed in the hallway trying to get attention from RN V by using hand motions and grabbing her head, then rubbed her stomach, and then rubbed her back side. RN V told R6 she will bring her medications to her after she finished passing medications to another resident she had prepared for. RN B repeated the sentence to the resident a couple times as R6 was trying to communicate with the nurse. During an observation and an interview on 8/10/22 at 9:06 AM, R6 did not eat her breakfast. Certified Nursing Assistant (CNA) U reported R6 will not eat the food the facility provides but her family brings in food every night for her to eat and she will eat it. When queried about communicating with the resident, CNA U reported she could not understand the residents needs due to the language barrier, but the resident will try to use hand motions. The facility can call the family if she gets frustrated but that takes time. CNA U is unaware of any professional translators for the resident. Resident is observed sitting in the hallway in a chair soaking up the sun with her hat, robe, and slippers on. In an interview on 8/10/22 at 9:13 AM, Activities Director (AD) O reported she uses the Google Translator app and a Burmese communication board to communicate meal preferences with the resident. Review of the Electronic Medical Records (EMR) revealed R6 does not have a legal guardian or a power of attorney, but several legal documents had resident/legal representative signatures or an X in its place. Review of a Preadmission Screening and Resident Review (PASRR) dated 11/18/21 for R6 revealed an incomplete/inaccurate document that indicates the resident is a male with no court-appointed guardian or legal representative. The Resident is not documented as having dementia or mental illness. Review of the Advance Directives for R6 dated 11/20/21 revealed the document has a signature under the resident signature with two witnesses and unable to read what the residents' actual wishes are. The two witnesses signed that the declarant appears to be of sound mind, and declaring these wishes voluntarily, without fraud, duress, or undue influence. Review of a Consent for Care & Medical Treatment for R6 revealed a resident/representative signature on 11/20/21. Review of a vaccine consent for R6 dated 11/20/21 revealed a signature to decline the influenza vaccine. Review of an admission Agreement dated 11/23/21 for R6 revealed several X marks on the signature lines in several areas agreeing to different services, rights, and payments. Review of a Room Change notification for R6 dated 12/20/21 revealed no signature of acknowledgement. Review of two Notices of Medicare Non-Coverage (NOMNC) letters dated 12/27/21 and 7/29/21 revealed R6 did not sign these forms and her grandson was notified via phone. Review of a Podiatry consent dated 3/28/22 for R6 revealed the residents' initials agreeing to four different areas of the consent are legible and match the same handwriting as the person who wrote the residents name above the Patient legal Representative Signature line and the signature line has a scribbled H documented on it. Review of a Nursing Progress noted dated 6/18/22 for R6 revealed the resident held the side of her mouth as if she had a toothache, did not notice this behavior the rest of the shift. No further documentation or assessment indicating any communication or assessments were done. Review of a Physician Progress note dated 6/24/22 for R6 revealed the resident continues to require skilled nursing care for general well-being and help with activities of daily living. R6 has dementia and Alzheimer's and is on Gabapentin for neuropathic pain and methocarbamol (muscle relaxer) for pain. The Physician confirmed the residents Advance Care Plan is documented in the medical record either by discussing and documenting the patients Advance Care Plan, confirming the patient's surrogate decision maker is documented in the medical record, or confirming that the patient's Advance Care Plan is presently documented. Review of a Social Services Progress Note dated 6/28/22 for R6 revealed the social worker called the residents grandson to interpret a supportive visit. The resident told the grandson that she felt safe in the facility and feels well. R6 reported she was sad and wanted to return home and misses her family. Review of the Physician Progress note dated 7/25/22 for R6 revealed: She is from Myanmar and doesn't speak English. Speaks the [NAME] dialect and family has been the only reliable translator so far. Apparently, this is a rare enough language as to not be readily available on over the phone medical translating services. Patient has dementia and does not speak English. Review of a Progress note dated 7/26/22 for R6 revealed that the resident was on isolation precautions and ambulated out of her room multiple times, grandson educated on ISO precautions and rational to help educate resident . Review of a Progress note dated 7/31/22 for R6 revealed she continues to be non-compliant with staying in her room, redirected to her room multiple times. In an interview on 8/10/22 at 9:18, the Social Services Coordinator (SSC) R reported R6 has a staff assessed BIMS score of 00 now based on staff observations. When the resident was admitted to the facility, they tried to use a translator service over the phone, but the resident would not answer the questions and was not always focused. So now the facility is basing a BIMS score based on staff observations instead of interviews. SSC R reported R6 knows her name but not the days, months, or the seasons. SSC R reported in May the facility used the phone interpreter services to get an interview with the resident and the interpreter kept apologizing because she would not answer questions. SSC R reported she has been a Certified Nursing Assistant at the facility for several years and has been trained to be a Social Services Coordinator. SSC R reported she does the BIMS, PHQ9 assessments, the MDS portion related to social services, and obtains consents for the residents, does wellness visits, and other tasks. SSC R reported she is not sure who signed the advance directives for the resident but noticed it was witnessed by 2 staff. When questioned, SSC R reported R6 is her own person and that is why she did not have a legal guardian or a Power of Attorney (POA) but also stated the resident cannot make her own decisions. When queried, SSC R could not answer how the resident can be her own person then. SSC R reported the Unit Manager will usually initiate the process for residents to get a guardian or a POA if needed. When queried about consents for the podiatry and other healthcare services, SSC R reported that her son explained the consents and the resident agreed and put an H on the signature line. The resident is also on the list to see the dentist next week because the resident has been complaining her tooth is bothering her. In an interview on 8/10/22 at 10:46 AM, Social Worker (SW) S and Unit Manager T reported the Advance Directives are completed by the nurses that is included in the admission Packet upon admission and the 3877 (PASSR) upon admission will reveal if the resident is incompetent or not. UM T reported that if the resident is referred to be their own person, they would not have a representative. Both staff reported it was hard for the translators to communicate with the resident because the dialect is native to her family and her grandson can communicate very well with the resident. The Social Worker and Unit Manager reported they could not talk about the past Resident Assessments because they did not complete the assessments and could not say whether the grandson was present or on the phone for past assessments. SW S reported the SSC R does the BIMS assessments and signs off on them. Residents with a low BIMS score is brought to the morning meetings and then they have 2 physicians to review the mental capacity of the residents. SW S reported he had a pathway of steps he follows at that point but did not provide a copy by the end of survey when asked during this interview. SW S reported he has been here in this role for 7 months. Review of the Care Plan initiated 11/23/21 for R6 revealed she has a communication and/or comprehension concern r/t hearing deficits and language barrier and speaks Myanmar. Interventions included but not limited to: 1. Ask yes/no questions in order to determine the resident's needs. 2. Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off tv/radio to reduce environmental noise, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. 3. Provide translator, as necessary. Translator is the interpreter line. (R6) needs encouragement for meeting emotional, intellectual, physical, and social needs (related to): Able to make independent choices and preferences known Date Initiated: 11/22/2021. Interventions include but not limited to 1. (R6) speaks Burmese with a Myanmar dialect: 2. Communication board and translation services phone number available in room. 3. All staff to converse with (R6) while providing care. 4. Review (R6) activity needs with family/representative. Care Plan for R6 revealed a goal is for the resident/representative to maintain long term care within the facility related to the inability of family/others to provide support in the home. Interventions included but not limited to: 1. Provide resident/representative with additional information or referrals to community services as requested or needed. 2. Review resident/representative wishes in regards to placement quarterly and prn (as needed). Adjust plan of care as needed. Review of a Best Practice Resident Interviews-BIMS and PHQ9 Interviews provided by the facility revealed: Complete resident interviews or staff assessments using the UDA found under the Assessment tab in PCC on or before the MDS ARD to provide supporting documentation and validate MDS coding. Follow up: Email/Notify MDS team if change in status occurs or new condition such as consult, new medication, behaviors, or change in cognition that may warrant a new PHQ-9 or BIMs interview so that an IPA (Interim Payment Assessment) or SCSA (Significant Change in Status Assessment) can timely be initiated as applicable. Review of a policy titled Foreign Language Residents adopted 1/1/2020 revealed: It is the policy of this facility to provide assistance to residents who do no speak the dominant language in facility. The procedures included providing a communication book/board and providing interpreter services. Review of the Social Workers-Bachelors job description revealed: The Social Worker - Bachelors is responsible to provide medically related social work services so that each Resident may attain or maintain the highest practicable level of physical, mental, and psychosocial well-being. This position assesses and treats emotional and behavioral problems related to patient illness. Participates as a member of interdisciplinary team and may assist patients in treatment planning. The duties and responsibilities included but not limited to: Responsible for training and educating staff in the Social Services department. -Assesses and evaluates each Resident's psychosocial needs and develops goals for providing the necessary services and takes part in the admissions process as needed. -Incorporates the Social Service goals in the Resident's Plan of Care and attends care planning conferences. -Assists the Residents in adjusting to the facility and promotes a positive environment for the continuity of relationship with family and community. -Assists Residents and families to utilize the community resources when not provided directly by the facility. -Maintains confidential records and interviews with Residents and families as appropriate. -Assists in the development, supervision, and education of staff. -Serves as the team lead or assigns team lead to a staff in the department in discharge planning. -Ensures completion of any required components of DPOA or guardianship paperwork. -Coordinates services with psychiatric providers. -Coordinate services with OBRA including assisting in overseeing proper completion and management of the PASARR program. -Assists the Clinical IDT in resident room management. -Assists residents and families in resolving grievances as assigned. -Attend Clinical IDT Meetings and serves as an advocate for Resident Rights. -Reports all hazardous conditions, damaged equipment, and supply issues to appropriate persons.

Based on observation, interview, and record review the facility failed to: 1. Properly date mark potentially hazardous ready to eat foods, 2. Ensure that the dish machine was sanitizing the dishes properly. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that could affect the 78 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the main kitchen starting at 10:55 AM on 8/8/221, with Food Service Director (FSD) I, a review of the Walk-In Cooler found open package of ham and salami without being date marked. When asked about the dates (FSD) I revealed that the deli meat was good for 3 days and should have been date marked. FSD I removed the item's from the Walk-In Cooler. According to the 2013 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT . 2. During the initial tour of the dish washing area on 8/8/20, observation that the water temperature on the high temp dish machine was not getting hot enough (180-200 degrees Fahrenheit) during the rinse/sanitizing cycle. Upon watching the gauge on the dish machine for an additional two complete cycles, it was noted that sanitizing temperatures were not being reached. FSD I was asked to provide a test strip or device (a mechanism that is used to measure the water temperature on the surfaces of the dishes inside the machine during the final/sanitizing cycle). Staff provided a square yellow digital dishwasher thermometer, that is waterproof and used for measuring the surface temperature of water inside a commercial dish machine. The thermometer was turned on and placed inside the dish machine, with a rack of dirty dishes. After the cycle, the reading on the thermometer read 158.4 degrees F the max temperature. The thermometer was cleared after every complete cycle, and the dish machine was run three more times. Observation of the digital thermometer noted the measuring device never read above 158-degree range. On the 7th run of the dish machine, the gauge on the outside of the machine read 158 degrees during the wash cycle and 161 degrees during the rinse/ sanitizing cycle, the digital thermometer read 158.7 degrees F as the max temp. FSD I stated she would have the Maintenance Director (MD) K to look at it right away. According to the 2013 FDA Food Code section 4-703.11 Hot Water and Chemical. After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: (B) Hot water mechanical operations by being cycled through equipment that is set up as specified under 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71 degrees Celsius (160 degrees Fahrenheit) as measured by and irreversible registering temperature indicator, During an interview on 8/9/22 at 10:45 AM, Registered Dietitian (RD) N informed this surveyor that staff education on Date Marking and on the Dish Machine were taking place. RD N stated the dish machine was repaired.