Based on observations, record review, staff interviews and review of the manufacturers guidelines the facility failed to discard an expired multi dose oral inhaler, and expired nebulizer solutions, and record an opened date on a nebulizer solution on 2 of 3 medication carts and failed to discard an expired influenza vaccine and nebulizer solution in 1 of 2 medication rooms reviewed for medication storage. Findings included. Review of the manufactures guidelines revealed Trelegy multi dose oral inhalers should be discarded 6 weeks after opening. Ipratropium Bromide 0.2% nebulizer solution and Levalbuterol 1.25 milligram (mg) nebulizer solution should be discarded 2 weeks after opening the foil pouch. An observation of the B hall medication cart on 06/08/23 at 10:00 AM revealed a Trelegy oral inhaler with an opened date of 03/27/23. The label on the inhaler instructed to discard 6 weeks after opening. Ipratropium Bromide 0.2% nebulizer solution was observed in an opened foil pouch with no opened date. During an interview with Medications Aide #1 on 06/08/23 at 10:00 AM she stated expiration dates should be checked prior to administering the medications. She stated she was not aware the Trelegy oral inhaler, or the Ipratropium Bromide nebulizer solution were expired because she had not administered those medications. She stated the nurses were responsible for checking the medication carts for expired medications. An observation of the C hall medication cart on 06/08/23 at 10:30 AM revealed an Ipratropium Bromide 0.2% nebulizer solution with an opened date of 03/20/23. Levalbuterol 1.25 mg nebulizer solution with an opened date of 05/07/23. The instructions on the foil pouch of the Ipratropium Bromide nebulizer solution and the Levalbuterol nebulizer solution read to discard 2 weeks after opening. During an interview with Nurse #1 on 06/08/23 at 10:30 AM she stated she was not aware the Ipratropium Bromide or the Levalbuterol solution was expired. She stated Medication Aide #2 was working on the medication cart today and Nurse #1 had not checked the cart yet for expired medications. She stated the nurse, or the medication aides were responsible for checking expiration dates prior to administering the medications. She stated the night shift nurses also checked the medication carts on Friday nights for expired medications. She stated it was an oversight. An observation of the B/C hall medication storage room on 06/08/23 at 10:45 AM revealed Levalbuterol 1.25 mg nebulizer solution in a foil pouch with an opened date of 05/15/23. Ipratropium Bromide 0.2% nebulizer solution was observed with no opened date. The instructions on the foil pouch of the Ipratropium Bromide solution and the Levalbuterol solution read to discard 2 weeks after opening. An observation of the B/C hall medication storage room refrigerator on 06/08/23 at 10:45 AM revealed an opened vial of Influenza vaccine with an expiration date of 05/25/23. During an interview on 06/08/23 at 1:00 PM the Director of Nursing stated the nurses and medication aides should be checking the carts for expired medications. She stated they had a process in place to check for expired medications which included checking the medication expiration date prior to administration, night shift checked all carts once a week on Friday, and the Consultant Pharmacist also checked for expired medications monthly. She stated the expired medications should not have been on the medication cart or in the medication storage rooms. She stated education would be provided to nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to protect a resident's right to be free from mistreatment by a staff member (Nursing Assistant #3) due to being rough while provide care and making disrespectful comments to 1 of 1 resident reviewed for mistreatment (Resident#49). The Findings included: Resident #49 was admitted to the facility on [DATE]with a diagnosis of metabolic encephalopathy and Parkinson's disease. The Annal Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was cognitively intact. A review of the email correspondence included in the facilities investigation dated 8/24/21 at 10:46 AM from the Facility Supervisor nurse to the Staff Development Coordinator (SDC) read: [Resident #49] told [Nurse #1] today [8/24/21] that last night [Nursing Assistant (NA) #3] was rough with [Resident #49]. She also explains that [NA #3] kept complaining that her back was hurting. [Resident #49] states that [NA #3] would grab her legs and when they got into the bathroom had to be asked to help her on the toilet. [Resident #49] told [Nurse #1] that when she was getting back to bed [NA #3] had grabbed her legs so hard that she was yelling to let go because of the pain. [Resident #49] then stated that [NA #3] told her 'I did not put them bruises on your legs, I know that is what you white women try to say about us black women'. An email from the Staff Development Coordinator (SDC) on 8/24/21 at 11:20 AM to the Facility Supervisor read; does she have any bruises. The email response at 8/24/21 at 12:07 PM back from the Facility supervisor to the SDC read: [Nurse #1] says she does but they were there previously. A review of Resident #49's skin evaluations revealed the following skin assessments: August 20,2021 8:07 PM - skin is warm, dry, fragile. Discoloration noted to both lower extremities (BLE). Some bruising noted to both upper extremities (BUE). No new areas noted. August 25th, 2021- 8:06 AM pressure reducing matters in place to help prevent skin breakdown. August 27th, 2021- 8:30 PM - Skin is warm, dry, fragile. Discoloration noted to BLE. Skin tear to back side of right hand. Some bruising noted to BUE. No new areas noted. There was no skin evaluation documented after the facility became aware of the incident with Resident #49 and NA #3 on August 24, 2021. A review of the Social Workers (SW) interview with Resident #49 included in the facilities investigation dated 8/24/21 read in part; [Resident #49] felt like [NA #3] was upset about something because she stated to [Resident #49] 'I don't have time to mess with you,' the NA then grabbed Resident #49's calves and squeezed them while she was helping her get up. [Resident #49] screamed because it hurt, and she asked the NA to please not do that, it hurt. When [Resident #49] was being put back to bed, the NA squeezed her calves again. [Resident #49] stated that NA #3 said 'I know what you white women will say to us black women put bruises on you'. [Resident #49] stated she did not know why NA #3 said that. An interview and observation were completed with Resident #49 on 12/14/21 at 9:01 AM. An observation of Resident #49's both lower extremities revealed her legs are very small and skin was red and blotchy. Resident #49 stated a staff member was very rough with her one night back in the fall when she needed to use the bathroom. Resident #49 stated that she had pressed her call light and NA #3 came in and had asked me what I needed, and huffed and said lordy, lordy then grabbed my legs and snatched them around. Resident #49 mentioned that NA #3 stated to her I know all about you white people, you gather together and say anytime you get a bruise you say a black person did it. Resident #49 stated I really felt mad when that happened. Resident #49 stated that she told NA #3 that she was nothing but a racist because of what she said to me. Resident #49 stated that her comments still bother me and every time I think about how uncalled for it was. I get along with everyone and I don't know why she (NA #3) was so mean, I guess I am not made to be in nursing homes. An interview was completed with the Social Worker (SW) on 12/14/21 at 2:54 PM who stated she recalled that NA #3 (on 8/24/21) went into Resident #49's room and grabbed her legs and when NA #3 went to put her back to bed grabbed her legs again. The SW stated that Resident #49 told her she that NA #3 made a comment to Resident #49 that 'you white women get together and say black people put bruises on her'. The SW was asked did you ask Resident #49 how this made her feel and the SW responded, well, she did not like it of course. The SW stated regarding the comment 'I don't have time to mess with you' NA #3 should not have said that. An interview was completed with the SDC and the Facility Supervisor on 12/14/21 at 3:10 PM. The Facility Supervisor stated that she did go in and speak with Resident #49 and did look at her legs but did not chart it. The Facility Supervisor stated that Resident #49 had stated that the NA #3 did grab her legs and her legs had hurt from what happened. The Facility Supervisor stated she did have scattered bruising but like the Nurse #1 stated the bruising was already there The Facility Supervisor stated that Resident #49 stated her legs hurt from what happened. An interview was completed on 12/15/21 at 2:53 PM with NA #5 who was asked how she assists Resident #49 to get up out of bed. NA #5 stated she would first get her walker and put this by the bed and then would put her one arm under her thighs and the other around her shoulder and rotate her. NA #4 stated that you do have to be careful of her calf areas as they can be sensitive. An interview was completed on 12/15/21 at 2:53 PM with NA #6 who was asked how she assists Resident #49 to get up out of bed. NA #6 stated that Resident #49 does hurt a lot and you have to be very careful with her and one must turn her legs straight out and help her sit up. Once she would sit up you cannot rush her as she needs to get her balance. When you grab her [Resident #49's] legs you just lightly pull on her legs to the side and move her by her hips, if you pull to hard you will really hurt her and stated, Resident #49 will always let you know. An interview was completed on 12/15/21 at 5:13 PM with Nurse #4 who was working third shift on 8/23/21 from 11:00 PM to 7:00 AM who was asked if she had heard any yelling from Resident #49's room that evening. Nurse #4 stated, I did not hear her [Resident #49] scream. An interview was completed on 12/15/21 at 8:53 PM with NA #3 who stated that it is very hard to get Resident #49 out of bed as you need to hold her walker and hold her at the same time. NA #3 stated that Resident #49 was concerned about the bruises on her legs and NA #3 stated the bruises were not that bad and was trying to re-direct Resident #49 instead of focusing on her legs. NA #3 was asked if she had grabbed Resident #49's calves and NA #3 stated that she did not remember and stated that you have to put your hands underneath her calves and bring her legs around to the side of the bed and physically pull her legs and you have to put some energy into it and put pressure on her legs. NA#3 was asked if she was too rough with Resident #49, and she stated she did not think she had been too rough with Resident #49 but there was a lot of pushing and pulling and nothing was intentional. NA #3 stated it had been a rough night. NA #3 stated she did not remember her screaming in pain and was not rushing her. NA #3 stated she knew Resident #49's legs are sensitive, and Resident #49 told NA #3 to go slower. NA #3 stated that she did tell her to come on that her back was about to give out. NA #3 was read the statement interview from the SW and Resident #49 which indicated NA #3 stated to Resident #49 'I don't have time to mess with you' 'I know all about you white people, you gather together and say anytime you get a bruise you say a black person did it. NA #3 stated that she did not say those things to Resident #49 and would never put anybody down. NA #3 stated she had not been asked to write any statements about what happened but stated; I wish they would have, as I cannot remember the details of what happened now.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #49 was admitted to the facility on [DATE]with a diagnosis of metabolic encephalopathy and Parkinson's disease. The Annal Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was cognitively intact. A review of a policy titled: Abuse Investigations and Reporting for Senior Services revision date 3/5/21 read in part: Identification and Investigation: 2. The administrator or designee is responsible for ensuring the thorough investigation of the allegation. 3. Upon receiving a report of physical abuse, the nursing supervisor (or designee) shall immediately examine the resident. Finding of the examination must be recorded in the resident's record. 5. The director of nursing or designee will begin the abuse investigation which will consist of: Completing the Division of Health Service Regulation (DHSR) required reporting from the (initial allegation report) Interviewing the person(s) reporting the incident Interviewing staff members (on all shifts) that have had contact with the resident during the period of this alleged incident Reviewing all circumstances and events leading up to the incident 6. Witness reports will be made in writing, signed and dated. Witness reports will be maintained with all written reports. The director of social work or designee will monitor the resident's feeling concerning the incident, as well as the resident's reaction to his/her involvement in the investigation. Reporting: For certified nursing facilities and skilled nursing facilities, all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than two hours after the allegation is made A review of the facility's reportable incidents revealed no reportable investigations were completed related to the allegation of staff to resident abuse for Resident #49. The facility completed an investigation which included the following: Social Worker's (SW) interview with the resident, email correspondence between the Facility supervisor and the SDC, a signed statement from the Administrator and a Employee Coaching/Disciplinary Action Report. There were not signed statements from any staff. A review of the email correspondence included in the facilities investigation dated 8/24/21 at 10:46 AM from the Facility Supervisor nurse to the Staff Development Coordinator (SDC) read: [Resident #49] told [Nurse #1] today [8/24/21] that last night [Nursing Assistant (NA) #3] was rough with [Resident #49]. She also explains that [NA #3] kept complaining that her back was hurting. [Resident #49] states that [NA #3] had grabbed her legs and then they got into the bathroom had to be asked to help her on the toilet. [Resident #49] told [Nurse #1] that when she was getting back to bed [NA #3] had grabbed her legs so hard that she was yelling to let go because of the pain. [Resident #49] then stated that [NA #3] told her 'I did not put them bruises on your legs, I know that is what you white women try to say about us black women'. An email from the Staff Development Coordinator (SDC) on 8/24/21 at 11:20 AM to the Facility Supervisor read; does she have any bruises. The email response at 8/24/21 at 12:07 PM back from the Facility supervisor to the SDC read: [Nurse #1] says she does but they were there previously. A review of Resident #49's skin evaluations revealed the following skin assessments: August 20,2021 8:07 PM - skin is warm, dry, fragile. Discoloration noted to both lower extremities (BLE). Some bruising noted to both upper extremities (BUE). No new areas noted. August 25th, 2021- 8:06 AM pressure reducing matters in place to help prevent skin breakdown. August 27th, 2021- 8:30 PM - Skin is warm, dry, fragile. Discoloration noted to BLE. Skin tear to back side of right hand. Some bruising noted to BUE. No new areas noted. There was no skin evaluation documented after the facility became aware of the incident with Resident #49 and NA #3 on August 24, 2021. A review of the Social Workers (SW) interview with Resident #49 included in the facilities investigation dated 8/24/21 read in part; [Resident #49] felt like [NA #3] was upset about something because she stated to [Resident #49] 'I don't have time to mess with you', the NA then grabbed Resident #49's calves and squeezed them while she was helping her get up. [Resident #49] screamed because it hurt, and she asked the NA to please not do that, it hurt. When [Resident #49] was being put back to bed, the NA squeezed her calves again. [Resident #49] stated that NA #3 said 'I know what you white women will say to us black women put bruises on you'. [Resident #49] stated she did not know why NA #3 said that. A signed statement from the Administrator dated 8/24/21 read in part; After reviewing interviews conducted by the social worker on 8/24/21, with [Resident #49] and other residents on that assignment and reviewing recent body assessments of [Resident #49], I concluded that abuse did not take place. The encounter with the third shift [NA #3] and [Resident #49] was inappropriate but the behavior did not meet the definition of abuse defined by the Centers for Medicaid Services (CMS). Abuse, means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.'(42 CFR 488.301). However, this encounter did not meet the facility's expectation with the standard set-in place for customer service and professionalism. These expectations clearly stated in the LSC (Lutheran Services Carolina) WAY policy. Teammate [NA #3] was removed from this resident's [Resident #49] assignment. An interview and observation were completed with Resident #49 on 12/14/21 at 9:01 AM who stated that a staff member was very rough with her one night back in the fall when she needed to use the bathroom. Resident #49 stated that she had pressed her call light and NA #3 came in and had asked me what I needed, and huffed and said 'lordy, lordy' then grabbed my legs and snatched them around. She grabbed my legs below the knee and was very rough and squeezed them, she left fingerprints. Resident #49 stated she had used the walker to walk to the bathroom and when NA #3 had put Resident #49 back to bed she threw her back into bed and was very rough. Resident #49 described that her right calf was the worst because of the pain. Resident #49 stated that NA #3 said to her I know all about you white people, you gather together and say anytime you get a bruise you say a black person did it. Resident #49 stated I really felt mad when that happened. I told NA #3 that she was nothing but a racist because of what she said to me. Resident #49 stated I was not bleeding it just really hurt. Resident #49 stated that NA #3 is no longer able to come into my room. An observation of Resident #49's BLE revealed her legs are very small and skin was red and blotchy. A follow up interview was completed with Resident #49 on 12/15/21 at 5:30 PM who stated that her comments still bother me and every time I think about how uncalled for it was. I get along with everyone and I don't know why she (NA #3) was so mean, I guess I am not made to be in nursing homes. An interview was completed with the Social Worker (SW) on 12/14/21 at 2:54 PM who was asked if she had asked Resident #49 how this made her feel and the SW responded, well, she did not like it of course, but was not asked. The SW stated I do not know why it was not reported. An interview was completed with the SDC and the Facility Supervisor on 12/14/21 at 3:10 PM The Facility Supervisor stated the SDC notified the Administrator, and she did not direct a 24-hour report to be completed. The Facility Supervisor stated that she did go in and speak with Resident #49 and did look at her legs but did not chart it. The Facility Supervisor stated that Resident #49 had stated that the NA #3 did grab her legs and she did have scattered bruising but like the Nurse #1 stated the bruising was already there. The Facility Supervisor stated that Resident #49 stated her legs hurt from what happened. The SDC and the Facility Supervisor was asked if NA #3 was suspended. The SDC stated that she did not work the next night as she had called out, and by then the investigation was completed and we did not need to suspend her. She was removed from performing care to Resident #49. An interview was completed with the Administrator on 12/15/21 at 9:16 AM who stated that the facility became aware of the allegation of staff to resident abuse for Resident #49 at 10:45 AM on 8/24/21 and started the investigation. The Administrator was asked what the allegation was about, and the Administrator stated it was an allegation of an unpleasant encounter and Resident #49 was upset about the encounter and the facility wanted to follow up. The Administrator stated the facility did not report this allegation to the state as it did not meet the definition of abuse per the regulation. The Administrator stated that Resident's #49 does have frequent pain and when she if they are moving her legs, she would be in chronic pain regardless of if she had complained of pain. The Administrator stated, Do I think the encounter should have gone differently absolutely, but I don't think the criteria of abuse was met. The Administrator was asked why they did an investigation and the Administrator stated that we do an investigation with any conduct that does not meet our customers expectations. An telephone interview was competed with Resident #49's responsible party (RP) on 12/15/21 at 10:45 AM who stated they had visited Resident #49 that morning on 8/24/21. The RP stated they did remember some racial comments that were made. The RP was asked if they remember any way Resident #49 was treated physically and the RP responded, I do remember [Resident #49] saying that [NA #3] squeezed her legs but did not recall if she had any marks. The RP stated that my mom is not one to get upset but would get mad if she thought something was wrong. The RP stated Resident #49 has on-going skin issues and if the aides would accidentally bump it on a wheelchair or something it causes her discomfort. An interview was completed on 12/15/21 at 5:13 PM with Nurse #4 who was working third shift on 8/23/21 from 11:00 PM to 7:00 AM and was asked if she was interviewed about the incident with Resident #49 and NA #3. Nurse #4 stated that no one had interviewed her about the incident. An interview was completed on 12/15/21 at 8:53 PM with NA #3 who stated she did not think she had been too rough with Resident #49 but there was a lot of pushing and pulling and you have to guide her legs and put pressure on them. NA #3 stated she did not remember her screaming in pain and was not rushing her. NA #3 stated she knew Resident #49's legs are sensitive, and Resident #49 told NA #3 to go slower. NA #3 stated that she did tell her to come on that her back was about to give out. NA #3 stated that she did not recall Resident #49 screaming out in pain. NA #3 was read the statement interview from the SW and Resident #49 which indicated NA #3 stated to Resident #49 'I don't have time to mess with you' 'I know all about you white people, you gather together and say anytime you get a bruise you say a black person did it. NA #3 stated that she did not say those things to Resident #49. NA #3 stated she had not been asked to write any statements about what happened but stated; I wish they would have, as I cannot remember the details of what happened now. An interview was completed with the DON on 12/16/21 at 10:11 AM who was asked what the process was for reporting abuse allegations. The DON stated that if the resident said it was on purpose, they would report it and if there was full intent, we would do an investigation. The DON stated that any allegation of abuse should be reported to the state. The DON stated that she did remember that there was an incident with NA #3 and Resident #49 during a transfer and stated that she felt that the NA had moved too quickly for the resident and did not think that NA #3 would do anything intentional. The DON stated that Resident #49 likes to be moved slowly and she will tense up and complain of pain. The DON stated that she thought she had been on vacation during the incident and that is all she could remember. A follow up interview was completed with the Administrator on 12/16/21 at 2:26 PM who stated that once the interviews were completed with Resident #49 and NA #3 it seemed to be more of a customer service situation, and it was not reported. The Administrator stated that during an investigation the facility would get interviews and written statements from staff but was not sure if they had gotten one from NA #3. The Administrator stated the night nurse should have been interviewed and a skin assessment should have been completed. Based on record review and family and staff interviews facility staff failed to follow the facility's Abuse Investigation and Reporting for Senior Services Policy when they failed to promptly report allegations of abuse for 2 of 3 residents, Residents #113, and Resident #49, reviewed for abuse. Resident #113 reported allegations of abuse to a staff member who did not report the allegation to facility management, which resulted in the accused staff member not being removed from the facility and an investigation being delayed. Resident #49 also reported allegation of abuse to staff, and they failed to report the allegation to the Division of Health Service Regulation and failed to assess Resident #49 and investigated the allegation. The findings included: 1. A review of the Abuse Investigation and Reporting for Senior Services revised on 3/5/2021 revealed facility staff should report observed or suspected incidents of abuse to his/her department manager as soon as he is aware of an incident or potential incident. The nursing supervisor or department manager must notify the administrator and the director of nursing immediately. The administrator or designee is responsible for ensuring the thorough investigation of the allegation. While the investigation is pending, the accused individual employed by the facility will be suspended, pending the results of the investigation. Resident #113 admitted to the facility on [DATE] with diagnoses of heart disease and dementia. Resident #113's Annual Minimum Data Set assessment dated [DATE] indicated she was moderately cognitively impaired and required extensive assistance with bed mobility and set up assistance with her meal trays. A review of an abuse investigation dated 5/14/2021 revealed Resident #113's Family Member called the facility to report Resident #113 had told him, while she was visiting with the Family Member in his home, Nurse Aide #1 had slammed her dinner tray down on her over bed table several weeks ago, causing pain in her legs, and had threatened to do it again. The Family Member asked Resident #113 if the incident was an accident and she stated Nurse Aide #1 had meant to do it and she was afraid of him. During an interview with Nurse Aide #1 on 12/15/2021 at 3:58 pm he stated Resident #113 told him he had hit her with the over the bed table, but he could not remember the date it happened. He stated he told Nurse #4 when the incident occurred that Resident #113 had accused him of hitting her with the over the bed table and he was reassigned to another resident and did not take care of Resident #113 again. Nurse Aide #1 stated he was not suspended when he reported the incident to Nurse #4, and he continued to work that night. Nurse Aide #1 stated about 2 weeks after the incident the Staff Development Coordinator called him and suspended him pending an allegation and then three days later the Director of Nursing called him and told him to come to work early and she interviewed me before I went back to work. During an interview with Nurse #4 on 12/15/2021 at 5:13 pm she stated Nurse Aide #1 did not report Resident #113's allegation to her when it occurred on 4/30/2021. Nurse #4 stated Resident #113 told her Nurse Aide #1 intentionally slammed the over bed table on her knees on 5/7/2021, a week after the incident happened. Nurse #4 stated she immediately went to Nurse Aide #4, who was working at the time, and asked him what happened, and he told her it was an accident. Nurse #4 stated Nurse Aide #1 stated the over the bed table dropped and hit her knees and he looked at her knees but did not see any injury. Nurse #4 stated she reported the incident to the Charge Nurse on 5/7/2021 when Resident #113 reported the allegation to her. An interview was conducted with the Charge Nurse on 12/15/2021 at 5:38 pm and she stated she did not remember Nurse #4 reporting an allegation of abuse involving Resident #113 and was not aware of the incident. On 12/16/2021 at 1:05 pm an interview was conducted with the Director of Nursing and she stated she was not aware of Resident #113 reporting the allegation of abuse until the Family Member called the Staff Development Coordinator on 5/14/2021 and reported the allegation. The Director of Nursing stated she was not working when the allegation was reported, and the Staff Development Coordinator had suspended Nurse Aide #1 and obtained the statements from the staff. The Staff Development Coordinator was interviewed on 12/16/2021 at 2:07 pm and stated he was not aware of the abuse allegation regarding Resident #113 until 5/14/2021 when the Family Member called him to report Resident #113 told him that Nurse Aide #1 intentionally slammed the over the bed table on her legs several weeks ago. He stated he had immediately made the Administrator aware of the allegation and suspended Nurse Aide #1 until the investigation was completed. The Staff Development Coordinator stated the staff receive abuse education at least annually and any time there is an allegation of abuse. During an interview with the Administrator on 12/16/2021 at 2:21 pm she stated she was not aware Resident #113 had reported the allegation of abuse to Nurse #4 before it was reported by the Family Member to the Staff Development Coordinator on 5/14/2021. The Administrator stated Nurse #4 should have reported Resident #113's allegation of abuse regarding Nurse Aide #1 slamming the over the bed table down on her legs intentionally to her immediately. The Administrator stated Nurse Aide #1 should have reported to Nurse #1 and the Charge Nurse when the resident told him her hurt her legs with the over the bed table. The Administrator stated the staff should follow the facility's policy for Abuse Investigation and Reporting for Senior Services and report any allegations of abuse immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #42 was admitted to the facility on [DATE] with diagnoses that included muscle weakness and gait abnormalities. A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted. The functional status section of the MDS reported the resident required supervision only for transfer, dressing, toilet use and personal hygiene and the assistance of 1 person. For eating she required supervision only with meal set up assistance. She needed limited assistance from staff for bed mobility with the assistance of 1 person. Locomotion occurred only 1-2 times with 1 person assist on the unit. A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted. The functional status section of the MDS reported the resident required supervision only with eating and one person physical assist. She required extensive assist of 2 staff with bed mobility, extensive assist with 1 person assist for transfer, dressing, toilet use and personal hygiene An interview was conducted with MDS Nurse #1 on 12/15/21 at 9:45 AM regarding the decline in the functional status on Resident #42's Quarterly assessments from 08/04/21 to 10/27/21. The MDS nurse stated the resident had not changed much and did not indicate a need for a significant change assessment to be completed. She stated they looked at the Activities of Daily Living (ADL's), but they can fluctuate and if they need a significant difference in care and had 2 or more differences in care, they might do one. An interview was done on 12/15/21 at 10:33 AM with Nurse #5 regarding Resident #42. He stated the resident used to be very independent and after one of her falls, she now required a lot more assistance. An interview was done on 12/15/21 at 11:11 AM with PT #1 that completed the requested rehabilitation evaluation after some falls. He stated he evaluated her post falls on 09/15/21 and she had she absolutely refused to participate. He noted she would not stand when asked or actively participate and had become more non-compliant since completing therapy in June 2021. Record review indicated Resident #42 had 7 falls since admission including 08/31/21 and 11/14/21. Record review of X-rays from 9/17 indicated a pelvis fracture. A follow-up interview was done on 12/16/21 at 12:03 PM with MDS Nurse #1 and she was asked why a significant change assessment was not done with 2 or more changes, and with several functional area declines. She stated the final decision if a significant change needed to be done was made by the Interdisciplinary Team, which consisted of the 2 MDS nurses. An interview was done on 12/16/21 at 1:05 PM with the Administrator. She stated if there were changes on the MDS assessment in 2 or more areas and the changes were for a prolonged time, a significant change should be done. Based on staff and resident interviews and record reviews the facility failed to complete significant change Minimum Data Sets (MDSs) for 2 of 2 residents reviewed for a change in status (Resident # 39 and resident # 42). Findings included: 1.Resident # 39 was readmitted to the facility on [DATE] with diagnoses of spinal stenosis, peripheral vascular disease (PVD) and transient ischemic attack (TIA). Review of an annual MDS dated [DATE] revealed that Resident # 39 had moderate cognitive impairment and required extensive assist of at least 2 staff for bed mobility ,transfers and toileting. Resident # 39 required supervision to limited assist of 1 staff to eat, was always incontinent of bladder and bowel and had no pain. A quarterly MDS dated [DATE] for Resident # 39 included that Resident # 39 had significant cognitive impairment, felt down, depressed, or hopeless on at least 1day of the review period and 12 to 14 days of feeling bad about herself. Resident # 39 required extensive assist of 1 staff to eat and was frequently incontinent of bladder and bowel. Resident # 39 had no pain. A review of a quarterly MDS dated [DATE] included that Resident # 39 required supervision and set up to eat and she had frequent pain that limited her day-to-day activities. An interview conducted with MDS nurse # 1 on 12/16/2021 at 11:00 AM. MDS nurse #1 stated that a significant change MDS was required if a resident had 2 areas of decline or improvement in resident status as determined by the interdisciplinary team that consisted of MDS nurse #1 and MDS nurse #2. MDS nurse # 1 stated that there had been a difference in MDS coding for Resident # 39 but that she was not certain the MDS was coded correctly. The administrator was interviewed on 12/16/2021 at 1:22 PM. The administrator stated that she expected that significant change MDSs be completed as stated in the regulation and the Resident Assessment Manual (RAI).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop and implement comprehensive care plans for 2 of 2 residents (Resident #42, Resident #59) reviewed for care plans. The findings included: 1. Resident #42 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, muscle weakness and gait abnormalities. A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted. The functional status section of the MDS reported the resident required supervision only for transfer, dressing, toilet use and personal hygiene and the assistance of 1 person. For eating she required supervision only with meal set up assistance. She needed limited assistance from staff for bed mobility with the assistance of 1 person. Locomotion occurred only 1-2 times with 1 person assist on the unit. A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted and indicated several areas of decline. The functional status section of the MDS reported the resident required supervision only with eating and one person physical assist. She required extensive assist of 2 staff with bed mobility, extensive assist with 1 person assist for transfer, dressing, toilet use and personal hygiene A review of Resident #42's care plan initiated on 05/25/21 and most recently revised on 10/29/21 indicated a care area for Help with my ADL's. The care area only addressed oral hygiene and refusal of care for her ADL's. An interview was conducted with MDS Nurse #1 on 12/15/21 at 9:45 AM regarding the care plan not reflecting the ADL decline in the functional areas. She stated she did not know what the staff would see on Resident #42's care plan as she had a different view. She stated the ADL information displayed in her view. A follow-up interview was done with MDS Nurse #1 on 12/15/21 at 12:03 PM. She stated the nurses were not able to view the ADL functional need information on Resident #42's care plan and she did not know why. The MDS nurse noted that usually the care plan had more information than just oral care such as transfers, bathing and mobility in the care plan. An interview was done on 12/16/21 at 1:05 PM with the Administrator regarding Resident #42's ADL decline and her care plan. She stated the care plan should be all inclusive and everyone should be able to see the care areas and interventions. 2. Resident # 59 was admitted to the facility on [DATE] with diagnoses that included dementia, insomnia, and a history of falls. A significant change Minimum Data Set (MDS) dated [DATE] included that Resident # 59 had severe cognitive impairment and required supervision of 1 staff with meals. Resident # 59 weighed 109 pounds and was not on a physician prescribed weight loss regimen. Review of a nutritional progress note dated 11/17/2021 at 12:07 PM included that Resident # 59 had a significant weight loss. She received a regular diet and a nutritional supplement two times a day. Resident # 59 was recorded to consume an average of 49% of meals. On 12/16/2021 the care plans for resident # 59 were reviewed and had been updated on 09/16/2021 and on 11/23/2021. The nutritional status and weight loss of resident # 59 was not included in the comprehensive care plans. MDS # 1 was interviewed on 12/16/2021 at 11:00 AM. MDS nurse #1 reviewed the current care plans for Resident # 59 and stated that she did not see nutritional or weight loss care plans for Resident # 59 and that there should be care plans to address those areas. The facility administrator was interviewed on 12/16/2021 at 1:22 PM and she stated that she expected care plans to be implemented and revised to reflect the status of the resident.

Based on record review and staff and family interviews the facility failed to provide effective oversight to ensure abuse allegations made by 2 of 3 residents, Resident #113 and Resident #49, were assessed, investigated, and reported according to the facility's Abuse Investigation and Reporting for Senior Services Policy. Findings included: This tag is cross referenced to: F607- Based on record review and family and staff interviews facility staff failed to follow the facility's Abuse Investigation and Reporting for Senior Services Policy when they failed to promptly report allegations of abuse for 2 of 3 residents, Residents #113, and Resident #49, reviewed for abuse. Resident #113 reported allegations of abuse to a staff member who did not report the allegation to facility management, which resulted in the accused staff member not being removed from the facility and an investigation being delayed. Resident #49 also reported allegation of abuse to staff, and they failed to report the allegation to the Division of Health Service Regulation and failed to assess Resident #49 and investigated the allegation. The Administrator was interviewed on 12/16/2021 at 2:21 pm and stated the staff should report any allegation of abuse to their supervisor immediately and then the supervisor should report the allegation to the Director of Nursing and Administrator. The Administrator stated the staff are educated on abuse at least once a year and whenever an incident occurs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and physician interview, the facility failed to provide pressure ulcer treatment for 1 of 1 resident (Resident #61) reviewed for pressure ulcers. The findings included: Resident #61 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with multiple diagnoses that included Dementia, muscle weakness and pressure ulcer. Resident #61 had a significant change Minimum Data Set (MDS) dated [DATE] which revealed she was moderately cognitively impaired with a Stage 4 facility acquired pressure ulcer. She required extensive assistance with bed mobility, toileting and eating. Resident #61 was incontinent of bowel and bladder. The care plan updated on 11/24/21 indicated Resident #61 had a Stage 4 wound to the coccyx and the goal was to heal without signs or symptoms of complications or infection in three months. One of the interventions was to provide treatment as ordered. Resident #61 had a physician order dated 11/16/21 to apply menthol zinc oxide to buttocks every shift to excoriated areas. Review of the Treatment Administration Records revealed there was no documentation of the application of menthol zinc oxide to the buttocks on: 11/17/21 11/20/21 11/21/21 11/24/21 11/27/21 11/30/21 12/11/21 12/12/21 Resident #61 had a physician order dated 11/30/21 to clean coccyx pressure ulcer, pack with silver alginate dressing then cover and secure. Change daily every morning until healed. Review of the November Treatment Administration Record revealed no documentation of treatment to the coccyx on: 11/13/21 11/14/21 11/15/21 11/20/21 11/21/21 11/24/21 11/27/21 Review of the medical record revealed Wound Care Physician measurements of coccyx wound were as follows: 11/9/21 0.6x0.5x0.6 centimeters (cm.) (length x width x depth) 11/30/21 0.9x0.9x0.5 cm. (length x width x depth) Resident #61 had a physician order dated 12/7/21 to clean right buttock with normal saline, apply silver alginate dressing, gauze and secure and change daily to area of moisture associated skin damage. Review of the December Treatment Administration Record revealed there was no documentation of the treatment to the coccyx and right buttock areas on 12/8/21 12/11/21 12/12/21 Review of the medical record revealed Wound Care Physician measurements of coccyx wound were as follows 12/7/21 1.1 cm x 1.1 cm x 0.8 cm (length x width x depth) 12/14/21 0.9 cm x 0.9 cm x 0.5 cm (length x width x depth) During an interview on 12/15/21 at 10:37 AM, Treatment Aide ll stated she worked Monday through Friday and was responsible for treatments. She stated she was reassigned to the floor to provide patient care at times and then the floor nurses were responsible for completing wound care. During an interview on 12/15/21 at 11:16 AM, the Wound Care Nurse stated she worked Monday through Friday. She stated the Treatment Aide ll provided wound care Monday through Friday. On the weekends and in the absence of an assigned treatment nurse, the nurse on the floor provided the wound care. She stated she rounded weekly with the Wound Care Physician. She further stated she did not review the Treatment Administration Records to ensure treatments were completed. Record review of the facility Daily Assignment Sheets revealed the following assignment for treatments: 11/20/21: Nurse #2 11/21/21: no assigned nurse 11/24/21: no assigned nurse 11/27/21: no assigned nurse 12/8/21: floor nurses' complete own treatments 12/11/21: no assigned nurse 12/12/21: no assigned nurse During an interview via phone on 12/15/21 at 3:18PM, Nurse #1, indicated she was aware of her responsibility to administer the wound treatments to her assigned residents including Resident #61 in the absence of Treatment Aide ll or designated treatment nurse. She had not completed the assigned wound care for Resident #61 on dates listed below and was unable to verbalize why: 11/13/21 11/14/21 11/15/21 11/20/21 11/21/21 11/24/21 11/27/21 11/30/21 12/8/21 12/11/21 12/12/21 During an interview on 12/16/21 at 10:33 AM, Nurse #2 indicated initially on 11/20/21 she was assigned to do all treatments but one of the nurses went home early, and the schedule was changed. She was reassigned to a medication cart and resident assignment. Nurse #2 indicated she had not completed the treatment for Resident #61 prior to the assignment change and that she informed the nurses of the change in the schedule and that they were to complete their assigned residents' treatments. During an interview via phone on 12/16/21 at 9:53 AM the Wound Care Physician revealed wound care was ordered daily for Resident #61 and should be followed as written. She indicated she visits the facility briefly each week. She indicated wound healing could be impacted by not changing the dressing daily as ordered. During an interview on 12/16/21 at 1:00 PM, the Director of Nursing indicated that the nurses were aware to complete wound care in the absence of a wound care aide or nurse. She stated she was not aware of any problems with completing daily wound treatments and she does not review Treatment Administration Records.